It is important for health professionals to document if a wound has eschar, both to help in wound staging and to determine if the wound is healing.  It order for bed sores (also referred to as pressure sores, decubitus ulcers or pressure ulcers) to heal , the eschar must be removed from the wound via natural abrasion or  surgical debridement.

If eschar is on a limb, it is important to assess peripheral pulses of the affected limb to make sure blood and lymphatic circulation is not compromised. If circulation is compromised, surgical intervention such as amputation may be necessary.

A numerical score is assigned to category depending on the individuals needs and level of assistance.  In general, the scores correlate the likelihood of development of bed sores and dictate what preventative tools should be implemented.  The lower the individual scores on the Braden Scale for Predicting Pressure Sore Risk, the more likely the individual is to develop bed sores.  A Braden Score of 12 or less is considered to be ‘high risk’ for development of bed sores.

The goal behind implementation of the Braden Scale for Predicting Pressure Sore Risk is that it can assist medical professionals with varied experience and judgment to consistently identify patients at risk for developing bed sores and to quantify the severity of risk.  The Braden Scale for Predicting Pressure Sore Risk is completed on admission to a facility and should be updated quarterly to help provide the best care to a residents changing physical condition.

A completed Braden Scale for Predicting Pressure Sore Risk becomes part of the residents chart and can be used a reference for all care givers to address medical needs.  In a busy nursing home or hospital setting, the Braden Scale serves as a reminder to busy nursing staff to attend to this aspect of patient assessment and care with the consistency necessary to influence outcomes.  The Braden Scale for Predicting Pressure Sore Risk also helps direct the attention of the nursing staff to six specific risk factors so that preventive care can be appropriately prescribed.

Below is the Braden Scale for Predicting Pressure Ulcer Risk. Copyright.  Barbara Braden and Nancy Bergstrom, 1988.  Reprinted with permission.  All Rights Reserved.

When wound complications or changes in wound characteristics are noted, documentation should be completed daily until the wound is stable. Documentation should include:

Assessment findings: Type of wound, staging, correct anatomical location, measurements; presence of tunneling/undermining; drainage (amount, color, consistency, odor); wound base tissue (slough, eschar, granulation, epithelialization); wound edges (curled, callused, macerated, detached);  periwound (intact, scaly, induration, edema, redness, warmth, color).

Symptoms of infection: Fever, increased white count, hypotension, general malaise, redness, swelling, induration, streaking, purulent drainage, temperature of surrounding tissue.

Pain: Intensity, location, quality/patterns of radiation and character, duration, variations, patterns, alleviating and aggravating factors, current and past pain management plan, effects of pain, pain goal, physical exam of pain.

If your family member’s medical chart does not properly address the above documentation, it is unlikely they are receiving the care necessary to heal from the bed sore or wound.

Stage I: A reddened area on the skin that, when pressed, is “non-blanchable” (does not turn white). This indicates that a pressure ulcer is starting to develop.

Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.

Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin.

Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints.

Occasionally, reference will be made to a bed sore that is “unstageable.”  An unstageable bed sore is usually indicative of a bed sore that has advanced so far that a large area of skin, tissue and bone is involved.

Interestingly, once a bed sore has progressed to a certain point, it can not be improved in terms of level of severity.  For example, even after a stage IV bed sore has begun the healing process, it is still considered to be a stage IV bed sore.