Pressure Ulcers

Question 1

What is the Waterlow Score?

Answer 1

It is a screening tool to see which patients are at risk of developing pressure areas.

Includes things like BMI, nutritional status, skin type, mobility and continence.

Question 2

What classification system is used to grade pressure ulcers?

Answer 2

The European Pressure Ulcer Advisory Panel classification system.

Question 3

Describe the grades of pressure ulcer according to the European Pressure Ulcer Advisory Panel classification system.

Answer 3

• Grade 1 - Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin
• Grade 2 - Partial thickness skin loss involving epidermis or dermis, or both. The
  ulcer is superficial and presents clinically as an abrasion or blister
• Grade 3 - Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
• Grade 4 -Extensive destruction, tissue necrosis, or damage to muscle, bone or
  supporting structures with or without full thickness skin loss

Question 4

How do you manage a pressure ulcer?

Answer 4

1. Hydrocolloid dressings & hydrogels to keep the wound moist to encourage healing.
2. Wound swabs are routine to exclude infection.
3. Tissue viability nurse
4. Surgical debridement in severe cases.