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
- 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
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
- A pressure ulcer grading tool acts as a method of
Healthcare Improvement Scotland
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Published Date: 05/05/2009