Glenn Smith Tissue Viability and Nutrition Clinical Nurse Specialist

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Presentation transcript:

Glenn Smith Tissue Viability and Nutrition Clinical Nurse Specialist Categorising pressure ulcers – taken from PUCLAS international consensus tool on pressure ulcer grading Glenn Smith Tissue Viability and Nutrition Clinical Nurse Specialist

Category 1 non blanching redness

Category 2 epidermal loss

Category 3 down to but not through fascia

Unstageable pressure ulcer

Suspected Deep Tissue Injury

Blanching erythema

Non blanching erythema (category 1)

Blanching erythema

Using a transparent disc

Different areas: grade 4 big toe

Knee: category 3

Hips: category 4

Hip – unstageable pressure ulcer

Hip – unstageable pressure ulcer

Ears: category 4

Child – unstageable ulcer

Back of head – category 3

Back - unstageable

Elbow - unstageable

Elbow - category 3

Ankle – category 3

Heels – deep tissue injuries

Heels Unstageable Deep Tissue Injury

Moisture lesions: anal cleft

Perianal redness

Lying on a catheter – yes it is a Medical Device related pressure ulcer

Diffuse spotting – not a pressure ulcer

Necrosis – unstageable

Necrotic progression- day 1

Necrotic progression – day 8

Necrotic progression – day 20

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