Chapter 15 Skin Integrity Figure 15.3 Pressure Ulcer Scale for Healing (PUSH Tool 3.0)

Patient Name:_____________________________________ Patient ID#:_________________________________ Ulcer Location: ____________________________________ Date:______________________________________

DIRECTIONS:

Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area, exudate, and type of wound tissue. Record a subscore for each of these ulcer characteristics. Add the subscores to obtain the total score. A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing.

0 0 cm2

Length × Width

Exudate Amount

Tissue Type

0

None 0

1 <0.3 cm2

3.1–4 cm2 1

Light 1

Epithelial tissue

2

0.3–0.6 cm2 7

4.1–8 cm2 2

Moderate 2

Granulation tissue

3

0.7–1 cm2 8

8.1–12 cm2 3

Heavy 3

Slough 4

1.1–2 cm2 9

12.1–24 cm2 5

2.1–3 cm 10

>24 cm2 Subscore Subscore 4

Necrotic tissue

Subscore Total Score

Length × width: Measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler. Multiply these two measurements (length × width) to obtain an estimate of surface area in square centimeters (cm2 Caveat: Do not guess! Always use a centimeter ruler and always use the same method each time the ulcer is measured.

).

Exudate amount: Estimate the amount of exudate (drainage) present after removal of the dressing and before applying any topical agent to the ulcer. Estimate the exudate (drainage) as none, light, moderate, or heavy.

Tissue type: This refers to the types of tissue that are present in the wound (ulcer) bed. Score as a 4 if there is any necrotic tissue present. Score as a 3 if there is any amount of slough present and necrotic tissue is absent. Score as a 2 if the wound is

score as a 0. 4—Necrotic tissue (eschar):

3—Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. 2—Granulation tissue: pink or beefy red tissue with a shiny, moist, granular appearance.

1—Epithelial tissue: the ulcer surface. 0—Closed/resurfaced: the wound is completely covered with epithelium (new skin).

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