NWCSP Pressure Ulcer categorisation tool
When categorising a pressure ulcer, it is important to consider not just what you see but also what you feel, and what you know about anatomy. For example, understanding what the layers of the skin are, the location of bony prominences, and whether there is muscle or fat over the bony structure. These factors all contribute to our understanding regarding the depth of the tissues, and layers which might be implicated in damage. In particular, a good understanding of the skin is important. See Figures 1, 2 and 3.
The International Pressure Ulcer Guidelines (EPUAP, NPIAP, PPPIA 2019)1 recommend that inspection of the skin should include a visual assessment performed under good lighting conditions. This should be conducted in conjunction with other skin assessment techniques such as touch and palpation for differences in temperature and tissue consistency.
Relative skin temperature changes over areas of inflammation can present as warmer than surrounding skin and tissue. By contrast, tissue which is ischaemic may feel colder to touch than the surrounding tissue. The findings of skin and tissue assessment should be considered in the context of the individual’s overall presentation and pressure ulcer risk profile. The latter can be assessed using a structured, evidence-based risk assessment tool, for example PURPOSE-T.
When assessing patients with dark skin tones, additional consideration should be given to detecting the early signs of skin damage, which are often overlooked as erythema may not be clearly visible. Where visible signs of damage are diminished, more focus should be placed on temperature and tissue consistency, as well as patient reported pain or itching in relation to surrounding tissue (e.g., induration/hardness).
A good understanding of anatomy will help to understand what structures should be present beneath the skin e.g. subcutaneous fat, fascia, muscle, bone, cartilage, tendon, and this information should also inform the allocation of the correct category. See figure 2 for location of muscles, an example would be: there is no muscle over the calcaneus, there is just subcutaneous fat between the skin and the bone, therefore it is more likely that a deep pressure ulcer at this site will be a category 4…
Per scaricare il PDF –> NWCSP-Pressure-Ulcer-Categorisation-Tool-2024
[Tratto da: www.nationalwoundcarestrategy.net ]
