TITLE: GUIDELINE FOR THE USE OF PRESSURE ULCER DOCUMENTATION RECORD

DENUDED: Loss of superficial layer of skin.

EPITHELIALIZATION: Process of growth of epithelial cells "resurfacing".

GRANULATION: Soft tissue consisting of newly formed connective tissue and many new capillaries; typically appears beefy and red and "granular". Precursor to scar tissue.

INFLAMMATION: Defensive reaction to tissue injury: involves increased blood flow and capillary permeability and facilitates physiologic "clean up" of wound. Accompanied by increase in heat, redness, swelling and/or pain in affected area.

TUNNELING: Tissue destruction underlying intact skin along wound edges.

INSTRUCTIONS:

1. Label the form with the patient’s sticker in the upper left-hand corner.

2. Circle the location of each ulcer on the figure. Number each ulcer on the figure if there is more than one.

3. Date and time of the dressing.

4. Location of the ulcer.

5. State the stage or type of skin breakdown using the key on the left of the page below the patient label.

6-7. Measure the size and depth in centimeters and document the results.

8-11. Complete the boxes with the correct responses using the key at the mid-right of the page.

12. Record location of tunneling by using a clock as orientation; head=12:00. If tunneling is not present, place a "-".

13. Measure and record in centimeters the amount of tunneling.

14-15. Complete the boxes with the correct response using the key at the mid-right of the page.

16. Document the treatment and frequency ordered.

17. Document presence/absence of pain by code.

18. The nurse will place his/her initials in this space after the form has been completed.

REFERENCES:

Bryant, Ruth, Acute and Chronic Wounds: Mursing Management, Mosby, Inc. 2nd Edition, 2000

RESOURCE PERSON(S): Kathy Cochran, RN, COCN; Donella Doctor, RN CWOCN

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