Charting a bedsore, also known as a pressure ulcer, involves a detailed assessment and documentation process to track its progress and guide treatment. This process includes observing and measuring specific characteristics of the wound and assigning numerical scores to them. Here's a breakdown of how to effectively chart a bedsore, incorporating the provided reference:
Detailed Bedsore Charting Process
The following approach will ensure a comprehensive evaluation of a bedsore:
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Observation and Measurement:
- Surface Area: Measure the length and width of the pressure ulcer in centimeters or millimeters. You can use a disposable ruler or even a wound tracing to accurately record its dimensions.
- Exudate (Drainage): Assess the amount, color, and consistency of any fluid coming from the wound.
- Amount: Is it scant, minimal, moderate, or copious?
- Color: Is it clear, serous, sanguineous (bloody), serosanguinous (mix of blood and serum), or purulent (pus-like)?
- Consistency: Is it thin, thick, watery, or viscous?
- Wound Tissue Type: Identify the type of tissue visible within the wound bed:
- Granulation Tissue: This is healthy, red, bumpy tissue indicating healing.
- Slough: This is yellow or white, moist tissue that needs to be removed.
- Eschar: This is black, dry, and necrotic (dead) tissue, which also needs to be removed.
- Epithelial Tissue: This is new, pink tissue growing in from the edges, indicating wound closure.
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Categorization and Scoring:
- Once observed and measured, categorize the ulcer based on each characteristic.
- Surface Area: Small, Medium, Large
- Exudate: Scant, Minimal, Moderate, Copious
- Tissue Type: Granulation, Slough, Eschar, Epithelial
- Assign a numerical score to each of the ulcer characteristics (Surface area, exudate, and tissue type), based on pre-established criteria. These scoring systems may vary by institution.
- Once observed and measured, categorize the ulcer based on each characteristic.
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Sub-scoring:
- Record a sub-score for each of these ulcer characteristics. This means each characteristic such as surface area, exudate, and type of wound tissue gets its own individual score based on its category. For example:
- A wound with a surface area over a certain size might get a score of 3.
- Moderate exudate might score a 2.
- Slough covering a large area might also score a 3.
- Record a sub-score for each of these ulcer characteristics. This means each characteristic such as surface area, exudate, and type of wound tissue gets its own individual score based on its category. For example:
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Total Scoring:
- Add the sub-scores to obtain the total score. This total score is then used to track the progress and effectiveness of the treatment. In our example from the Sub-scoring section, the total score would be 3 + 2 + 3 = 8.
Charting Elements to Include
A comprehensive bedsore chart should include the following:
- Date and Time of Assessment: This is crucial for tracking the progression or regression of the ulcer.
- Location of the Ulcer: Be specific (e.g., right heel, sacrum, left hip).
- Stage of the Ulcer: Use a recognized staging system (e.g., the National Pressure Ulcer Advisory Panel (NPUAP) staging system).
- Measurements: Include length, width, and depth, as well as the presence of any tunneling or undermining.
- Description of Wound Bed: Note the tissue types, exudate, and odor.
- Pain Level: Use a numerical pain scale to assess the patient's pain level related to the wound.
- Treatment: Document all treatments applied (e.g., dressing changes, debridement, topical medications).
- Patient's Response to Treatment: Record how the wound is responding to treatment, and if there are any signs of complications such as infections.
- Photographic Evidence: Including photographs is helpful for visual tracking and for consultations with wound care specialists.
Example of Charting
| Date | Location | Stage | Surface Area | Exudate | Tissue Type | Sub-Score (Area) | Sub-Score (Exudate) | Sub-Score (Tissue) | Total Score |
|---|---|---|---|---|---|---|---|---|---|
| 2024-07-26 | Right Hip | II | 3cm x 2cm | Moderate | Granulation | 2 | 2 | 1 | 5 |
| 2024-07-30 | Right Hip | II | 2.5cm x 1.5cm | Minimal | Granulation | 1 | 1 | 1 | 3 |
By charting bedsore information accurately and consistently, healthcare professionals can better manage wound care, improve patient outcomes, and prevent complications.
