Staging and Defining Characteristics of Pressure Ulcers Using Photographs by Staff Nurses in Acute Care Settings

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The aim of this study was to determine if a digital photograph obtained by a staff nurse in the acute care setting could be used to determine staging and wound characteristics of a pressure ulcer when viewed by a panel of wound experts as compared to a bedside assessment by a wound expert.


One hundred digital photographs of pressure ulcers were obtained from 69 patients on general and critical care medical-surgical nursing units from 2 Magnet-designated hospitals belonging to a large Mid-Atlantic health care system. Four certified wound ostomy nurses (CWONs), 2 at each hospital site, identified patients with a pressure ulcer for bedside assessment and digital photography.


This multisite nonexperimental study compared bedside assessment of wound characteristics and staging of 100 pressure ulcers by the hospital CWON to assessment of the same wound by an expert panel of 3 CWONs via digital photography. This study examined 13 wound characteristics and a total score on the Bates-Jensen Wound Assessment Tool (BWAT) as well as the staging of a pressure ulcer using the National Pressure Ulcer Advisory Panel definitions. A nonprobability sampling plan used a convenience sample of 69 adult inpatients at the 2 hospitals to obtain photographs of 100 pressure ulcers.


The BWAT, formerly the Pressure Sore Status Tool, was used by the bedside and expert panelists to assess the pressure ulcer characteristics. This tool assesses 13 wound characteristics from best to worst, using a modified Likert scale. Studies examining reliability and validity of the BWAT support it as an effective instrument.


Interrater reliability among the hospital CWONs using bedside assessment and panelist CWONs using digital photography assessment for the BWAT 13 characteristics ranged from slight to fair agreement for skin color surrounding wound (κ range = 0.12–0.21, P ≤ .02) to fair to moderate agreement for necrotic tissue type (κ range = 0.37–0.60, P = .000). Only slight agreement for total BWAT score was found among on-site bedside CWONs and off-site expert panelist CWONs (κ range = 0.01–0.05, P ≤ .05). Results of the interrater analysis for staging of pressure ulcers had fair to moderate agreement (κ range = 0.39–0.58 (P = .000).


The findings of this study indicate that a digital photograph alone cannot reliably convey the characteristics of a pressure ulcer. A digital photo, in combination with clinical information, may increase the accuracy of the assessment and documentation. Systems designed to provide digital photography wound measurements may improve consistency, along with the development of standardized education for examining digital photographs by wound experts.

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