Pressure Ulcer Checklist
ASSESS
Trained personnel or interdisciplinary team
Evaluate and document patient medical/surgical
history, physical exam/posturing limitations,
psychosocial condition, environment and goals.
Perform whole body visual and tactile skin
inspection within 72 hours after admission and
 Regularly per setting protocol  and
 On change in patient status 
Pay special attention to more darkly
pigmented skin as changes may be obscure
Within 72 h after admission, assess PU risk
using clinical judgment and reliable, valid scale
(circle one) Braden, Norton, Waterlow or _____
Check for other PU-risk factors including:
 Diabetes 
 Extremes of age 
 Body mass index (BMI) extremes 
 As feasible, assess skin where devices may
cause pressure, e.g. splints, casts, tubes 
Document ulcer progress weekly using
reliable, valid measures, e.g. length x width to
estimate area.
Document partial- or full-thickness depth.
Ensure all formal assessments are accessible to
those providing/consulting on pressure ulcer care
Improve Patient Outcomes
PREVENT
HEAL
+ Individual receiving care, family and caregivers =
Address identified patient PU risk factors
Limited mobility, activity, cognition, sensation:
 Redistribute pressure every 4 hr or as indicated
and feasible 
 Properly trained staff select and use indicated
pressure redistribution devices for beds, chairs
and wheelchairs that meet psychological, social,
anatomic and physiologic needs for those at PU
risk if patient-appropriate 
 Use patient-appropriate positioning standards of
care per institution protocol.
 Implement patient-appropriate exercise program
 Consistently train patient and care providers on PU
prevention, treatment as appropriate and feasible
Excess moisture: Protect skin with barrier and wick
fluid away from skin
Restore, maintain good nutrition, hydration,
circulation and infection control consistent with
patient and family goals and professional consult
advice as appropriate and feasible.
Protect skin from chemical or physical trauma,
e.g. appropriate incontinence plan, lift sheet.
Avoid vigorous massage on boney prominences
Moisturize dry skin to prevent cracking
Complete pressure ulcer (PU) team
Treat patient and pressure ulcer (PU) to optimize healing
Continue or implement all measures to prevent PU
Properly trained staff select and use appropriate
pressure redistribution devices with verified
functionality for the stage of PU as feasible.
If appropriate, use a dynamic air support surface if
individual cannot be positioned without pressure on
PU (e.g. if static support surface bottoms out)
Avoid positioning directly on PU on any surface
Manage local and systemic factors per institutional
protocols and to meet patient / family needs / goals
Nutrition  Circulation  Infection  Other____
Cleanse PU (4-15 psi: water, saline, non-toxic cleanser )
Debride  autolytically surgically with enzyme
Evaluate PU at each dressing change for signs and
symptoms of clinical infection
Dress PU to maintain a moist environment, protect it
and local skin from friction, shear, pressure, trauma,
irritation, excess fluid (e.g. fiber, foam, hydrocolloid )
Manage PU-related pain to meet patient needs.
Identify and address nutrient deficiencies.
After 4 weeks if there is no PU area decrease,
 Revaluate and improve care plan 
 Try adjunct therapy e.g. electrical stimulation 