Grading and Prevalence tools
The pressure ulcer grading tool provides a consistent approach
to detecting different grades of pressure ulcer severity from a
Grade 1 (redness) through to a Grade 4 (extensive tissue damage).
The excoriation tool supplements this. When assessing damage to
darkly pigmented skin the relevant tool should be employed.
A number of prevalence tools can be found below. Whilst a
prevalence study is helpful, it is important to remember that this
provide a ‘snap-shot’ and will not tell the story of the data over
Pressure ulcer grading resources
Best Practice Statement
Grading Tool - how to use this tool well
- First of all recognise when a lesion is a pressure ulcer and
when it is not.
- Use both the grading and excoriation tools to help you
- Grading tools are diagnostic tools. Don’t use them as tools to
measure wound healing.
- Remember the key elements of assessing darkly pigmented skin
for pressure ulcers.
- Document the grade of pressure ulcer. The Scottish Adapted
EPUAP Grading Tool contains images and descriptions to help you
grade a pressure ulcer.
Key principles of pressure ulcer grading
- Knowing how to grade a pressure ulcer accurately requires
knowledge of the skin and its underlying anatomy. You should be
able to recognise different types of tissue and be able to
differentiate between healthy tissue and damaged tissue.
- Making a visual assessment of a lesion is the most common way
to defining whether or not it is a pressure ulcer. Our grading and
excoriation tools as well as discussion with colleagues can assist
your assessment. Nurse specialists in the field of Tissue Viability
and Dermatology are also excellent points of reference.
- Once a lesion is classified as a pressure ulcer, it is
important that the ulcer is assessed. You can determine its
severity by allocating an appropriate grade.
- Once a grade is allocated, you should formulate an appropriate
plan of care, allocate appropriate resources and implement the
plan. Such action(s) should prevent the ulcer from getting worse
and prevent further ulcers from developing. (See SSKIN Care
- In accordance with good practice, you should always document
your actions, and this information should be made accessible to all
staff involved in the care of an individual who has developed a
pressure ulcer, or who is at risk of doing so.
- You must evaluate all plans of care on a regular basis in order
to determine if the plan of care is working in the way that it is
- Remember prevention is the key.