Pressure ulcer grading tool

 

Pressure ulcer grading and excoriation 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.
  • Accurately document your decision and what you plan to do to prevent the ulcer from getting worse and prevent further ulcers occurring.

Identify a pressure ulcer and rate its severity with this tool. Contains images and descriptions to help you grade.

Key Principles of pressure ulcer grading

  • Knowing how to grade a pressure ulcer accurately requires knowledge of the skin and its underlying anatomy. You must also 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.
  • 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.
  • A pressure ulcer grading tool acts as a method of communication.

Source

Healthcare Improvement Scotland

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Published Date: 05/05/2009