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Toolkit

Validated Tool

Wound Assessment Validated Tool

Wound Location Stage Size Other Descriptors Signs of Infection Validated Tool

A validated wound assessment tool helps to systematically evaluate and document details of the wound to improve treatment planning and re-assessment. To date, there is limited evidence for SCI and SB-specific tools for pressure injury assessment.

The most appropriate selection of tools is listed here.

Downloadable Tool

Bates-Jensen Wound Assessment Tool (BWAT)

  • Developed by Bates-Jensen.
  • Consists of 15 items to assess the wound, allows for detailed reassessment and monitoring of healing process.
  • 13 of the 15 items are scored on a 1-5 scale (where 1 is best score).
  • Total score related to one of four categories of risk and severity.

Downloadable Tool

Pressure Ulcer Scale for Healing (PUSH)

  • To measure the dimensions and parameters of the wound and graph results over time to demonstrate progress.

Acetate tracing

A two-layer acetate sheet can be used to trace the perimeter of the wound. The layer which comes into contact with the skin is discarded. Retain the other layer with date and location and orientation of wound. Ensure the tracing is done with the person in the same position each time.

Serial photographs

  • Document date, time and location
  • Ensure the person is in the same position each time
  • Cover sensitive areas and identifying features
  • Place a disposable measure ruler approximately 1cm from wound edge to show scale
  • Take two photos, one close up and one from a distance showing body part for anatomical orientation and identification of left Vs right side. To further assist orientation, use an arrow to point in the direction of the person’s head
  • Take the ‘close up’ photo at 90o to wound surface, about 30-50 centimetres from wound
  • Review photo to determine whether flash is required
  • Consult the relevant policy in your organisation regarding digital photography

The clinical features of pressure ulcers that are captured in four commonly used tools1

Features

Tools for measuring the severity of pressure ulcers

PUSH

BWAT

PWAT

Location

Size

Depth

Tissue type

Edge

Exudate

Undermining and tunnelling

Odour

Surrounding skin characteristics

Pain

Psychometric properties of tools for measuring pressure ulcers1

Tool

Validity

Reliability

Responsiveness

PUSH

PSST:

Pearson’s r 0.95;

P < 0.00011

Agreement among the personnel was 95%; no other available data1

PUSH scores decreased significantly from week 1 through to week 5 in the healing ulcers indicating that the PUSH is sensitive to change over time (P = 0.001)1

Acetate tracings:

Pearson’s r 0.83;

P < 0.0011

BWAT

NPUAP stage:

Pearson’s r 0.61;

P < 0.0011

Inter-rater: intra-class coefficient 0.92;

Intra-rater: intra-class coefficient 0.98;1

No available data

revPWAT

Bedside assessment:

intra-class coefficient: -0.89; 95% CI: 0.83 to 0.931

Inter-rater:

intra-class coefficient 0.71;

Intra-rater:

intra-class coefficient 0.931

No available data