Defloor, T., Schoonhoven, Lisette, Fletcher, J., Furtado, K., Heyman, H., Lubbers, M., Witherow, A., Bale, S., Bellingeri, A., Cherry, G., Clark, M., Colin, D., Dassen, T., Dealey, C., Gulasci, L., Haalboom, J., Halfens, R., Hietanen, H., Lindholm, C., Moore, Z., Romanelli, M. and Soriano, J. , Doughty, D. (ed.) (2005) Statement of the European Pressure Ulcer Advisory Panel —pressure ulcer classification: differentiation between pressure ulcers and moisture lesions. Journal of Wound, Ostomy and Continence Nursing, 32 (5), 302-306. (PMID:16234722)
Abstract
A pressure ulcer is an area of localized damage to the skin and underlying tissue caused by pressure or shear and/or a combination of these.
The identification of pressure damage is an essential and integral part of clinical practice and pressure ulcer research. Pressure ulcer classification is a method of determining the severity of a pressure ulcer and is also used to distinguish pressure ulcers from other skin lesions. A classification system describes a series of numbered grades or stages, each determining a different degree of
tissue damage.
The European Pressure Ulcer Advisory Panel (EPUAP) defined 4 different pressure ulcer grades (Table 1).1 Nonblanchable erythema is a sign that pressure and shear are causing tissue damage and that preventive measures should be taken without delay to prevent the development of pressure ulcer lesions (Grade 2, 3, or 4).
The diagnosis of the existence of a pressure ulcer is more difficult than one commonly assumes. There is often confusion between a pressure ulcer and a lesion that is caused by the presence of moisture, for example, because of incontinence of urine and/or feces. Differentiation between the two is clinically important, because prevention and treatment strategies differ largely and the consequences of the outcome for the patient are imminently important.
This statement on pressure ulcer classification is limited to the differentiation between pressure ulcers and moisture lesions. Obviously, there are numerous other lesions that might be misclassified as a pressure ulcer (eg, leg ulcer and diabetic foot). Experience has shown that because of their location, moisture lesions are the ones most often misclassified as pressure ulcers. 2-3
Wound-related characteristics (causes, location, shape, depth, edges, and color), along with patient-related characteristics, are helpful to differentiate between a pressure ulcer and a moisture lesion.
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