- The healing process of a person’s pressure injuries should be reassessed on a regular basis (as determined by the interprofessional team) and during dressing changes using the same wound assessment tool that was used on initial examination, as determined by the health-care setting and agency guidelines.
- Periodic assessment of wound healing helps to determine (1) the trajectory of wound healing, and (2) whether continued intervention or modifications to treatment are required.
- The rate of pressure injury healing may be affected by factors including variations in the initial size and stage of the wound, the extent of infection, the person’s co-morbidities (if any), the person’s nutritional status, and the appropriateness of the initial intervention plan.
- Non-healing may also occur despite appropriate local wound care and interventions directed at the causes of the pressure injuries.
- When progress toward wound healing does not occur, the interprofessional team should reassess the person for additional correctable factors and modify the intervention plan.
- If wound healing is not a realistic goal, the interprofessional team, in collaboration with the person and his/her circle of care, should focus on limiting the impact of the pressure injury on the person’s quality of life.
- Objective and reproducible evaluation of wound healing is best achieved by implementing a valid and reliable wound assessment tool that is responsive to wound changes over time.
- It is also important to use clinical judgment to assess for signs of healing or non-healing.
- A standardized and systematic approach to measuring wound healing promotes consistency in clinical interpretation and communication, and increases the reliability of measured data.
- Evaluative tools or outcome measures that are used more frequently (e.g., weekly) also tend to contain fewer components, which means they take less time to complete.
Clinical Management
Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition
Point of Care Resources