Statement of the European Pressure Ulcer Advisory Panel-Pressure Ulcer Classification: differentiation between pressure ulcers and moisture lesions

Ghent University, Gand, Flanders, Belgium
Journal of WOCN (Impact Factor: 1.18). 09/2005; 32(5):302-6; discussion 306.
Source: PubMed


Apressure ulcer is an area of localized damage to the
skin and underlying tissue caused by pressure or shear
and/or a combination of these.
The identification of pressure damage is an essential
and integral part of clinical practice and pressure ulcer
research. Pressure ulcer classification is a method of determining
the severity of a pressure ulcer and is also used
to distinguish pressure ulcers from other skin lesions. A
classification system describes a series of numbered
grades or stages, each determining a different degree of
tissue damage.
The European Pressure Ulcer Advisory Panel (EPUAP)
defined 4 different pressure ulcer grades (Table 1).1
Nonblanchable erythema is a sign that pressure and
shear are causing tissue damage and that preventive measures
should be taken without delay to prevent the development
of pressure ulcer lesions (Grade 2, 3, or 4).
The diagnosis of the existence of a pressure ulcer is
more difficult than one commonly assumes. There is often
confusion between a pressure ulcer and a lesion that is
caused by the presence of moisture, for example, because
of incontinence of urine and/or feces. Differentiation between
the two is clinically important, because prevention
and treatment strategies differ largely and the consequences
of the outcome for the patient are imminently
important. This statement on pressure ulcer classification is limited
to the differentiation between pressure ulcers and
moisture lesions. Obviously, there are numerous other lesions
that might be misclassified as a pressure ulcer (eg, leg
ulcer and diabetic foot). Experience has shown that because
of their location, moisture lesions are the ones most
often misclassified as pressure ulcers.2-3 ...........

Download full-text


Available from: Ruud J G Halfens
  • Source
    • "Within this study subjects with catheters were regarded as continent (Halfens et al., 2012). Incontinence-associated dermatitis was diagnosed based on the guidance provided by the European Pressure Ulcer Advisory Panel for the differentiation between pressure ulcers and moisture lesions (Defloor et al., 2005). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Incontinent patients are at risk for incontinence-associated dermatitis. Prolonged exposures of the skin to urine and/or stool are causal factors but the exact aetiology and pathophysiology are not fully understood. Objectives The aim of the current investigation was to identify person and health-related variables most strongly associated with incontinence-associated dermatitis development. Design Secondary data analysis of a multicentre-prevalence study in 2012. Settings: Hospitals, nursing homes, home care in Austria and the Netherlands. Participants: Nursing home residents, hospital patients, home care clients who completed an incontinence assessment and who were incontinent (n = 3713). Mean age 81.2 (SD 11.2) years. Methods Demographic, functional and physiological parameters were compared between subjects with incontinence-associated dermatitis and without. A logistic regression model predicting incontinence-associated dermatitis was build. Results Subjects with incontinence-associated dermatitis were statistically significantly more often male, had more often Diabetes mellitus, had a higher BMI, were less often affected by urinary but more often by faecal incontinence and showed higher degrees of functional and psychical impairments. Being faecal incontinent (OR 1.70 95% CI 1.14 to 2.55), having Diabetes mellitus (OR 1.46 95% CI 1.03 to 2.06) and having “Friction and shear” problems (OR 0.65 95% CI 0.51 to 0.81) according to the Braden scale item were the strongest covariates for the presence of incontinence-associated dermatitis. Conclusions It is recommended to target special preventive skin care interventions especially to persons who are faecal incontinent and who have moist perineal skin, who have higher BMIs, who are diabetics, and who need increased assistance in moving.
    Full-text · Article · Oct 2014 · International journal of nursing studies
  • Source
    • "PU cause a great deal of discomfort for patients and increase the workload in all health care sectors; PU slow the rehabilitation process, delay hospital discharge, and furthermore increase costs considerably [2] [3]. PU is an area of localized damage to the skin and underlying tissue caused by pressure or shear and/or a combination of these [4] [5]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Pressure ulcers (PU) remain a major health care problem throughout the world. Although malnutrition is considered to be one of the intrinsic risk factors for PU, more evidence is needed to identify the exact relation between PU and malnutrition. This study aims to identify whether there exists a relationship between PU and malnutrition in hospitals and nursing homes. A cross-sectional study was performed in April 2007 in hospitals and nursing homes in Germany. PU were assessed using the Braden scale. Malnutrition was assessed by low body mass index (BMI), undesired weight loss, and insufficient nutritional intake. Two thousand three hundred ninety-three patients from 29 nursing homes and 4067 patients from 22 hospitals participated in the study. PU in both hospital and nursing home patients were significantly (P < 0.01) related to undesired weight loss (5%-10%). Moreover low nutritional intake and low BMI (<18.5) were also significantly related to PU in hospitals and nursing homes. There is a significant relationship between malnutrition parameters like undesired weight loss, BMI < 18.5, and low nutritional intake and PU.
    Full-text · Article · May 2010 · Nutrition

  • No preview · Article ·
Show more