The PUSH assesses change in pressure ulcer status over time, including size, exudate amount, and tissue type.
3
20-30 minutes
Adolescent
13 - 17
yearsAdult
18 - 64
yearsElderly Adult
65 +
yearsCreated by Jason Raad, PhD in 7/2011; Updated by Jill Smiley, MPH in 12/2013.
In at least some studies, PUSH scores did not strongly correlate with the observations made by nursing staff (George-Saintilus, 2009)
The PUSH categorizes ulcers with an area greater than 24 cm2 as "very large", thus a decrease in wound area may occur without being recognized as such by subsequent PUSH scores (Lynn-West, 2007).
The PUSH is not intended to be a comprehensive assessment tool (Stotts, 2001)
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Various Diagnosis:
(Gardner, 2005; n = 23: dementia = 9, diabetes = 6; mean age = 79.5 (15.60) years)
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Week 1 Measures of Healing for all Ulcers and by Healing Outcome |
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All Ulcers (N = 32) |
Healed (n = 21) |
Unhealed (n = 11) |
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Mean total PUSH score |
8.6 (3.06) |
7.6 (2.99) |
10.5 (2.30) |
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Length X width item* |
5.6 (2.33) |
4.9 (2.37) |
7.0 (1.48) |
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Exudate amount item |
0.4 (0.49) |
0.3 (0.48 |
0.5 (0.52) |
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Tissue type item |
2.6 (0.91) |
2.4 (0.87) |
3.0 (0.90) |
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Notes: *p < 0.05 |
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Various Diagnosis:
(Gardner, 2005; n = 23, dementia = 9, diabetes = 6; mean age = 79.5 (15.60) years)
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Correlations of PUSH Scores with the PSST: |
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Week |
n |
Strength |
Pearson r |
p value |
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1 |
32 |
Excellent |
0.72 |
0.000 |
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2 |
32 |
Excellent |
0.76 |
0.000 |
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3 |
26 |
Excellent |
0.89 |
0.000 |
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4 |
24 |
Excellent |
0.90 |
0.000 |
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5 |
20 |
Excellent |
0.95 |
0.000 |
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PUSH = Pressure Ulcer Scale for Healing |
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Chronic Leg Ulcers:
(de Gouveia Santos, 2007; n = 41 patients with chronic leg ulcers; 49% right leg; 36% venous ulcers)
Long Term Care Facility Residence:
(Stotts et al, 2001, n = 1274 over a 12 week period; mean age = 80 (range = 18 - 102); at baseline stage II ulcers were most common, n = 1196)
Diabetic Foot Ulcers (DFUs):
(Gardner et al, 2011; n = 18 subjects with Wagner 2 or greater neuropathic, non-ischemic ulcers on the plantar surface of the foot, which healed completely over a 13-week follow-up period; mean age = 54.1 (11.1) years; 12 males; all Caucasion)
Nursing Home Residence:
(George-Saintilus et al, 2009, n = 48 residence aged 65 years or older)
Agreement between clinical observation and PUSH scores was found to be weak. Specifically, Of 370 observations, there was agreement in only 159 (43%) of cases.
Poor agreement between clinical observations and PUSH scores:
Stage II ulcers; Kappa = 0.132 (p = 0.029)
Stage III ulcers; Kappa = 0.129 (p = 0.04)
Stage IV ulcers; Kappa = 0.111 (p = 0.029)
Pressure, Venous, and Diabetic Foot Ulcers:
(Hon et al, 2010; n = 98 people, 47 with pressure (PU), 23 with venous leg (VLU), and 28 with diabetic foot (DFU) ulcers; mean wound size at baseline (cm2) = 71.1 (10.1); mean wound size at follow-up (cm2) = 4.7 (9.1); mean age = 60 (20-89) years)
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Baseline Wound Size and Baseline Total PUSH Score Correlation |
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Total Group |
Pressure Ulcer (all) |
Venous Leg Ulcer |
Diabetic Foot Ulcer |
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Pearson’s r |
0.66 Excellent |
0.63 Excellent |
0.74 Excellent |
0.71 Excellent |
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P value |
0.01 |
0.01 |
0.01 |
0.01 |
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Baseline Wound Size and Individual PUSH Score Components Correlation |
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Size (l x w) Range 0 – 10 |
Exudate Range 0 - 3 |
Tissue Type Range 0 - 4 |
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Spearman’s rho |
0.83 Excellent |
0.54 Adequate |
0.41 Adequate |
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P value |
0.01 |
0.01 |
0.01 |
Pressure, Venous, and Diabetic Foot Ulcers:
(Hon et al, 2010)
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Responsiveness of Individual PUSH Score Components |
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Score Components (normal range) |
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Size (l x w)a(range 0 – 10) |
Exudate Amount (range 0 – 3) |
Tissue Type (range 0 – 4) |
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Mean (SD) baseline score |
6.5 (2.3) |
2.0 (0.7) |
2.6 (0.7) |
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Mean (SD) follow-up score |
4.8 (2.3) |
1.5 (0.9) |
1.7 (0.7) |
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Mean (SD) score change |
1.7 (2.4) |
0.5 (0.9) |
0.9 (0.9) |
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P value |
0.0001b |
0.0001b |
0.0001b |
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Effect size |
0.74 (large change) |
0.71 (large change) |
1.29 (large change) |
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Standardized response mean |
0.71 |
0.56 |
1.00 |
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a obtained using a disposable ruler b statistically significant difference (alpha = 0.05) between baseline and follow-up assessments (31.7 +/- 20.1 days later) |
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Elderly:
(Stotts et al, 2001; n = 103 across 10 sites; mean age = 74.6 (15.0) years, baseline stage III ulcers = 4704, Stage II = 34.9%, stage IV = 11% and 6.6% could not be staged; sample drawn from clinics, nursing homes, research study sites, and home care settings)
Elderly:
(Stotts et al, 2001)
Changes over time (suggestive of healing), were evaluated with pairwise comparisons across each of the 10 weeks participants were assessed.
PUSH total scores were significantly different from baseline to each time the patient was assessed (weeks 1 to 10; p < 0.05)
Berlowitz, D. R., Ratliff, C., et al. (2005). "The PUSH tool: a survey to determine its perceived usefulness." Adv Skin Wound Care 18(9): 480-483. Find it on PubMed
de Gouveia Santos, V. L., Sellmer, D., et al. (2007). "Inter rater reliability of Pressure Ulcer Scale for Healing (PUSH) in patients with chronic leg ulcers." Rev Lat Am Enfermagem 15(3): 391-396. Find it on PubMed
Gardner, S. E., Frantz, R. A., et al. (2005). "A prospective study of the pressure ulcer scale for healing (PUSH)." Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 60(1): 93-97. Find it on PubMed
Gardner, S. E., Hillis, S. L., et al. (2011). "A prospective study of the PUSH tool in diabetic foot ulcers." J Wound Ostomy Continence Nurs 38(4): 385-393. Find it on PubMed
George-Saintilus, E., Tommasulo, B., et al. (2009). "Pressure Ulcer PUSH Score and Traditional Nursing Assessment in Nursing Home Residents: Do They Correlate?" Journal of the American Medical Directors Association 10(2): 141-144.
Hon, J., Lagden, K., et al. (2010). "A Prospective, Multicenter Study to Validate Use of the Pressure Ulcer Scale for Healing (PUSH©) in Patients with Diabetic, Venous, and Pressure Ulcers." Ostomy wound management 56(2).
Lynn, J., West, J., et al. (2007). "Collaborative clinical quality improvement for pressure ulcers in nursing homes." Journal of the American Geriatrics Society 55(10): 1663-1669. Find it on PubMed
Stotts, N. A., Rodeheaver, G. T., et al. (2001). "An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH)." Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 56(12): M795-799. Find it on PubMed
We have reviewed more than 500 instruments for use with a number of diagnoses including stroke, spinal cord injury and traumatic brain injury among several others.