Pressure Ulcers Toolkit

This toolkit contains helpful resources to assist in improving processes associated with pressure ulcers. These processes include identification of high-risk patients and prevention of pressure ulcers as well as facilitating improved documentation of existing pressure ulcers.

Wound Assessment Tools

Assessment of pressure ulcers requires skill, knowledge and competency. Resources are provided to aid in properly assessing these types of wounds for accurate documentation.

  • Guidelines/Recommendations


    Pressure Ulcer Care Planning Assessment Form

    A tool to guide the development of nursing care plans for patients who either have pressure ulcers or are at risk of developing pressure ulcers.

    TAGS: Tools, nursing, Patient, Risk

  • Assessment tools

    Assessment tools

    Braden Scale for Predicting Pressure Sore Risk

    Use of the Braden Scale is a best practice in patient assessment for determining which patients are at the highest risk of developing pressure sores. This table format of the Braden Scale is a quick and easy risk assessment for staff to use which can be incorporated into the medical record.

    TAGS: determine, Patient, highest, developing, Assessment, Staff, Medical, Records

  • Articles


    Wound Healing Phases

    This resource provides a description of the wound healing phases.

    TAGS: phases, wound, Clinical, Infection

Wound Management Tools

Documentation of pressure ulcers can be a challenging task. Resources here provide information on how to properly document pressure sores and the healing process, including use of photography.

  • Assessment tools

    Assessment tools

    Wound Photo Documentation Tool

    A tool to facilitate appropriate documentation of pressure ulcers. This tool provides a place to insert a photo, prompts staff to answer descriptive questions regarding the wound and also provides definitions to ensure consistency of descriptions among staff.

    TAGS: Facilitate, pressure, ulcers, insert, questions

  • Policy Templates

    Policy Templates

    Wound Photo Documentation Protocol

    A sample policy that can be used as a guide in development of your own organizational policy for photographic documentation of pressure ulcers.

    TAGS: Policy, Development, pressure, ulcers, photographic

  • Guidelines/Recommendations


    Photography in Wound Documentation Fact Sheet

    Photography is a common method used to document pressure ulcers. The use of photography for wound documentation is an organizational choice and not mandatory. However, if an organization chooses to use photography, care should be taken to ensure polices are in place for its use and staff are trained in the use of this type of documentation. The Fact Sheet, developed by the Wound Ostomy and Continence Nurses Society, outlines what processes should be in place at an organization that uses photography for documentation of pressure ulcers.

    TAGS: Organization, mandatory, Trained, ostomy, continence, Nurse, society, pressure

Wound Prevention Tools

Prevention of wounds is the best strategy for patient care. These resources offer information on best practices in preventing skin breakdown in patients.

  • Evaluation tools

    Evaluation tools

    Pressure Ulcer Adverse Event Reporting Tool

    This tool will help the Risk Manager evaluate occurrences which involve the development or worsening of pressure ulcers during a patient’s admission.

    TAGS: Risk, Managers, Patient, worsening, Development

  • Checklists


    Pressure Ulcer Pathway

    A checklist that can be used to evaluate pressure ulcer prevention practices. This tool assists your organization in determining if individual staff techniques are in line with current best practices in pressure ulcer prevention.

    TAGS: Evaluate, Organization, Individual, Staff, techniques

  • AHRQ Preventing Pressure Ulcers in Hospitals

    Provides resources of best practices of multidisciplinary teams for wound management.

    TAGS: multidisciplinary, Team, Management