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(a) History and physical exam: see Table 1 and Table 2
(b) Risk factors:
b1. For development of PU/PI: neurological conditionsimpeding movement, lower extremity trauma (e.g. hipfractures), older age, prolonged surgical procedures, criticallyill patients, incontinence, malnutrition. See Structured RiskAssessment and validated tools (Braden, Norton, Waterlow)b2. For infection: onset > 4 weeks, location near frequentlycontaminated areas (e.g, near anus), cardiovascular andendocrine conditions, malnutrition
(c) Blood supply: If PU/PI on lower extremity, conduct non-invasive arterial tests to rule out peripheral arterial disease. Seetable with values and interpretations in topic"How to SelectAdequate Compression Therapy Pressure Levels and Products".
(d) Differential diagnoses: see Table 3 (e) Determine healability: see Table 4(f) PU/PI classification/stages: see topic "PressureUlcers/Injuries - Classification/Staging". Stage drawings NPUAPcopyright & used with permission
History focused on identification of risk factors for development of PU/PI and infection
See detailed framework for chief complaint and history of present illness, medications, social history,review of systems. Conduct a structured risk assessment with validated tools (e.g.“Braden Scale for Predicting PressureSore Risk”) and clinical judgement
Patient's and caregiver's concerns
Pain, depression, social and financial support, ability/willingness to adhere to care plan. Resources: Wound-Quality of Life (QoL) and patient-reported Wound Outcome, validated painmeasurement tools (CRIES, FLACC, FACES, Braden Scale)
Nutritional Assessment
Complete food log covering 2-3 days, BMIMalnutrition (2 out of the following 6 parameters): Insufficient energy intake, Weight loss, Loss ofmuscle mass, Loss of subcutaneous fat, Localized or generalized fluid accumulation that may maskweight loss, Decreased functional status measured by hand grip Labs: albumin, pre-albumin, HbA1c, blood glucose, complete blood count, C‐reactive protein, ESRStandardized tools: "Nestlé MNA" and "Self-MNA®" It is important that a registered dietitian be involved in the evaluation if possible
Functional, Equipment, and Seating Evaluation
Assess level of activity in the last 24h, mobility (with/ without assistance), posture, neurological function,bowel and bladder control, pressure redistribution devices, sleeping surface, wheelchair, cushion, etcConsider ordering a Physical Therapy or Occupational Therapy Evaluation
Focused Physical Examination:
Rectum/Genitalia/Pelvic: incontinence associated dermatitis (consultation with nurse specialized incontinence recommended) Neurologic: mental status, motor, sensation, cerebellar function, bladder and bowel controlSkin: local edema, lymphedema, scars, erythema, ecchymosis, dermatitis, skin tears, signs of abuse orneglectIf PU/PI on lower extremity, perform non-invasive arterial tests. See table with values andinterpretations in topic "How to Select Adequate Compression Therapy Pressure Levels and Products".
Diabetic foot ulcer, arterial ulcer, venous ulcer, inflammatory ulcer (e.g.pyoderma gangrenosum), erythema that blanches on compression, moisture-associated dermatitis, skin tears, tape burns, excoriationsPatient may also have PU/PI with mixed etiology
Table 4. Determining Healability of PU/PI
Healable wound: the cause is corrected, there is enough blood supply to heal;moist interactive healing Maintenance wound: the wound could heal, but the cause is not correcteddue to patient unwillingness to adhere to treatment or a lack of required systemresources Non-healable wound: the patient is ill or may have negative protein balance orinadequate blood supply that is not bypassable or dilatable
Labs: White blood cells and differential (WBC), C-reactive protein anderythrocyte sedimentation rate (ESR), Complete metabolic panel, Coagulationpanel, Urinalysis and culture/sensitivity Radiographs: If indicated (e.g. PU/PI located on sacrum or trochanters) plain X-rays of the pelvis in the antero-posterior (AP) position, and bilateral hip X-ray inthe lateral position
For suspected soft tissue infection or non-healing ulcer:
Tissue biopsy or quantitative validated swab technique (e.g., Levine) forculture, obtained after debridement, ORChronic wound fluid protein analysis
For suspected osteomyelitis:
Bone biopsy for culture and histology: gold standard but invasive Imaging modalities: magnetic resonance imaging has the greatest sensitivity