5.6 Validated Healing Instruments: The PUSH Tool, BWAT, and Evaluating Adherence
Key Takeaways
- Blueprint objective 3.05 names the PUSH tool explicitly, making it the one healing-progress instrument a WCC candidate must be able to score from memory.
- The PUSH tool sums three subscores — surface area 0 to 10, exudate amount 0 to 3, and tissue type 0 to 4 — for a total of 0 to 17, where a falling score means healing and 0 means closed.
- On the PUSH tissue subscore the numbering runs opposite to intuition: 0 is closed, 1 is epithelial, 2 is granulation, 3 is slough, and 4 is necrotic tissue.
- The Bates-Jensen Wound Assessment Tool scores 13 items from 1 to 5 for a total of 13 to 65, giving a far more granular picture than PUSH at the cost of taking much longer to complete.
- Objective 3.04 asks you to evaluate adherence in terms of barriers and reasons, so the exam-correct response to a missed treatment is to identify the obstacle rather than to document noncompliance.
Validated Healing Instruments: The PUSH Tool, BWAT, and Evaluating Adherence
Section 5.1 established percent area reduction as the quantitative healing benchmark, and section 5.2 covered serial measurement technique. This section adds the two validated composite instruments the exam expects you to know, plus the adherence evaluation that objective 3.04 requires.
Objective 3.05 names its expected content directly: evaluate the progression of wound healing through weekly measurements, treatment revision, updated risk assessment tools, updated labs, and PUSH. The PUSH tool is the only healing instrument the blueprint names by name, which makes it the highest-yield item in this section.
1. The PUSH Tool (Pressure Ulcer Scale for Healing)
Developed by the National Pressure Injury Advisory Panel, PUSH version 3.0 is deliberately short — it can be completed in under two minutes at the bedside — and it is designed to be tracked serially rather than read as a one-time severity score.
The three subscores
A. Length × Width (surface area, cm²) — scored 0 to 10
Multiply the greatest head-to-toe length by the greatest side-to-side width perpendicular to it, then convert the area to a score:
| Area (cm²) | Score | Area (cm²) | Score | |
|---|---|---|---|---|
| 0 | 0 | 2.1 – 3.0 | 5 | |
| < 0.3 | 1 | 3.1 – 4.0 | 6 | |
| 0.3 – 0.6 | 2 | 4.1 – 8.0 | 7 | |
| 0.7 – 1.0 | 3 | 8.1 – 12.0 | 8 | |
| 1.1 – 2.0 | 4 | 12.1 – 24.0 | 9 | |
| > 24.0 | 10 |
B. Exudate amount — scored 0 to 3
- 0 — None
- 1 — Light
- 2 — Moderate
- 3 — Heavy
Assess after removing the dressing and before applying a topical agent.
C. Tissue type — scored 0 to 4
- 0 — Closed / resurfaced: the wound is completely covered with epithelium
- 1 — Epithelial tissue: new pink shiny tissue growing in from the edges or as islands
- 2 — Granulation tissue: pink or beefy red, moist, granular
- 3 — Slough: yellow or white adherent or loose stringy non-viable tissue
- 4 — Necrotic tissue (eschar): black, brown, or tan adherent devitalized tissue
The direction trap: every other number on a wound assessment rises with severity, but here the lowest number is the best tissue. Record the tissue type that is dominant in the wound bed. If any necrotic tissue is present, the tool directs you to score 4 — necrosis outranks the rest.
Total score and interpretation
Total = area score + exudate score + tissue score, giving a range of 0 to 17.
- A decreasing total over successive assessments means the wound is healing.
- An unchanged or increasing total means the wound is static or deteriorating, and the plan needs revision.
- 0 means healed.
PUSH is validated for pressure injuries and has been applied in practice to venous and diabetic ulcers, though its formal validation is strongest in pressure injury. Its limitation is that it captures nothing about depth, undermining, tunneling, infection, or periwound status — a wound can improve its PUSH score while tunneling deepens. PUSH complements, but never replaces, the full assessment.
2. The Bates-Jensen Wound Assessment Tool (BWAT)
Originally published as the Pressure Sore Status Tool (PSST), the BWAT is the comprehensive alternative when a granular picture matters — in research, in complex non-healing wounds, and in medico-legal documentation.
- 13 scored items, each rated 1 (healthiest) to 5 (least healthy), plus location and shape, which are recorded but not scored.
- The 13 items: size, depth, edges, undermining, necrotic tissue type, necrotic tissue amount, exudate type, exudate amount, surrounding skin color, peripheral tissue edema, peripheral tissue induration, granulation tissue, and epithelialization.
- Total range: 13 to 65. A lower total indicates a healthier wound; 13 represents a fully healed wound.
- BWAT captures what PUSH omits — undermining, edges, and periwound status — but takes substantially longer, which is precisely why PUSH exists for routine weekly tracking.
3. Building the Re-Evaluation Picture
Objective 3.05 lists five inputs, and the exam expects you to use them together rather than in isolation:
- Weekly measurements — length, width, depth, undermining, and tunneling, measured the same way each time (see section 5.2).
- A validated instrument — PUSH for routine tracking, BWAT when granularity is required.
- Updated risk assessment tools — re-score the Braden (or Norton, Braden Q, or Braden QD as appropriate) whenever the patient's condition changes, not only on admission. A patient whose mobility subscale drops after surgery has a new risk profile that the original score no longer represents.
- Updated labs — repeat A1C, CRP, prealbumin, and CBC as clinically indicated (see section 2.6), interpreting protein markers against CRP.
- Treatment revision — the output. A wound failing to achieve roughly 40 to 50 percent area reduction by week four is unlikely to heal on the current plan and requires escalation, not patience.
4. Evaluating Adherence (Objective 3.04)
NAWCO words this objective as evaluate adherence to the treatment plan (barriers, reasons). The parenthetical is the whole assessment. Recording "patient noncompliant" is a conclusion, not an evaluation, and it closes off the only line of inquiry that could fix the problem.
The common barrier categories
| Barrier | How it presents | Corrective action |
|---|---|---|
| Cost | Supplies run out mid-cycle; patient rations dressings | Switch to a covered or longer-wear product; social work referral |
| Access and transport | Missed clinic appointments; no car, no bus route | Home health; telehealth review; consolidate visits |
| Physical capability | Cannot don a stocking, reach the wound, or open the package | Wrap system, donning aid, caregiver, long-handled mirror |
| Pain | Dressing left in place past the change date | Pre-medication, silicone contact layer, longer wear time |
| Comprehension and literacy | Steps performed out of order; product used incorrectly | Teach-back; plain-language written instructions with pictures |
| Off-loading burden | Removable boot found by the bed, not on the foot | Convert to an irremovable device (iTCC); see section 4.3 |
| Depression, substance use, cognition | Global disengagement from self-care | Behavioral health referral; simplify to the minimum viable plan |
| Belief and expectation | "It isn't working anyway"; conflicting advice from family | Show the trend data; renegotiate goals; involve the family |
How the exam frames it
A stem describing a patient who "has not been wearing the compression" is asking you to find out why, then modify the plan to remove that obstacle. Escalating the same unachievable plan, documenting noncompliance, or discharging the patient are all distractors. The therapeutic value of any intervention is the product of its efficacy and the probability that it is actually used — a modestly effective plan the patient can follow beats an optimal plan they cannot.
| Instrument | Items | Score Range | Direction | Time to Complete | Best Use |
|---|---|---|---|---|---|
| PUSH (v3.0) | 3 (area, exudate, tissue type) | 0 – 17 | Lower = healing; 0 = healed | ~2 minutes | Routine weekly trend tracking; named in blueprint objective 3.05 |
| BWAT (formerly PSST) | 13 scored (+ location and shape unscored) | 13 – 65 | Lower = healthier; 13 = healed | 10–15 minutes | Complex wounds, research, medico-legal documentation |
| Percent area reduction | Serial area measurement | Percentage | ≥40–50% by week 4 predicts closure | ~1 minute | Deciding whether to escalate at the 4-week checkpoint |
| PUSH Tissue Subscore | Value | Memory Anchor |
|---|---|---|
| Closed / resurfaced | 0 | Best possible |
| Epithelial tissue | 1 | New pink shiny margin advance |
| Granulation tissue | 2 | Beefy red, moist, granular |
| Slough | 3 | Yellow or white, stringy |
| Necrotic tissue / eschar | 4 | Black or brown — necrosis outranks everything else present |
A sacral pressure injury measures 3.0 cm by 2.0 cm, produces moderate exudate, and has a wound bed that is predominantly granulation tissue with no slough or eschar. What is the total PUSH score?
A wound has a small area of black adherent eschar at one edge, but roughly 80 percent of the wound bed is healthy granulation tissue. How should the PUSH tissue subscore be recorded?
A patient with a venous leg ulcer has an unchanged PUSH score across four weekly visits. On questioning, he reveals that he removes the compression wrap every evening because it makes his calf ache and he cannot sleep. What is the most appropriate next step?