Assessment of pressure ulcers

The pressure ulcer assessment should be aimed at the following.
1. Selection of an established risk calculator that is suited to the individual patient.
2. All patients with impaired mobility should be considered at risk.
3. Risk assessments should be repeated at the appropriate intervals.
4. Factors that may delay healing when a pressure ulcer is already established should be taken into account.
5. Intrinsic and extrinsic factors should be accounted for (see info).
The use of a research based patient risk calculator will ensure systematic evaluation of the individuals risk factors. But this should not be used to replace clinical judgment. Once the overall assessment has been performed, the patients pressure ulcer should be graded.

 

 

Stage 0


No clinical evidence of a pressure ulcer Normal appearance intact skin Healed with scarring 
Tissue damage but not assessed as a pressure ulcer

Stage 1


Discolouration of intact skin:- 
Light finger pressure applied to the skin does not alter the discolouration 
Non blanchable erythema with increased local heat 
Blue/purple/black discolouration ulcer is at least stage 1

Stage 2


Partial thickness skin loss or damage involving epidermis and/or dermis Blister 
Abrasion  Shallow ulcer without undermining of adjacent tissue 
Any of these with underlying blue/purple/black discolouration. Ulcer is at least stage 2

Stage 3


Full thickness skin loss involving damage or necrosis of subcutaneous tissue but not extending to underlying bone, tendon or joint capsule. Full thickness skin loss but wound bed covered with necrotic tissue ( hard or leathery black/brown tissue or softer yellow/cream/grey slough) which masks the true extent of tissue damage. The ulcer  is at least stage 3 
Until debrided it is not possible to observe whether damage extends into muscle or involves damage to bone or supporting structures.

Stage 4


Full thickness skin loss with extensive destruction and tissue necrosis extending to underlying bone, tendon or joint capsule. Visual exposure of bone tendon or capsule 
Sinus assessed as extending to bone, tendon or capsule.