Grading and other tools

 Pressure Ulcer Grading resources

• Excoriation tool
• Pressure ulcer grading tool
• Pressure ulcer grade recording chart
• Assessment tool for darkly pigmented skin
• Scottish Wound Assessment and Action Guide (SWAAG)
• Scottish Wound Assessment and Action Guide (SWAGG) Quick Reference Guide
• General wound assessment chart
• Paediatric wound assessment chart

Best Practice Statement

• Best Practice Statement on the prevention and management of pressure ulcers
• Best Practice Statement audit tool
• Care Bundle

Prevalance resources

• Prevalence survey checklist
• Prevalence recording sheet
• Pressure ulcer pool form
• Prevalence count checklist

Grading

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 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 an 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.

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 developing.

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 implemented.

Prevalence

 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.