Assessment & Stages
High reliance on risk assessment tools alone does not substitute for clinical judgement. Along with an assessment tool it is required that a visual assessment and subsequent clinical judgement is made. This makes risk assessment much more reliable and individualised. It is important that clinical assessors undertaking pressure ulcer assessments are well educated in the use of risk assessment tools and also skin and tissue assessments. It is recommended that regular education sessions be undertaken to maintain a high level of professional ability to assess risk.
Risk Factor Assessment:
- Use a structured approach to risk assessment that is refined through the use of clinical judgement and informed by knowledge of relevant risk factors.
- There is no universally agreed best approach for conducting a risk assessment; however, expert consensus suggests that the approach be ‘structured’ in order to facilitate consideration of all relevant risk factors.
Risk Assessment Tools:
- Recognise additional risk factors and use clinical judgement when using a risk assessment tool.
- Caution: Do not rely on the results of a risk assessment tool alone when assessing an individual’s pressure ulcer risk.
- When using a risk assessment tool, select a tool that is appropriate to the population, is valid, and is reliable.
Skin and Tissue Assessment:
- Ensure that a complete skin assessment is part of the risk assessment screening policy in place in all health care settings.
- Educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localised heat, oedema, and induration.
Commonly Used Structured Risk Assessment Tools
Waterlow Pressure Injury Prevention & Treatment Policy:
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Norton scale assessment:
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Braden Scale Assessment:
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Stages of Pressure Ulcers
Stage 1: A persistent area of red skin that may itch or hurt, and feel warm and spongy, or firm to the touch. For people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage 1 wounds are superficial and go away soon after pressure is relieved.
Stage 2: At this point, some skin loss has already occurred – either in the epidermis, the outmost layer of skin; the dermis, the skin’s deeper layer; or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discolouration. If treated promptly, Stage 2 sores usually heal fairly quickly.
Stage 3: By the time a pressure ulcer reaches Stage 3, it has extended through all the skin layers down to the muscle, damaging or destroying the affected tissue and creating a deep, crater like-wound.
Stage 4: In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to the muscle, bone and even supporting structures such as tendons and joints. Stage 4 wounds are extremely difficult to heal and can lead to lethal infections.
Unstageable: Full thickness tissue loss in which the base of the injury is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ‘the body’s natural (biological) cover’ and should not be removed.
Suspected Deep Tissue Injury: Purple or maroon localised area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
In the next instalment of this series we'll look at Pressure Ulcer Strategy in Relation to Equipment Provision. Mattresses, cushions, heel protectors and range of beds. We also have available a Pressure Care Guide & Product Selection flip book for the best advice on what equipment to use in the prevention and treatment of pressure injuries. Request your copy.
For products to assist in pressure injury prevention and treatment please call Sharon Woodward on 0800 656 527. Please follow Cubro’s LinkedIn page for regular updates on this topic and other associated articles. Visit cubro.co.nz to view our product range.
