Topic One: Documentation

Documentation aSSKINg Bundles, Care Pathways and Wound Care Assessment/Wound Care Plans are all part of the patient’s medical records. It is important to assess the patient regularly and to record any observations within these records. All pressure ulcers should be...

Topic One: Prevention of Device-Related Pressure Damage

Prevention of Device-Related Pressure Damage Regular assessment of the skin allows prompt detection of pressure-related injury. By identifying risks early, strategies to redistribute pressure can be implemented. Frequently inspect the skin beneath adjustable medical...

Topic Seven: Reassessment of Risk

Reassessment of Risk Reassessment of Risk and Reverse Grading Reverse grading should never be used to describe the healing of a pressure ulcer/injury. A Category 4 cannot become Category 3, Category 2, and/or Category 1. Healing of pressure ulcers should be documented...

Topic Six: Deep Tissue Injury

Deep Tissue Injury Deep Tissue Injury/Suspected Deep Tissue Injury A purple or maroon localised area of discolouration intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is...

Topic Five: Unstageable

Unstageable The EPUAP/NPIAP/PPPIA (2019) has added two new categories to describe previously upgradeable pressure ulcers. Unstageable Full-thickness loss in which actual depth is completely obscured by slough and/or eschar in the wound bed. Until enough slough and/or...