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Statement of the European Pressure Ulcer Advisory Panel —pressure ulcer classification: differentiation between pressure ulcers and moisture lesions

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), pp. 302-306. (PMID:16234722).

Record type: Article

Abstract

Apressure 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 limitedto 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 becauseof 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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Published date: September 2005
Organisations: Faculty of Health Sciences

Identifiers

Local EPrints ID: 339745
URI: http://eprints.soton.ac.uk/id/eprint/339745
ISSN: 1071-5754
PURE UUID: 1645931d-ede1-424c-b1a7-030e1b2f73a8
ORCID for Lisette Schoonhoven: ORCID iD orcid.org/0000-0002-7129-3766

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Date deposited: 30 May 2012 10:25
Last modified: 11 Sep 2017 16:33

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Contributors

Author: T. Defloor
Author: J. Fletcher
Author: K. Furtado
Author: H. Heyman
Author: M. Lubbers
Author: A. Witherow
Author: S. Bale
Author: A. Bellingeri
Author: G. Cherry
Author: M. Clark
Author: D. Colin
Author: T. Dassen
Author: C. Dealey
Author: L. Gulasci
Author: J. Haalboom
Author: R. Halfens
Author: H. Hietanen
Author: C. Lindholm
Author: Z. Moore
Author: M. Romanelli
Author: J. Soriano
Editor: D. Doughty

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