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

By T. Defloor, Lisette Schoonhoven, J. Fletcher, K. Furtado, H. Heyman, M. Lubbers, A. Witherow, S. Bale, A. Bellingeri, G. Cherry, M. Clark, D. Colin, T. Dassen, C. Dealey, L. Gulasci, J. Haalboom, R. Halfens, H. Hietanen, C. Lindholm, Z. Moore, M. Romanelli and J. Soriano


Apressure ulcer is an area of localized damage to the<br/>skin and underlying tissue caused by pressure or shear<br/>and/or a combination of these.<br/>The identification of pressure damage is an essential<br/>and integral part of clinical practice and pressure ulcer<br/>research. Pressure ulcer classification is a method of determining<br/>the severity of a pressure ulcer and is also used<br/>to distinguish pressure ulcers from other skin lesions. A<br/>classification system describes a series of numbered<br/>grades or stages, each determining a different degree of<br/>tissue damage.<br/>The European Pressure Ulcer Advisory Panel (EPUAP)<br/>defined 4 different pressure ulcer grades (Table 1).1<br/>Nonblanchable erythema is a sign that pressure and<br/>shear are causing tissue damage and that preventive measures<br/>should be taken without delay to prevent the development<br/>of pressure ulcer lesions (Grade 2, 3, or 4).<br/>The diagnosis of the existence of a pressure ulcer is<br/>more difficult than one commonly assumes. There is often<br/>confusion between a pressure ulcer and a lesion that is<br/>caused by the presence of moisture, for example, because<br/>of incontinence of urine and/or feces. Differentiation between<br/>the two is clinically important, because prevention<br/>and treatment strategies differ largely and the consequences<br/>of the outcome for the patient are imminently<br/>important.<br/>This statement on pressure ulcer classification is limitedto the differentiation between pressure ulcers and<br/>moisture lesions. Obviously, there are numerous other lesions<br/>that might be misclassified as a pressure ulcer (eg, leg<br/>ulcer and diabetic foot). Experience has shown that becauseof their location, moisture lesions are the ones most<br/>often misclassified as pressure ulcers.2-3<br/>Wound-related characteristics (causes, location, shape,<br/>depth, edges, and color), along with patient-related characteristics,<br/>are helpful to differentiate between a pressure<br/>ulcer and a moisture lesio

Topics: RD, RT
Year: 2005
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Provided by: e-Prints Soton
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