Grading and other tools
Pressure Ulcer Grading
Best Practice Statement
While our improvement efforts should focus on pressure ulcer
prevention, sometimes a pressure ulcer will occur. It is important
that when a pressure ulcer develops, it is detected early in
order to avoid the ulcer getting worse, or another ulcer
developing. It is also useful to know why a pressure ulcer has
occurred and learn from what is found.
By working in partnership with our Tissue Viability Nurse
Specialists in Scotland, a pressure ulcer grading tool has been
developed. This 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
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 an pressure ulcer.
Key principles of pressure ulcer
- 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.
Best Practice Statement
The tissue viability programme built on the
work in the practice development unit at NHS QIS (Healthcare
Improvement Scotland since 1 April 2011). The unit had developed a
Best Practice Statement on the prevention and
management of pressure ulcers. This was updated as part of the
programme. As national tools were developed it was possible
to shift the thinking from the original emphasis on consistent
identification, grading, counting and treatment towards prevention.
In the course of the programme the care
bundle was developed. This addresses the key care actions
that must occur to reduce the risk of a pressure ulcer
The Best Practice Statement continues to
provide information on pressure ulcers and a reference list; in
identifying the key actions, the care bundle is more easily
The original brief of the programme
requested the development of tools to count pressure ulcers in an
area. As the approach of the programme has matured the emphasis on
improvement and reducing the incidence of prevent pressure ulcers
has become the focus. Like all assessment activities, a prevalence
study is of limited value unless accompanied by an action plan. In
the course of the programme it has become evident that improvement
is the consequence of a many actions. These have been tested in the
programme. They are summarised in the change
package which outlines all the activity necessary for a
sustained reduction in the incidence of pressure ulcers.