How do you measure a decubitus ulcer?

Measure the length “head-to-toe” at the longest point (A). Measure the width side-to-side at the widest point (B) that is perpendicular to the length, forming a “+”. Measure the depth (C) at the deepest point of the wound. All measures should be in centimeters.

How do you document a pressure ulcer?

Document changes to pressure ulcers as they heal. Provide an accurate description of the pressure ulcer or of skin characteristics. Accurately measure the wound length, width, and depth, and note any drainage. Indicate changes in color, consistency, and odor.

What is the Braden Scale assessment tool?

The Braden Scale is a scale made up of six subscales, which measure elements of risk that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. These are: sensory perception, moisture, activity, mobility, friction, and shear.

What is the best preventive measure for decubitus ulcers?

Treat your skin gently to help prevent pressure ulcers.

• When washing, use a soft sponge or cloth.
• Use moisturizing cream and skin protectants on your skin every day.
• Clean and dry areas underneath your breasts and in your groin.
• DO NOT use talc powder or strong soaps.
• Try not to take a bath or shower every day.

How do we measure our pressure ulcer rates and practices?

PREVALENCE measures the number of patients with pressure ulcers at a certain point or period in time:

1. The numerator will be the number of patients with any pressure ulcer (count for both any ulcer and Stage II or greater).
2. Just count patients, not the number of ulcers.

How do you write a wound assessment?

Do describe what you see: type of wound, location, size, stage or depth, color, tissue type, exudate, erythema, condition of periwound. Don’t guess at the type or the stage of a pressure ulcer or injury (hereafter, pressure injury [PI]) or the depth of the wound.

What are bony prominences?

Areas where bones are close to the surface (called “bony prominences”) and areas that are under the most pressure are at greatest risk for developing pressure sores. In bed, body parts can be padded with pillows or foam to keep bony prominences (areas where bones are close to the skin surface) free of pressure.

What documentation should be included in a wound assessment?

A wound assessment must be made and accurately recorded at every dressing change: the size of the wound, its depth, colour and shape, as well as the condition of surrounding skin, should all be documented.

How do you measure a wound?

The wound is typically measured first by its length, then by width, and finally by depth. The length is always from the patient’s head to the toe. The width is always from the lateral positions on the patient. The depth is usually measured by inserting a q–tip in the deepest part of the wound with the tip of finger.