Grading and tools

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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 time.

Pressure ulcer grading resources

Best Practice Statement

Prevalance resources

Other tools

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 decide.
  • 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 Bundle).
  • 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 intended.
  • Remember prevention is the key.

Improvement

What’s the difference between pressure ulcers and tissue viability?

"Tissue viability is a growing speciality that primarily considers all aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers and all forms of leg ulceration." - (Tissue Viability Society 2009).

"Pressure ulcers are an injury that breaks down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They are sometimes known as 'bedsores' or 'pressure sores'." - (with thanks to NHS Choices).

Scottish Patient Safety Indicator

Scottish Patient Safety Programme logo

The Scottish Patient Safety Indicator (SPSI) was developed to help reduce the occurrence of specified harms, including pressure ulcers. Discover more on the Scottish Patient Safety Programme website.