Clinically, for every ulcer in a patient in the hospital, clinic, nursing home, or convalescent home setting, a health care provider (MD, nurse, allied health professional) should stage and document the ulcer for the following reasons:

With pressure ulcers, like any other wounds or illnesses, a complete medical history prior to examination of the wound is important to understanding the nature of the wound. The pressure ulcer is always secondary to the primary illness or trauma, and consequently a management plan is developed according to the information obtained from the patient or the caregiver. Therefore, examining a wound without a comprehensive medical history is considered incomplete diagnosis or management. History of spinal cord injury, level of injury, and whether it’s a complete or incomplete injury should be ascertained to determine the level of sensation in the patient, the level of muscle function, and whether the patient is ambulatory, walks with aids, or is wheelchair confined. Other primary diagnosis, for example, spina bifida, stroke, or neurological disease, will help determine how to treat the wound, either by conservative or surgical treatment. The medical history should include a complete history of illnesses and the medications the patient is taking. Illnesses such as heart disease, lung disease, diabetes, and vascular disease [2] affect healing and the ability of the patient to tolerate general anesthesia if surgery is indicated. History of bowel and urinary control is important knowledge for the postoperative management of the patient. History of the existing of muscle spasms should be investigated and controlled to avoid postoperative morbidities. Psychosocial evaluation [3, 4] is important for the success of the surgery, as the compliance of patient is important in the postoperative period. In addition, history of smoking, alcoholism, and drug abuse all factors affect healing (details are discussed in Chap. 5).

A history of food intake and patient appetite should be determined. In tetraplegia patients, feeding will depend on the caregiver. It is important that a dietician be involved in the evaluation (Chap. 6).

Patients with pressure ulcers should be evaluated by a physical therapist as a requirement of the pre-operative evaluation to determine important factors that may have contributed in the development of pressure ulcers, for example, patient mobility, range of motion, transfer, sitting, joint movement, contractures, type of wheelchair and cushion, and measurement of sitting pressure. Details of the role of physical therapy in patients with pressure ulcers are provided in Chap. 16.

Basic laboratory tests and specific tests should be ordered when evaluating any patient with pressure ulcers to determine the patient’s health status. The necessary steps should be taken to correct the abnormal laboratory data to help the patient’s healing process or in preparation for surgery. Details of the laboratory tests required are provided in Chap. 4.