How to categorise a pressure ulcer

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Pressure ulcers have been termed as Grade, Stage, superficial and deep and category. There isn’t really a law as to what you should call it. However, the updated guideline recommendations from NHS improvement following a consensus from tissue viability nurse panel was to formalise the term as category. This is due to be implemented by April 2019. I personally prefer grade for some reason, I'm not sure why apart from the fact this is the term I have used longest. 

That being said, it can still be difficult for nurses and carers to know WHICH category they're looking at in long term care.

A category 4 pressure ulcer may be pretty obvious with exposed muscle, tendon or bone, but people often get mixed between category 2 and 3, and category 2 and moisture lesions. A category 2 pressure ulcer and moisture lesion require separate care pathway, it gets confusing when your resident has both. These are know as ‘combination lesion’ ‘mixed aetiology’ lesion or incontinence associated dermatitis (MASD).

With suspected deep tissue injury (STDI) and ungradable being treated as would a category 3 or 4, nursing and residential homes do not yet report these to CQC. I imagine this will change as in the NHS these will be reported as potential serious incidences and require a root cause analysis to establish cause. It is therefore important that care providers understand that a reported ungradable or STDI in long term care receives the same planning as a category 3 or 4 pressure ulcer.


See below the breakdown of categories from the EPUAP Scottish guidelines:

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Remember blanching erythema, although not a pressure ulcer, can indicate the beginning of a pressure ulcer, so it’s important to check the skin regularly. If your resident has capacity, show them how to check the areas they can see and be skin self care champions. Always ‘React to Red’ as urgent. If you identify the cause of the pressure or shear then you will be able to act on this and possibly prevent deterioration. Always ask someone if you’re not sure. The researchers talk about a ‘window of prevention’ at approx 20 minutes before tissue hypoxia will lead to pressure damage. This depends on the underlying status of the resident but it does highlight that waiting days for advice may be too late. Utilise the SSKIN principles ASAP to be a key preventer.

If you would like more information on the above or need clinical advice feel free to contact me here at OSKA™.