Pressure Ulceration

• Skin assessment within 6 hours of admission - including under and around medical devices
• Risk assessment within 6 hours of admission
• SKINS pressure ulcer prevention care plan for patients identified as at risk - see preventative measures guidance on Tissue Viability intranet site if needed.

Category 1 - Red and unbroken skin that does not turn white when lightly pressed

N.B Pressure ulceration may be harder to visualise in patients with darker pigmented skin

Category 2 - Superficial ulceration or serous filled blister. *No slough/devitalised tissue or discolouration present

Category 3 - Full thickness skin loss, slough or devitalised tissue may be present

Category 4 - Full thickness skin loss & exposure of underlying structures

Suspected Deep Tissue Injury (SDTI) - Purple or maroon area of skin or blistered skin, with or without skin loss.

• Incident report upon identification
• Wound assessment and implement appropriate wound management care plan
• Review SKINS care plan and ensure appropriate measures in place - See preventative measures guidance on Tissue Viability intranet site
• Order equipment directly from rental company if required equipment not available
• Provide patient/carer education
• Escalate non-concordance to senior nursing or medical team