HISTORY. Generally, patients have a history of a condition that causes decreased circulation and sensation leading to inadequate tissue perfusion. Associated diseases and conditions include diabetes mellitus, arterial insufficiency, peripheral vascular disease, and decreased activity and mobility or spinal cord injury. Patients with casts, braces, and splints are also predisposed to developing pressure ulcers.

PHYSICAL EXAMINATION. The clinical manifestations of pressure ulcers are generally described in four stages that reflect the amount of tissue injury and the degree of underlying structural damage. Assess the wound to determine the precise location, along with size and depth. The color of the wound (whether pink, red, yellow, or black) indicates the stage of healing and the presence of epithelial tissue. A beefy red color signifies the presence of granulation tissue and denotes adequate healing. Black tissue indicates necrotic and devitalized tissue and signifies delayed healing. Observe for areas of sinus tracts and undermining, which indicate deeper involvement under intact wound margins. Determine the amount of drainage and the type, color, odor, consistency, and quantity. Assess the area around the wound for redness, edema, indurations, tenderness, and breakdown of healed tissues to identify signs and symptoms of infection.

PSYCHOSOCIAL ASSESSMENT. The patient may exhibit signs of anxiety and depression because of the potential setback in an already long list of medical problems. The condition may slow the patient's progress toward independence or necessitate a move from home to a nursing home for an elderly patient.

Diagnostic Highlights


Normal Result

Abnormality with Condition


Skin or wound

Negative for

Positive for microorganisms

Some pressure ulcers become

culture and sen


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