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Pressure injury assessment

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By: Sharon Baranoski

A Pressure Injury (PI) assessment is a written record or picture of the status and progress that the PI is making. Assessments should include a record of your initial assessment, ongoing assessments and any pertinent changes to the wound bed.  Documentation of the stage of the pressure injury is also an important component of care. What does the surrounding tissue look like, is undermining present, what treatment interventions should we use are some of the questions to include in an assessment. The initial assessment serves as the baseline for future comparisons, with ongoing assessments occurring at least weekly and when significant changes occur throughout the healing process.  A complete wound or PI assessment should be the driving element in all treatment decisions. The following acronym addresses the Principles of Care and should be included in all PI assessments.

Principles of wound care.  See MEASURES Acronym

Minimize trauma to wound bed
Eliminate dead space (tunnels, tracts, undermining)
Assess and manage the amount of exudates
Support the body’s tissue defense system,
Use nontoxic wound cleansers
Remove infection, debris, and necrotic tissue
Environment maintenance; thermal insulation and provide moist wound healing
Surrounding tissue, protect from injury and bacterial invasion

© Sharon Baranoski 2003

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