Medical history (history of illness) represents an important component in the diagnosis of pressure ulcers.
Family history
Social anamnesis
Current anamnesis/systemic anamnesis (somatic and psychological complaints).
- Do you have any pain? If yes, when does the pain occur?
- Where is the pain localized?
- Have you noticed any skin changes/skin defects?
- Do you have any functional limitations? Immobility?
- Do you have wetting due to urinary or fecal incontinence?
- How long have these symptoms existed?
Vegetative anamnesis including nutritional anamnesis.
- Are you underweight? Please tell us your body weight (in kg) and height (in cm).
- Do you eat enough and balanced?
- Do you drink enough?
- Do you get enough exercise every day?
Self anamnesis incl. medication anamnesis
- Pre-existing conditions (neurological diseases, chronic diseases).
- Operations
- Allergies
Medication history
- Medication side effects of
- Analgesics (painkillers)
- Non-steroidal anti-inflammatory drugs such as diclofenac.
- Sedatives/hypnotics (tranquilizers/sleeping pills).
- Sympathomimetics such as epinephrine, norepinephrine.
Braden scale – to assess the risk of pressure ulcers.
| 1 point | 2 points | 3 points | 4 points | |
| Sensory perception | Completely failed | Heavily restricted | Slightly restricted | Not restricted |
| Humidity | Constantly damp | Often damp | Sometimes damp | Rarely moist |
| Activity | Bedridden | Predominantly sedentary (barely able to walk) | Walking | Regular walking |
| Mobility | Complete immobility | Severely limited | Slightly restricted | Not restricted |
| Diet | Bad | Probably insufficient | Sufficient | Good |
| Frictional/shear forces | Problem | Potential problem | No problem detectable | – |
Interpretation
- 28-23 points – low risk
- 23-7 points – medium to high risk
Norton scale – to assess the risk of pressure ulcers.
| 1 point | 2 points | 3 points | 4 points | |
| Motivation, cooperation | None | Partial | Little | Full |
| Age (years) | > 60 | < 60 | < 30 | < 10 |
| Skin condition | Allergy, cracks | Damp | Scaly, dry | Normal |
| Diseases, other | pAVK | MS, cachexia, obesity | Fever, anemia, diabetes | None |
| Physical condition | Very bad | Poor | Poor | Good |
| Mental state | Stuporous | Confused | Apathetic | Clear |
| Activity | Bedridden | Wheelchair-bound | Walking with assistance | Walking without help |
| Mobility | Fully restricted | Very limited | Barely restricted | Full |
| Incontinence | Urine and stool | Mostly urine | Sometimes | None |
Interpretation
- Risk of decubitus at <25 points
