Guideline Development Group commentary

The EPUAP is the classification tool of choice as it identifies not only the skin colour change of grade 1 pressure ulcers but also other physiological signs resulting from tissue damage that many other tools ignore – namely the changes in skin temperature and skin texture due to the inflammation process.

Many clinicians identify any redness as a grade 1 pressure ulcer. A level of redness is normal – for example following crossed legs where the lower leg has a red mark when the upper leg is removed. This is not the redness of a grade 1 pressure ulcer – and it is not hot to touch etc. The classification system is about what the skin/tissue looks like and is not related to patient group/environment/context – these items are part of pressure ulcer risk assessment tools.
Research recommendations
Well-designed, large-scale, prospective cohort studies, including those with pressure ulcers and including relevant identified risk factors, to show how the identified risk factors lead to more severe ulcers or delayed healing or complications.

From: 6, Evidence reviews with guideline recommendations

Cover of The Management of Pressure Ulcers in Primary and Secondary Care
The Management of Pressure Ulcers in Primary and Secondary Care: A Clinical Practice Guideline [Internet].
NICE Clinical Guidelines, No. 29.
Royal College of Nursing (UK).
London: Royal College of Nursing (UK); 2005 Sep 22.
Copyright © 2005, Royal College of Nursing.

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