Risk assessment & Prevention
A pressure ulcer is defined as:
An area of localized damage to the skin and underlying tissue caused by pressure, Shear friction and/or a combination of these. EPUAP (2003) European Pressure Ulcer Advisory Panel. www.epuap.org.uk .
Classification of pressure ulcer severity: †EPUAP (2003) classification system
Grade 1: non-blanchable erythema of intact skin. Discoloration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin. Ÿ
Grade 2: partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister. Ÿ
Grade 3: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Ÿ
Grade 4: extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss.
The evidence-linked recommendations for identifying individuals ‘at risk’ includes aassessing an individual’s risk of developing pressure ulcers should involve both informal and formal assessment procedures, carried out by personnel who have undergone appropriate and adequate. It should be based on each individual case, recommended within six hours from admission. Reassessment should occur if there is a change in an individual’s condition. Assessments of risk should be documented /recorded and made accessible to all members of the multi-disciplinary team.
Development of pressure ulcers may be influenced by the following intrinsic risk factors which therefore should be considered when performing a risk assessment: (Reduced mobility or immobility; sensory impairment; illness & disease level of consciousness; previous history of pressure damage and malnutrition and dehydration). Extrinsic risk factors are involved in tissue damage and should be removed or...
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