Pressure Ulcer Risk Assessment
Pressure Ulcer’s
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
Ÿ 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 …show more content…
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 …show more content…
Repositioning should take into consideration other aspects of an individual’s condition – for example, medical condition, comfort, overall plan of care and support surface. Positioning of patients should ensure that: prolonged pressure on bony prominences is minimized. Manual handling devices should be used correctly in order to minimize shear and friction damage.
Seating assessments for aids and equipment should be carried out by trained assessors who have the acquired specific knowledge and expertise (for example, physiotherapists/occupational therapists).
Nutritional screening is part of the general evaluation of patients with pressure ulcers.
In patients who are malnourished, dietary consultation is recommended and a swallowing evaluation should be considered. Intervention should include encouraging adequate dietary intake. High-calorie foods and supplements should be used to prevent malnutrition. If oral dietary intake is inadequate or impractical, enteral or parenteral feeding should be considered. Supplements should be considered if intake is insufficient and deficiency is present.
A multi-disciplinary approach to the training and education of health care professionals should be
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
Ÿ 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 …show more content…
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 …show more content…
Repositioning should take into consideration other aspects of an individual’s condition – for example, medical condition, comfort, overall plan of care and support surface. Positioning of patients should ensure that: prolonged pressure on bony prominences is minimized. Manual handling devices should be used correctly in order to minimize shear and friction damage.
Seating assessments for aids and equipment should be carried out by trained assessors who have the acquired specific knowledge and expertise (for example, physiotherapists/occupational therapists).
Nutritional screening is part of the general evaluation of patients with pressure ulcers.
In patients who are malnourished, dietary consultation is recommended and a swallowing evaluation should be considered. Intervention should include encouraging adequate dietary intake. High-calorie foods and supplements should be used to prevent malnutrition. If oral dietary intake is inadequate or impractical, enteral or parenteral feeding should be considered. Supplements should be considered if intake is insufficient and deficiency is present.
A multi-disciplinary approach to the training and education of health care professionals should be