Patient SS# Ulcer #
Pressure Ulcer
Site: Sacrum-Coccyx Trochanter Ischium Heel Other Body Side: Right Left Midline
Orientation: Medial Lateral Positioning
Upper Leg Flexed When Turned: Yes No
Surface Turned Onto: Right Left Back Abdomen
Variables Scoring Options Variable Score
Geometric Factor
1
<1 cm2
2
>1 – <2.5 cm2
3 –
>2.5 <5 cm2
4
>5 <10 cm– 2
5 –
>10 <15 cm2 Surface Area
(L x W)
6
>15 - <25 cm2 – 7
>25 <35 cm2 – 8
>35 <55 cm2 – 9
>55 <85 cm2
10
>85 cm2
Depth 0
0 cm –
1
>0 <1 cm – 2
>1 <2 cm – 3
>2 <3 cm
4
>3 cm
Edges 1
· Indistinct, diffuse, none clearly visible
· Distinct, outline clearly visible, attached, even with ulcer base
· Well-defined, not attached to ulcer base
2
· Well-defined, not attached to base, rolled under, thickened
· Well-defined, fibrotic, scarred, or hyperkeratotic
Tunneling 0
None <
1
2 cm – <
2
> 2 4 cm
3
>4 cm
Undermining 0
None <
1
2 cm – <
2
> 2 4 cm
3
>4 cm
Sub-total Score Geometric Factor Substance Factor
Exudate Type 0
None
1
Serous/Sanguineous
2 Green/Purulent Necrotic Tissue
Amount
0 None
1
<25%
2
>25%
Sub-total Score Substance Factor TOTAL SCORE (Total of Geometric and Substance Sub-totals)
Maximum score =26 The HIGHER the score, the more severe the ulcer.
Evaluator: Date:
EXHIBIT 5.5
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SCI-PUMT Quick Reference Guide Specifi city
● The SCI-PUMT is specifi c only to pressure ulcers.
● Reliability and validity of the SCI-PUMT have not been established to track the healing of dermatitis, excoriations, mac- erations, skin tears, or neuropathic, venous, and arterial ulcers.
Scoring
● Determine the geometric subtotal scores (i.e., surface area, depth, edges, tunneling, undermining).
● Determine the substance subtotal scores (i.e., exudate type, necrotic tissue amount).
● Add geometric and substance subtotals to obtain the total score (maximum score is 26).
● The HIGHER the score, the more severe the ulcer.
General Guidelines
● Pressure Ulcer Location: Indicate the location of the pressure ulcer being assessed: sacrum, coccyx, trochanter, ischium, heel, other.
● Pressure Ulcer Body Side: Document the body side of the ulcer: left side, right side, midline.
● Positioning: Use consistent patient positioning to obtain accurate measurements. Two or more clinicians are often required to position the patient to optimize ulcer visualization and measurement. Use safe patient handling and move- ment techniques (e.g., use a sling to position the body to the side or lift the leg). Document the position to which the patient is turned onto during the assessment: left side, right side, prone, supine.
● Hip/Leg Flex: Flex the upper leg if the patient is turned to the side to maximize the ulcer’s surface area and visualization.
Supplies
● Use separate supplies for each ulcer to avoid cross contamination.
● Supplies include:
❍ Personal protective equipment (e.g., gloves)
❍ Biohazardous bag
❍ Linear guide in centimeters
❍ Measurement grid with blocks and/or marked into 4 quadrants
❍ Cotton-tipped applicators (1–2)
SCI-PUMT Assessment Variables—Geometric
Surface Area
Instruction Key Points
Measure the length as the greatest distance head-to-toe (12 o’clock to 6 o’clock)
Measure the distance inside the ulcer bed using a non- stretch linear guide with centimeters; use the patient’s head as 12 o’clock and the feet as 6 o’clock
Measure the width as the greatest distance side-to-side (9 o’clock to 3 o’clock)
Measure the width perpendicular to the length Multiply the length × width
Score 1–10 (Variable: ≤1 to >85 cm2)
Only measure open, uninterrupted, continuous areas;
avoid measuring over “islands” of intact skin that are within the ulcer bed
Depth
Instruction Key Points
Place a cotton-tipped applicator horizontally across the ulcer edges.
Establish a reference point for the periulcer skin surface.
Place a disposable ruler perpendicular to the horizontal applicator.
Measure the depth from the deepest point of the ulcer bed, excluding tunnels.
Measure the distance from the skin surface (i.e., horizontal applicator) to the deepest aspect of the ulcer base.
Score 0–4 (Variable: 0 to >3 cm2)
Use a second applicator to measure vertical distance if a disposable ruler is unavailable. Use a pen to mark the ver- tical applicator where the two applicators intersect. Place the vertical applicator beside a linear guide to measure.
EXHIBIT 5.6
(continued)
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EXHIBIT 5.6 (continued )
Edgesa
Instruction Key Points
Identify the worse case with any of the following descriptions:
The edge is where intact skin contacts the ulcer bed; the edge is sometimes known as the ulcer margin.
Variable 1
• Indistinct, diffuse, none clearly visible
• Distinct, outline clearly visible, attached, even with ulcer base
• Well defi ned, not attached to ulcer base Variable 2
• Well-defi ned, not attached to base, rolled under, thickened
• Well-defi ned, fi brotic, scarred, or hyperkeratotic Score the edges based upon the edge appearance and ulcer depth.
Edge integrity facilitates or impedes epithelialization.
Score 1–2 Score 1: Edges are not rolled/thickened and are even with
the ulcer base; sides/walls are not present.
Score 2: Edges are rolled and are typically higher than the ulcer base.
Tunneling
Instruction Key Points
Measure only the longest tunnel. A tunnel is a space that extends laterally, obliquely, or vertically from the ulcer bed or epithelium; a tunnel is sometimes known as a sinus tract or channel.b
Insert a ruler to measure the distance from the ulcer bed to the most distal aspect of the tunnel.
The Clinician should not be able to visualize skin elevation of the distal tip of an applicator when it is inserted into a tunnel.
Never force the ruler or applicator into a tunnel if resis- tance is encountered.
Use an applicator if a disposable ruler is unavailable or the tunnel is too narrow. Use a pen to mark the proximal part of the applicator where it contacts the ulcer bed. Place the applicator beside a linear guide to measure.
Score: 0–3 (Variable: None to >4 cm2) Tunnels inhibit granulation of full-thickness ulcers and may result in abscesses.
Undermining
Instruction Key Points
Measure only the greatest undermined distance. Undermining is an opening that begins at the ulcer edge and extends beneath the skin either parallel or tangential to the skin surface.b Undermining is under intact skin adjacent to the open ulcer.
Insert a ruler to measure the distance from the ulcer edge to the most distal aspect of undermined area.
The clinician should be able to visualize skin elevation of the distal tip of an applicator when it is inserted into an undermined area.
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EXHIBIT 5.6 (continued )
Never force the ruler or applicator into an undermined area if resistance is encountered.
Use an applicator if a disposable ruler is unavailable or the undermined area is too narrow. Use a pen to mark the proximal part of the applicator where it contacts the ulcer edge. Place the applicator beside a linear guide to measure.
Score: 0–3 (Variable: None to >4 cm2) Undermining negatively impacts the circulation of the intact epidermis and dermis.
SCI-PUMT Assessment Variables—Substance
Exudate Type
Instruction Key Points
Assess drainage on the soiled dressing, not the ulcer bed. Exudate is the fl uid that drains from tissues due to infl am- mation or injury.b
Assess the presence and type of drainage. Serous drainage is clear.
Variable 0 Sanguineous drainage is bloody.
• No drainage Green or purulent drainage is opaque.
Variable 1
• Serous
• Sanguineous Variable 2
• Green
• Purulent
Score 0–2 Green or purulent drainage may indicate infection that
may inhibit the healing process.
Necrotic Tissue Amounta
Instruction Key Points
Use a transparent metric measuring guide divided into 4 (25%) pie-shaped quadrants to determine the percent of the ulcer that has necrotic tissue.
Necrosis is the pathological death of tissues or cells result- ing from irreversible damage.b
Devitalized collagen may present as slough or eschar that may be relatively thick or thin.
• Slough is devitalized tissue that may involve a portion or all of the ulcer bed. Slough is typically yellow but may be green or brown. It is often stringy.
• Eschar is dark, leathery tissue that may involve a por- tion or all of the ulcer bed. It is typically dry but may be moist.
Score 0–2 (Variable: None to >25%) Necrosis inhibits granulation tissue in full-thickness ulcers.
aVariables of Edges and Necrotic Tissue Amount were adapted from the Bates-Jensen Wound Assessment Tool.
bConsortium for Spinal Cord Medicine (2000). Pressure ulcer prevention and treatment following spinal cord injury:
From A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America.
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REVIEW QUESTIONS
1. Predictive validity is best described as follows:
A. It tests the tool against present performance or status on a criterion.
B. It tests the tool against future performance or status on a criterion.
C. It tests scores from one rater against a second rater.
D. It tests the tool against a gold standard.
2. Which are wound characteristics commonly included in instruments to evaluate wound healing?
A. Size, shape, necrotic tissue characteristics, exudate B. Size, granulation tissue characteristics, exudate, ne-
crotic tissue characteristics
C. Size, stage, necrotic tissue characteristics, surrounding skin characteristics
D. Size, depth, necrotic tissue characteristics, exudate 3. Which is a recommended method of measuring wound
size?
A. Measure the longest length and the perpendicular wid- est width in centimeters.
B. Measure the wound circumference.
C. Measure the length from 12 o’clock to 6 o’clock and multiply by 2.
D. Measure the head-to-toe length and the side-to-side length.
4. Interrater reliability is best defi ned by which statement?
A. The consistency of the tool with repeated measures.
B. It is concerned with different clinicians getting the same score on the tool when evaluating the same wound.
C. It is the accuracy of the tool.
D. It is concerned with all items on a tool consistently measuring the same objective.
5. The ability of the tool to respond quickly to changes in the wound status is the defi nition of
A. intrarater reliability B. predictive validity C. responsiveness D. sensitivity
REFERENCES
1. Bates-Jensen BM, Vredevoe, D, Brecht ML. Validity and reliability of the Pressure Sore Status Tool. Decubitus. 1992;5(6):20–28.
2. Thomas DR, Rodeheaver GT, Bartolucci AA, et al. Pressure ulcer scale for healing: Derivation and validation of the PUSH tool. Adv Wound Care. 1997;10(5):96–101.
3. Krasner D. Wound healing scale, version 1.0: a proposal. Adv Wound Care. 1997;10(5):82–85.
4. Ferrell BA, Artinian BM, Sessing D. The Sessing scale for assessment of pressure ulcer healing. J Am Geriatr Soc. 1995;43:37–40.
5. Sussman C, Swanson G. The utility of Sussman Wound Healing Tool in predicting wound healing outcomes in physical therapy. Adv Wound Care. 1997;10(5):74–77.
6. Houghton PE, Kincaid CB, Campbell K, et al. Photographic assess- ment of the appearance of chronic pressure and leg ulcers. Ostomy Wound Manage. 2000;46(4):20–30.
7. Wagner FEW. The dysvascular foot: a system for diagnosis and treat- ment. Foot Ankle. 1981(2):64–122.
8. Falanga, V. Classifi cations for wound bed preparation and stimulation of chronic wounds. Wound Rep Reg. 2000;8(5):347–352.
9. Thomason SS, Nelson AL, Luther SL, Harrow JJ. Monitoring Pressure Ulcer Healing in Persons with Spinal Cord Impairment. 2009.
Department of Veteran Affairs, Veterans Health Administration, Health Services Research and Development Service, Nursing Research Initiative (NRI 03-245-4 (IRB#104145).
10. Burns N, Grove SK. The concepts of measurement. In: Burns N, ed.
The Practice of Nursing Research: Conduct, Critique & Utilization.
4th ed. Philadelphia, PA: WB Saunders; 2000:389–410.
11. Waltz CF, Strickland OL, Lenz ER. Reliability and validity of criterion-referenced measures. In: Waltz CF, Lenz ER, ed. Measurement in Nursing Research. 2nd ed. Philadelphia, PA: FA Davis; 1991:229–257.
12. Kennedy K. The prevalence of pressure ulcers in an intermediate care facility. Decubitus. 1989;2(2):44–45.
13. Sibbald RG, Krasner DL, Lutz JB, et al. The SCALE expert panel: skin changes at life’s end. Final Consensus Document. 2009.
14. Bartolucci AA, Thomas DR. Using principal component analysis to describe wound status. Adv Wound Care. 1997;10(5):93–95.
15. Stotts NA, Thomas DR, Frantz R, et al. An instrument to mea- sure healing in pressure ulcers: Development and validation of the Pressure Ulcer Scale for Healing (PUSH). J Gerontol A: Med Sci.
2001;56(12):M795–M799.
16. Ratiliff CR. Use of the PUSH Tool to measure venous ulcer healing.
Ostomy Wound Manage. 2005;51(5):58–63.
17. Hon J, Lagden K, McLaren AM, et al. A prospective, multicenter study to validate use of the Pressure Ulcer Scale for Healing (PUSH(c) ) in patients with diabetic, venous, and pressure ulcers. Ostomy Wound Manage. 2010;56(2):26–36.
18. Edwards H, Courtney M, Finlayson K, et al. Improved healing rates for chronic venous leg ulcers: pilot study results from a randomized controlled trial of a community nursing intervention. Int J Nurs Pract.
2005;11(4):169–176.
19. Posthaur ME. Nutrition: A key link in clinical decision trees. Adv Skin Wound Care. 2004;17(9):474,476.
20. Gunes, UY. A prospective study evaluating the Pressure Ulcer Scale for Healing (PUSH Tool) to assess stage II, stage III, and stage IV pressure ulcers. Ostomy Wound Manage. 2009;55(5):48–52.
21. Gardner SE, Frantz RA, Bergquist S, et al. A prospective study of the Pressure Ulcer Scale for Healing (PUSH). J Gerontol A: Med Sci.
2005;60A(1):93–97.
22. George-Saintilus E, Tommasulo B, Cal CE, et al. Pressure ulcer PUSH score and traditional nursing assessment in nursing home residents:
do they correlate? J Am Med Dir Assoc. 2009;10(2):141–144.
23. Pompeo M. Implementing the PUSH tool in clinical practice:
Revisions and results. Ostomy Wound Manage. 2003;49(8):32–46.
24. Harris C, Bates-Jensen B, Parslow N, et al. Bates-Jensen wound assessment tool: pictorial guide validation project. J Wound Ostomy Continence Nurs. 2010;37(3):253–259.
25. Harris C, Bates-Jensen B, Parslow N, et al. The Bates-Jensen Wound Assessment Tool (BWAT): development of a pictorial guide for train- ing nurses. Wound Care Canada. 2009;7(2):33–38.
26. Bates-Jensen BM, McNees, P. The wound intelligence system: Early issues and fi ndings from multi-site tests. Ostomy Wound Manage.
1996;42(suppl 7A):1–7.
27. Bates-Jensen B, McNees, P. Toward an intelligent wound assessment system. Ostomy Wound Manage. 1995;41(suppl 7A):80–88.
Sussman_Chap05.indd 160
Sussman_Chap05.indd 160 8/6/2011 12:32:02 PM8/6/2011 12:32:02 PM
pressure wound therapy for postsurgical patients in long-term acute care. Adv Skin Wound Care. 2009;22(3):122–127.
33. Houghton PE, Campbell KE, Fraser CH, et al. Electrical stimulation therapy increases rate of healing of pressure ulcers in community- dwelling people with spinal cord injury. Arch Phys Med Rehabil.
2010;91(5):669–678.
34. Falanga V. Measurements in wound healing. Int J Low Extrem Wounds.
2008;7(1):9–11.
35. Falanga V, Saap LJ, Ozonoff A. Wound bed score and its correlation with healing of chronic wounds. Dermatol Ther. 2006;19:383–390.
predictors of healing in pressure sores. Dissertation Abstracts International, Vol. 59, No. 11, Los Angeles: University of California, 1999.
29. De Laat EH, Scholte OP, Reimer WH, et al. Pressure ulcers: diagnos- tics and interventions aimed at wound-related complaints: a review of the literature. J Clin Nurs. 2005;14(4):464–472.
30. Bolton L, McNees P, Van Rijswijk L, et al. Wound-healing outcomes using standardized assessment and care in clinical practice. J Wound Ostomy Continence Nurs. 2004;31(2):65–71.
31. Bates-Jensen BM, Guihan M, Garber SL, et al. Characteristics of recur- rent pressure ulcers in veterans with spinal cord injury. J Spinal Cord Med. 2009;32(1):34–42.
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162
Sussman Wound Healing Tool (SWHT) WOUND ASSESSMENT FORM
NAME: _____________________________________ MEDICAL RECORD NO.: _______________________________
DATE: ______________________________________ EXAMINER: _________________________________________
CIRCLE WEEK OF CARE: B 1 2 3 4 5 6 7 8 9 10 11 12
SWHT Variable
Tissue Attribute Attribute Defi nition Rating Relationship to Healing
Score
1 Hemorrhage Purple ecchymosis of wound tissue or
surrounding skin
Present or absent
Not good 2 Maceration Softening of a tissue by soaking until
the connective tissue fi bers are soft and friable
Present or absent
Not good
3 Undermining Includes both undermining and
tunneling
Present or absent
Not good
4 Erythema Reddening or darkening of the skin
compared to surrounding skin; usually accompanied by heat
Present or absent
Not good
5 Necrosis All types of necrotic tissue, including eschar and slough
Present or absent
Not good 6 Adherence at wound
edge
Continuity of wound edge and the base of the wound
Present or absent
Good
7 Granulation
(Fibroplasia—signifi cant reduction in depth)
Pink/red granulation tissue fi lling in the wound bed, reducing wound depth
Present or absent
Good
8 Appearance
of contraction (reduced size)
First measurement of the wound drawing together, resulting in reduction in wound open surface area
Present or absent
Good
9 Sustained contraction (more reduced size)
Continued drawing together of wound edges, measured by reduced wound open surface area
Present or absent
Good
10 Epithelialization Appearance and continuation of resurfacing with new skin or scar at the wound edges or surface
Present or absent
Good
MEASURES AND EXTENT (Depth and Undermining: Not Good) Depth/
Location SCORE
Undermining/
Location SCORE Other Letter
11 General depth >0.2 cm 16 Underm @ 12:00 Location
12 General depth @ 12:00 >0.2 cm 17 Underm @ 3:00 Wound
healing phase
13 General depth @ 3:00 >0.2 cm 18 Underm @ 6:00 Total “Not
Good”
14 General depth @ 6:00 >0.2 cm 19 Underm @ 9:00 Total “Good”
15 General depth @ 9:00 >0.2 cm
Key: Present = 1. Absent = 0. Location choices: upper body (UB), coccyx (C), trochanter (T), ischial (I), heel (H), foot (F); add right or left (R or L). Wound healing phase: infl ammation (I), proliferation (P), epithelialization (E), remodeling (R).
Source: Copyright © 1997, Sussman Physical Therapy Inc.
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Location ____________________________________
Wound healing phase __________________________
Total “Not Good” _____________________________
Total “Good” _________________________________
Procedure for Using the SWHT
Completion of the SWHT is by observation and physical assessment, as follows:
1. Each wound of each patient needs its own SWHT attributes form.
2. The patient’s name, medical record number, and date of assessment are written at the top of the form.
3. The examiner signs the document.
4. As the wound is assessed, the rater marks a 1 or a 0 to signify present or absent on the form next to each of the 19 attri- butes. The squares in the column must be marked with one of the two scores.
5. The wound location and the current wound healing phase are marked with the appropriate letter. Choose the appropriate letter to represent the anatomic location of the wound and place it in the square at the time of the initial assessment and subsequent reassessments. The location will not change.
6. Letters are also used to represent the current wound healing phase: mark an I for infl ammatory, P for proliferative, E for epithelialization, and R for remodeling. In the appropriate box, the phase is noted initially and at each reassessment. The wound healing phase should change as the wound heals.
7. Undermining and depth require some physical assessment to determine presence or absence.
8. Open area measurements are made and listed on a separate form (see Chapter 4), then compared with subsequent mea- surements of these characteristics to determine contraction and sustained contraction, measured as reduction in linear size.
9. Scoring part I. Add the number of “not good for healing” attributes and the number of “good for healing” attributes listed. The score of “not good for healing” should diminish as the wound heals, and the score of “good for healing” attri- butes should increase.
10. A summary of the change is shown in Exhibit 5.4.
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164
PUSH Tool 3.0
Patient Name: _____________________________________ Patient ID#: _____________________________________
Ulcer Location: ____________________________________ Date: ___________________________________________
DIRECTIONS:
Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area, exudate, and type of wound tissue.
Record a subscore for each of these ulcer characteristics. Add the subscores to obtain the total score. A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing.
Length 0 1 2 3 4 5
0 cm2 <0.3 cm2 0.3–0.6 cm2 0.7–1.0 cm2 1.1–2.0 cm2 2.1–3.0 cm2
× Width 6 7 8 9 10 Subscore
3.1–4.0 cm2 4.1–8.0 cm2 8.1–12.0 cm2 12.1–24.0 cm2 >24 cm2 Exudate
Amount
0 1 2 3 Subscore
None Light Moderate Heavy
Tissue Type
0 1 2 3 4 Subscore
Closed Epithelial tissue Granulation tissue Slough Necrotic tissue
Total Score
Length × Width: Measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler.
Multiply these two measurements (length × width) to obtain an estimate of surface area in square centimeters (cm2). Caveat:
Do not guess! Always use a centimeter ruler and always use the same method each time the ulcer is measured.
Exudate Amount: Estimate the amount of exudate (drainage) present after removal of the dressing and before applying any topical agent to the ulcer. Estimate the exudate (drainage) as none, light, moderate, or heavy.
Tissue Type: This refers to the types of tissue that are present in the wound (ulcer) bed. Score as a “4” if there is any necrotic tissue present. Score as a “3” if there is any amount of slough present and necrotic tissue is absent. Score as a “2” if the wound is clean and contains granulation tissue. A superfi cial wound that is reepithelializing is scored as a “1.” When the wound is closed, score as a “0.”
4—Necrotic Tissue (Eschar): black, brown, or tan tissue that adheres fi rmly to the wound bed or ulcer edges and may be either fi rmer or softer than surrounding skin.
3—Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous.
2—Granulation Tissue: pink or beefy red tissue with a shiny, moist, granular appearance.
1—Epithelial Tissue: for superfi cial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface.
0—Closed/Resurfaced: the wound is completely covered with epithelium (new skin).
Version 3.0: 9/15/98
©National Pressure Ulcer Advisory Panel Source: Copyright © National Pressure Ulcer Advisory Panel.
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