A Pressure Ulcer A-S-S-E-S-S-M-E-N-T Tool
Elizabeth A. Ayello, PhD, RN, CWOCN
Although pressure ulcer staging systems are helpful in identifying a pressure ulcer's
depth, they do not give information on other important characteristics of the wound.
The following toolbased on the mnemonic A-S-S-E-S-S-M-E-N-T was
developed in a checklist format to provide a snapshot of the pressure ulcer's location, size, sinus tracts, tunneling, exudate,
necrotic tissue, epithelialization, and presence or absence of granulation tissue.
It is not intended to measure healing but to provide data on wound status at a point
in time. Additional findings that are not included on this tool, but should be documented in the patient's record, include
physical and psychosocial health, complications of the pressure ulcer, and nutritional status.
Elizabeth A. Ayello, PhD, Rn, CWOCN, is Clinical Assistant Professor at New York
University, New York, N.Y. Adapated from Nursing96 1996;26(10):62-3.
Client's Name _________________________________ Age _________
Date ________Time
____________ Number of pressure ulcers ________
A.
ANATOMIC LOCATION OF WOUND
- Sacrum
- Heel R L
- Trochanter R L
- Lateral malleolus R L
- Ishcium R L
- Elbow R L
AGE OF WOUND
_______ days or ________ months client has
had the pressure ulcer
S. SIZE
_____ cm length _______ cm width _____ cm depth
