The prevention and treatment of pressure ulcers

National Institute for Health and Clinical Excellence

Key priorities for implementation

The following recommendations are identified as priorities for implementation:

• Patients should receive an initial and ongoing risk assessment in the first episode of care (within 6 hours)
• The pressure ulcer grade should be recorded using the European Pressure Ulcer Advisory Panel Classification System (see below)
• Patients should receive an initial and ongoing pressure ulcer assessment. This should be supported by photography and/or tracings (ruler for calibration)
• All those who are vulnerable to pressure ulcers should as a minimum be placed on a high specification foam mattress
• For patients undergoing surgery, as a minimum provision a high specification foam theatre mattress or other pressure redistributing surface should be used
• All pressure ulcers graded 2 and above should be documented as a local clinical incident
• Patients with a grade 1–2 pressure ulcer should:
  • as a minimum provision be placed on a high specification foam mattress/cushion with pressure-reducing properties
  • be closely observed for skin changes
• Patients with a grade 3–4 pressure ulcer should as a minimum provision be placed on:
  • a high specification foam mattress with an alternating pressure overlay, or
  • a sophisticated continuous low pressure system (for example, low air loss, air flotation, viscous fluid)
• The optimum wound healing environment should be created by using modern dressings (for example, hydrocolloids, hydrogels, hydrofibres, foams, films, alginates, soft silicones)

European Pressure Ulcer Advisory Panel classification system of pressure ulcer grades

• Grade 1: non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin
• Grade 2: partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister
• Grade 3: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
• Grade 4: extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full thickness skin loss

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG29

National Institute for Health and Clinical Excellence. The prevention and treatment of pressure ulcers. Quick Reference Guide. April 2001