Mrs Lee is a 80-year-old lady who was admitted to hospital yesterday because of fever. She...

Mrs Lee is a 80-year-old lady who was admitted to hospital yesterday because of fever. She was paralysed after a stroke attack two years ago and had double incontinence. She developed an infected pressure sore at the sacral region last week and daily dressing was prescribed.

Explain the components to be included when assessing pressure sore.

Expert Solution

Assessment of an established pressure ulcer involves a thorough medical evaluation of the patient. A comprehensive history that includes the onset and duration of ulcers, previous wound care, risk factors, and the list of health problems and medications. The presence of a pressure ulcer indicates that the patient may need more intensive support services or caregivers may need more training.

Wound assessment is a very important factor in this case. When assessing a wound, the specialist should note the number of pressure sores, it’s location, size (length, width, and depth) of ulcers and assess for the presence of exudate, odor, sinus tracts, necrosis or eschar formation, tunneling, undermining, infection, healing (granulation and epithelialization), and wound margins.

In addition to this, determining the Stages of pressure sores is also very important. There are 4 stages of pressure ulcers.

Stage I pressure ulcer: Intact skin with non-blanching redness.

Stage II pressure ulcer: Shallow, open ulcer with red-pink wound bed.

Stage III pressure ulcer: Full-thickness tissue loss with visible subcutaneous fat.

Stage IV pressure ulcer: Full-thickness tissue loss with exposed muscle and bone.

These are the major components included in a pressure sore assessment.

Nightingale answered 2 years ago

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