Get Pressure Ulcer Form 2008-2024

The stages are as follows: Stage I: The skin is intact with the presence of non-blanchable erythema. Stage II: There is partial-thickness skin loss involving the epidermis and dermis. Stage III: There is a full-thickness loss of skin that extends to the subcutaneous tissue but does not cross the fascia beneath it.

The Braden Scale was developed by Barbara Braden and Nancy Bergstrom in 1988 and has since been used widely in the general adult patient population. The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development.

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.

Pressure ulcer documentation should record linked areas of care: ►Skin assessment and damage categorisation ►Risk assessment ►Care plan ►Pressure ulcer wound care.

A number of tools have been developed for the formal assessment of risk for pressure ulcers. The three most widely used scales are the Braden Scale, the Norton Scale, and the Waterlow Scale.

Below are helpful hints when documenting pressure injuries: Providers must state the following: o Location of the pressure injury or injuries o Whether the pressure injury is present on admission o Stage of the pressure injury ▪ For coding purposes, staging information may be taken for the wound nurse consult note.

Pressure ulcers are an injury that breaks down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They are sometimes known as "bedsores" or "pressure sores".

The documentation should specify if the ulcer is a pressure ulcer or a non-pressure ulcer and also the stage of the ulcer as defined by the National Pressure Ulcer Advisory Panel (NPUAP) The concept of laterality (such as, left or right) should be included in the clinical documentation.