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Pressure Ulcer Prevention and Management Best Practice Guidelines Pressure Ulcer Prevention and Management Best Practice Guideline Document Type Clinical Guideline Unique Identifier CL-056 Document Purpose To increase awareness of the SHA ambition to eliminate avoidable pressure ulcers. To offer guidance to clinical staff in the prevention and management of pressure ulcers. Document Author Jackie Stephen-Haynes; Nurse in Tissue Viability Professor and Consultant Target Audience All clinical staff within Trust Responsible Group Clinical Policies Group Date Ratified 28th November 2012 Expiry Date 28th November 2015 The validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on 01905 760020 or email [email protected]. Pressure Ulcer Prevention and Management Best Practice Guideline Page 1 of 68 Version History Version Circulation Job Title of Person/Name of Date Group circulated to V1 30.6.12 Jackie Stephen-Haynes, Consultant Nurse in Tissue Viability Rosie Callaghan, Tissue Viability Nurse V2 31.7.12 Michelle Allen, Community Staff Nurse, Abbottswood Medical Centre Dani Atkinson, Community Staff Nurse, Abbottswood Medical Centre Carrie Banks, Community Staff Nurse, Albany House Surgery Judy Belcher, Tissue Viability Nurse, Acute Trust Carol Bennett, Community Staff Nurse, Riverside Surgery Andrea Carroll, District Nurse Team Leader, Hagley Surgery Amanda Cassell, Community Staff Nurse, Malvern Claire Clayton, Wound Care Nurse, Alexandra Hospital Lynn Cox, Practice Nurse, Churchfields Surgery, Bromsgrove Dee Davies, District Nurse Team Leader, Knightwick Surgery Sarah Degville, Practice Nurse, Riverside Surgery Nikki Farrell, Community Staff Nurse, Thorneloe Surgery Trisha Futers, Staff Nurse, Evesham Hospital Caroline Gaynor, Practice Nurse, Spa Medical Centre Alison Glover, District Nurse Team Leader, The Dow Surgery Linda Green, Community Staff Nurse, Church Street Surgery Kathryn Greenwood, Lead Nurse, Evesham Hospital Michelle Hill, Community Staff Nurse, Haresfield House Brief Summary Change of Review and update of existing Guidelines Appendices numbered and amended to ensure easy to follow Paediatric risk assessment added Ambassadors list updated Correction of title of Wound Management Formulary Prevention and treatment flow chart added Pressure Ulcer Prevention and Management Best Practice Guideline Page 2 of 68 Surgery Jane Hipwell, District Nurse Team Leader, Crossgates House Pippa Humble, District Nurse Team Leader, Winyates Jayne Humphries, District Nurse Team Leader, Cluster B, Redditch Mary James, District Nurse Team Leader, Elbury Moor Medical Centre Sue Jones, Community Staff Nurse, Shrubbery Avenue Charlotte Jordon, District Nurse Team Leader, Broadway Surgery Debbie Keelor, Sister, Malvern Community Hospital Mandy Lawrence, Staff Nurse, Bredon Ward, Evesham Hospital Ann Lofthouse, District Nurse Team Leader Team 19, Catshill Clinic Karen Mann, Staff Nurse, MIU, POWCH Claire Mason, Community Staff Nurse, Bewdley and Forest Glades Jola Merrick, Clinical Nurse Manager, Herons Nursing Home Denise Moore , District Nurse Team Leader, Ombersley Surgery Julie Money, Community Staff Nurse, Elbury Moor Medical Centre Deva Mooten, Staff Nurse, Clent Ward, POWCH Lorraine Newton, Community Staff Nurse, Stourport Health Centre Rachel Nichols, Community Staff Nurse, Haresfield House Surgery Elizabeth Nutland, Staff Nurse, Witley Ward, The Robertson Centre Rebecca O‟Sullivan, Staff Pressure Ulcer Prevention and Management Best Practice Guideline Page 3 of 68 Nurse, Malvern Community Hospital Claire Peacock, Staff Nurse, Tenbury Hospital Julie Reece, District Nurse Team Leader, Droitwich Geraldine Stanton, Nurse Advisor for Older People, Crossgates House Suzanne Tandler, Community Staff Nurse, Tenbury Gill Wills, Community Staff Nurse, Aylmer Lodge Sarah Winfield, Community Staff Nurse, Pershore Medical Centre Vicky Preece , Deputy Director of Nursing Carol Clive , Nurse Consultant in Infection Prevention and Control Jenny Stanford, Manager, Central Equipment Services Pauline Demel, Deputy Chief Pharmacist, WHCT Lesley Way, Patient Safety Manager Ruth Ward, Quality Manager Janet Austin, Clinical Manager Rachel Martin, Practice Development and Service Lead – Mental Health Maria Wilday, Community Hospital Matron Sue Lahiff, Community Hospital Matron Karen Young, Community Hospital Matron Linda Ingles, Community Hospital Matron Ginny Snape, Community Hospital Matron Ann Clapham , Lymphoedema Specialist Nurse Della Lewis, Clinical Governance Manager Stephanie Courts, Clinical Lead, Orchard Service Nicola George, Podiatry Joan Fisher, Podiatry Ann Bateman, Podiatry Pressure Ulcer Prevention and Management Best Practice Guideline Page 4 of 68 V3 29.10.12 V4 06.11.12 Sharon Robey, Podiatry Carole Roberson, Professional Practice Facilitator for District Nursing Chris Freke, Clinical Services Operational Lead Alison Double, Clinical Services Operational Lead Fiona McKellor, Dietician Clinical Policies Administrator Formatting, minor amendments and Appendices added Audit, Research and Clinical Section of Pressure Effectiveness Manager, Ulcers and Integrated Safeguarding Team Safeguarding added. Manager, Nurse Consultant, Prevention and Control of Infection, Patient Safety Manager, Training and development Manager, Accessibility Worcestershire Health and Care NHS Trust has a contract with Applied Language Solutions to handle all interpreting and translation needs. This service is available to all staff in the trust via a free-phone number (0800 084 2003). Interpreters and translators are available for over 150 languages. From this number staff can arrange: Face to face interpreting; Instant telephone interpreting; Document translation; and British Sign Language interpreting. Training and Development Worcestershire Health and Care NHS Trust recognises the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development. Pressure Ulcer Prevention and Management Best Practice Guideline Page 5 of 68 Content 1.0 Introduction 8 1.1 Aetiology of Pressure Ulcers 9 1.2 Patients included 10 1.3 Prevalence and impact 11 1.4 Competencies required 12 2.0 Aim and Purpose of Guideline 12 3.0 Risk Assessment 12 3.1 Paediatric risk assessment 13 3.2 Risk factors 13 3.3 Assessment and Re-assessment 14 4.0 Pressure Ulcers and Safeguarding 14 4.1 What is Neglect of Acts of Omission 14 4.2 Pressure Ulcer Safeguarding Triggers – Pathways 1 and 2 14 4.2.1 Pressure Ulcer Safeguarding Trigger – Pathway 1 15 4.2.2 Pressure Ulcer Safeguarding Trigger – Pathway 2 16 5.0 Skin Assessment 17 5.1 Individuals vulnerable to developing pressure ulcers 17 5.2 Skincare 17 6.0 Documentation (initial and on-going assessment) 18 7.0 Prevention of pressure damage 18 7.1 Positioning and re-positioning 18 7.2 Re-positioning and mobilising 19 7.3 Re-positioning the seated individual 20 7.4 Nutrition 21 8.0 Equipment Selection 22 8.1 Support surface characteristics 22 8.2 Allocation of support surfaces 22 8.3 Support surfaces for children 23 9.0 Management of existing pressure damage 24 9.1 Assessment of pressure damage 24 9.2 Documentation 25 9.3 Treatment of pressure ulcers 25 9.4 Management of pain 26 9.5 Consent 27 10.0 Clinical Audit and Safety Thermometer 27 Pressure Ulcer Prevention and Management Best Practice Guideline Page 6 of 68 11.0 Pressure Ulcer Prevention and Management Algorithm 28 12.0 References 29 13.0 Links to National and Local Standards and Guidelines 32 Appendix 1 High Impact Actions Ambassador List 33 Appendix 2 Care Rounds 34 Appendix 3 Root Cause Analysis 36 Appendix 4 Waterlow Pressure Ulcer Risk Assessment Tool (Revised 2005) 39 Appendix 5 SSKIN Bundle/ Skin Assessment 42 Appendix 6 Wound Assessment Chart 44 Appendix 7 Equipment Selection Flow Chart 46 Appendix 8 Children’s Pressure Ulcer Risk Assessment Tool 50 Appendix 9 Bariatric Care: Pressure Ulcer Prevention 52 Appendix 10 Your Turn 57 Appendix 11 EPUAP Pressure Ulcer Classification System 59 Appendix 12 Additional Web-Site Links and Information Sources 65 Appendix 13 Pressure Ulcer Discharge/Transfer Information List 66 Pressure Ulcer Prevention and Management Best Practice Guideline Page 7 of 68 1.0 Introduction a. One of NHS Midlands and East's five ambitions is to "Eliminate avoidable grade 2, 3 and 4 pressure ulcers by December 2012." www.eoe.nhs.uk.This guideline reflects Ambition 1, the prevention and management of pressure ulcers. It is based on the NICE Clinical Guideline 29 “The Prevention and Treatment of Pressure Ulcers” (September 2005), the European Pressure Ulcer Advisory Panel (EPUAP 2009), the clinical benchmark outlined in „The Essence of Care‟ (DH 2001), and Department of Health Quality Initiatives (High Impact Actions – Skin Matters, DH 2009, Energising for Excellence (2010) and the Strategic Health Authority stop the pressure campaign aiming to eliminate avoidable pressure ulcers (www.stopthepressure.com). b. A large number of chronic wounds, including pressure ulcers, are preventable and this has been recognised in both Saving Lives: High Impact Interventions (Clean Safe Care 2007) and High Impact Actions for Nursing and Midwifery (National Institute for Innovation and Improvement 2009). c. A multi-professional approach is fundamental in the prevention and treatment of pressure ulcers (Rycroft-Malone 2001, NICE 2005 and EPUAP 2009). d. The NICE (2005) guideline for the prevention and treatment of pressure ulcers was developed to assist: All Healthcare Professionals who have direct contact with, and make decisions concerning the treatment of patients who are at risk of developing pressure ulcers and those with pressure ulcers within primary, secondary and specialist care; Service managers; Commissioners; Clinical governance and education leads; and Patients and carers. e. High Impact Action (HIA) “Champions” have been appointed: Jackie Stephen-Haynes for Worcestershire Health and Care NHS Trust and Rosie Callaghan for the nursing home sector within Worcestershire. Additionally 30 HIA “ambassadors” have been signed up to cascade awareness and training on the prevention of pressure ulcers. (The Ambassador list is included as Appendix 1.) f. It is the responsibility of Healthcare Practitioners (NMC 2008) to: Be familiar with new guidelines; Facilitate an integrated approach to the management of pressure ulcers across the hospital community interface; Ensure continuity of care between shifts and Healthcare Professionals; Ensure their local risk assessment tool incorporates the NICE risk factors; Access training on a regular basis; and Provide patient and carer information. g. Healthcare Professionals‟ responsibilities include the need to: Pressure Ulcer Prevention and Management Best Practice Guideline Page 8 of 68 Record pressure ulcer category using the adapted Midlands and East classification based upon the European Pressure Ulcer Advisory Panel Classification System (2009). Ensure all patients receive an initial and on-going risk assessment. Implement care rounds (see Appendix 2) to continually review care progress to detect improvement or deterioration. Recognise that all pressure ulcers of category 2, 3 and 4 are to be reported as a local clinical incident and categories 3 and 4 must be recorded as a serious incident and will require the completion of a root cause analysis (see Appendix 3). Recognise the importance of and act upon the outcome of risk assessment with preventative care. Understand the role and responsibilities during the requisition of equipment such as mattresses, cushions and the monitoring of their use in clinical practice. Understand the roles of the multidisciplinary team in preventing pressure ulcers. Understand the involvement of clinical experts such as the Tissue Viability Service as and when appropriate and be able to initiate such a referral. Recognise and support carers and relatives who play vital roles in the prevention and management of pressure ulcers. Maintain accurate records. Participate in audit including safety thermometer. h. NICE guidance does not override individual responsibility or accountability of Healthcare Professionals to make decisions appropriate to the needs of the individual patient. i. A structured approach to risk assessment, comprehensive skin assessment, clinical judgement, education programs and care protocols can reduce the incidence of pressure ulcers (EPUAP 2009). j. This guideline integrates eight main areas of care surrounding prevention and treatment: Aetiology; Risk Assessment; Skin Assessment; Management; Pain; Positioning; Support Surfaces; and Nutrition. 1.1 Aetiology of Pressure Ulcers a. “A Pressure Ulcer can be defined as localised damage to the skin caused by a disruption of the blood supply to the area, usually caused by pressure, shear or compress force, or a combination of these.” (European Pressure Ulcer Prevention and Management Best Practice Guideline Page 9 of 68 Pressure Ulcer Advisory Panel EPUAP 2009). They can also be caused by a combination of intrinsic and extrinsic factors to the patient (Defloor & Grypdonck 1999). Pressure ulcers can occur on any area of the body, but mainly occur over bony prominences such as: sacrum, heels, hips, shoulders and elbows (NICE 2005). Tissue damage may involve skin, subcutaneous tissue, deep fascia, muscle and bone (Bridel 1993). Pressure is considered to be the major causative factor causing occlusion of blood flow to the network of vascular and lymph vessels supplying oxygen and nutrients to the tissues (Maklebust 1987). This can lead to tissue ischemia and re-perfusion injury leading to cell destruction and tissue death (Maklebust 1987, Braden and Bergstorm 1987 and Bridel 1993). Several factors play a role in determining whether the pressure is sufficient to create an ulcer: intensity of the pressure, the duration of exposure and the ability of tissue to tolerate pressure (Braden & Bergstorm 1987) which should be considered and assessed for each patient on an individual basis. b. There is a clear link between incontinence and the formation of pressure ulceration, it is therefore also important to differentiate between pressure ulceration and the formation of a moisture lesion (Beldon 2008). c. A moisture lesion is defined as prolonged exposure of the skin to excessive fluid because of urinary incontinence or faecal incontinence, perfuse sweating or wound exudate (Maklebust and Sieggreen 1995). The key to the difference between pressure and moisture lesions lies in the location, shape and depth of the damage (Evans and StephenHaynes 2007). d. The causes of pressure ulcers are: Pressure – normal body weight can squeeze the skin and underlying tissues in people at risk diminishing the blood supply to the area, which can lead to tissue damage. Shearing – strain forces the skin and upper layers away from deeper layers of skin, leading to a distortion in the blood supply and subsequent cell death. This can happen when people slide down or are dragged up a bed or chair. Friction – Inappropriate manual handling methods can remove the top layers (epidermis and dermis) of the skin resulting in superficial tissue loss. Repeated friction can increase the risk of pressure ulcers. Moisture – there is debate questioning if moisture precipitates pressure ulcer development by exacerbating the effect of friction, and whether the damage seen is true pressure damage or moisture related trauma (Butcher 2005) in clinical practice this is a significant factor to consider (Cooper and Gray 2001). e. The common sites of pressure ulcers are outlined in Figure 1 below. 1.2 Patients included a. This guideline outlines recommendations in both preventing and managing pressure damage. The guideline applies to all patient groups including adults, young people and Children. This guideline is to be used by all staff employed by the Worcestershire Health and Care NHS Trust engaged in the prevention and management of pressure damage. Its use is also to be promoted and encouraged within the Worcestershire Nursing Home sector. Pressure Ulcer Prevention and Management Best Practice Guideline Page 10 of 68 Figure 1 Common sites of pressure ulcers 1.3 Prevalence and impact a. Patient safety has become an increasing concern and the National Patient Safety Agency aims to lead and contribute to safe patient care by informing, supporting and influencing organisations and people working in the health sector (National Patient Safety Agency 2012). b. Pressure ulcers currently represent a significant problem in both acute and primary health care settings with approximately 412,000 people in the UK developing a pressure ulcer annually (Bennett et al 2004), the majority considered as being preventable (Hibbs 1998 and Bennett et al 2004). The true extent of pressure damage is unknown nationally but it is estimated that pressure ulcers affect approximately 10% of the UK population (DH 1992 and Clark and Cullum 1993). Dealey (1994) found that 62.9% of patients with pressure ulcers were over 65 years of age, which supports the findings of Callaghan (2009) reporting a 7.9% incidence in Care Homes (Nursing). c. The cost of treating pressure ulcers is estimated in the region of £1.4 £2.1 billion annually, equating to £60 per second, equivalent to 4% of total NHS expenditure (Bennett et al 2006) and excludes litigation costs. The financial cost of a single category 4 pressure ulcer in the UK has been estimated between £40 - £50.000 (Franks and Posnett 2008). More importantly pressure ulcers can be very detrimental to patients in terms of physical, psychological and social issues, resulting in reduction of quality of life and maybe mortality (Fox 2002). For the Department of Health Pressure ulcer productivity calculator see. www.dh.gov.uk/en/Publicationsandstatistics/.../DH_116669 Pressure Ulcer Prevention and Management Best Practice Guideline Page 11 of 68 1.4 Competencies required a. Registered health care professionals MUST demonstrate theoretical underpinning and practical competence in pressure ulcer prevention and management. b. Educational programmes, incorporating internal courses are available to all staff groups and forms a major part of the individuals overall professional development. Each course contains core competencies which will be approved (signed off) and it is the responsibility of the individual to ensure no task is undertaken outside of completed competency. 2.0 Aim and Purpose of Guideline a. The aim of of this guideline is to improve and maintain quality care and provide educational support enabling clinicians to work through best practice principles of care systematically and implement them into their clinical practice. b. The purpose being: The prevention of avoidable pressure ulcers; Effective management of pressure ulcers Worcestershire Health and Care NHS Trust; transferred into Maintenance of incidence and prevalence rates below estimated national average; and Implementation of best practice pressure ulcer prevention and management principles. 3.0 Risk assessment a. Assessment of risk is fundamental to pressure ulcer prevention and is acknowledged by (Waterlow 2005) and EPUAP (2009) who recognise a structured approach to risk assessment, comprehensive skin assessment and informed clinical judgement will reduce the incidence of avoidable pressure ulcers. Initial and on-going risk assessment is the responsibility of a registered healthcare professional using a combination of both clinical judgement and the Trust approved risk assessment tool. Risk assessment tools attempt to identify a patient‟s risk status by quantifying the most common risk factors affecting a patient at a given time (Edwards 1994). Individuals who are bedfast and/or chair fast should be considered to be at risk of pressure ulcer development. An individual‟s reduction in the ability to move and the frequency of movement are usually described as mobility limitations and will increase their level of risk. b. The recommended tool in Worcestershire Health and Care NHS Trust is the Revised (2005) Waterlow Tool (see Appendix 4). Waterlow risk assessment should be undertaken within 6 hours of the patient‟s first episode of care (NICE 2005) within the community hospital in patients‟ areas and on admission to the caseload in community. c. Frequency of re-assessments depends on the individual patient circumstances. However, the following information provides some guidance. Pressure Ulcer Prevention and Management Best Practice Guideline Page 12 of 68 Venue Community Community Hospitals independent care sector Action Patient‟s risk assessment will be assessed on admission to the caseload and then will be reassessed once a month or when their condition changes e.g. if the patient undergoes surgery or if they deteriorate. For those with very high risk a risk assessment should be undertaken weekly. If at risk, their pressure areas will be checked at every visit and the SSKIN bundle completed. For patients who are on the „inactive‟ caseload they will be reassessed at least once every six months. Patients who have been allocated pressure reducing equipment must be on either the „active‟ or „inactive‟ caseload. and Patient‟s risk assessment will be assessed within 6 hours of admission and then re-assessed every week and their pressure areas inspected daily using the SSKIN bundle to monitor skin integrity. d. These assessments will be documented in the nursing care plan and on the Waterlow Risk Assessment Score (see Appendix 4). e. Nursing staff will use the SSKIN bundle (encompassing the Thompson chart) (see Appendix 5 and 6) for recording the visual appearance and condition of pressure areas. f. Nursing staff will use the Flowchart for Selecting Pressure Re-distributing Support Surfaces (mattresses, cushions, integrated bed systems) (see Appendix 7) as guidance to ensure patients receive appropriate pressure relieving and pressure reducing equipment. 3.1 Paediatric Risk Assessment Tool a. The recommended paediatric assessment tools has been selected by the WHCT paediatric team (see Appendix 8). Paediatric risk assessment may be undertaken on all children admitted onto the caseload and reassessed depending upon their circumstances, but at least 6 monthly or when their condition changes. Skin assessment will be undertaken at agreed intervals dependent on the identified risk and care plan. A reassessment should be undertaken if there is any change in the child or young person‟s condition. 3.2 Risk factors a. The development of pressure ulceration is dependent upon both extrinsic and intrinsic factors which affect tissue tolerance and potential skin breakdown (Braden and Bergstorm 1987). b. Areas for consideration are: General health status: acute, chronic, surgery and terminal illness; Co-morbidities such as diabetes; Obesity or malnutrition; Extremes of age; Level of mobility; Body temperature; Posture, in particular orthopaedic conditions; Pressure Ulcer Prevention and Management Best Practice Guideline Page 13 of 68 Sensory impairment, loss of feeling; Level of consciousness; Continence status; Systemic signs of infection; Nutrition to include hydration status; Previous pressure damage – weak tissue; Excessive Pain; Psychological factors and cognition; Social factors; Pressure, Shearing and Friction; and Excess moisture exposure of the skin. 3.3 Assessment and Re-assessment a. Risk assessment should always be performed by healthcare professionals who have undergone training and are competent to calculate and interpret (act upon) the level of risk. Risk assessment should be repeated dependent on the patient‟s level of risk and comorbidities. Re-assessment should also be undertaken if there is any change in the patient‟s condition and both patients and carers should be fully aware of the level of risk (Nice 2005). 4.0 Pressure Ulcers and Safeguarding a. In some circumstances, skin damage resulting in pressure ulcers can be a sign of neglect either because of a deliberate act or an act of omission. b. This may be the case whether a pressure ulcer is deemed avoidable or unavoidable as the causes for the pressure damage can be varied. c. Therefore development of all pressure ulcers should have an initial consideration as to any elements of neglect. 4.1 What is Neglect or Acts of Omission? a. The withholding, either deliberately or unintentionally, of help or support necessary to carry out daily living tasks. This includes ignoring medical and physical care needs or failing to provide access to health, social or educational support, the withholding of medication, nutrition and heating. b. Neglect of an adult or child at risk is a safeguarding issue and such cases should be discussed with the safeguarding lead and appropriate referrals made in line with the Trust safeguarding policies for adults and children and young people. c. Where such referrals are made, the SI reporting and Root Cause Analysis must continue but will inform any safeguarding investigation. 4.2 Pressure Ulcers Safeguarding Triggers - Pathways 1 and 2 a. Pathways 1 and 2 below will help inform this process. Pressure Ulcer Prevention and Management Best Practice Guideline Page 14 of 68 4.2.1 Pressure Ulcers Safeguarding Triggers - Pathway 1 a. To determine if the identification of a pressure ulcer on an individual receiving professional support (in a care home, hospital or from domiciliary care of nursing services or agency care) should result in a safeguarding referral the following triggers should be considered. b. IF IN DOUBT: Initiate safeguarding procedures; Discuss with senior manager; and Record decision and reasons for decision. 1. What is the severity (grade) of the pressure ulcer? 2. Does the individual have mental capacity and have they been compliant with treatment? Possibly NOT Safeguarding at this stage Grade 2 pressure ulcer or below – care plan required Possibly Safeguarding Definitely Safeguarding Several grade 2 pressure ulcers/grade 3 to 4 pressure ulcersconsider question 2 Grade 4 and other issues of significant concern Has capacity and declined treatment Does not have capacity or capacity has not been assessed continue to question 3 Assessed as NOT having capacity and treatmet NOT provided Capacity assessment is recorded. Has a capacity assessment been completed? 3. Full assessment completed and care plan developed in a timely manner and care plan implemented? Documentation and equipment available to demonstrate full assessment completed, care plan developed and implemented. 4. This incident is part of a trend or pattern - there have been other similar incidents with this individual or others. Evidence suggests this is an isolated incident. NOT SAFEGUARDING Documentation and equipment NOT fully available to demonstrate full assessment completed, care plan developed or care plan implemented BUT general care regime (e.g. nutrition, hydration) not of concern - continue to question 4 Little or no documentation available to demonstrate a full assessment has been completed, or care plan implemented AND general care regime (e.g. nutrition, hydration) is of concern. There have been other Evidence similar incidents demonstrates this is a pattern or trend. If 2 or more of the above apply SAFEGUARDING Pressure Ulcer Prevention and Management Best Practice Guideline SAFEGUARDING Page 15 of 68 4.2.4 Pressure Ulcers Safeguarding Triggers - Pathway 2 a. To determine if the identification of a pressure ulcer on an individual with No professional support (i.e. the only support available is from an unpaid carer/ family member) should result in a safeguarding referral the following steps should be considered. b. IF IN DOUBT Initiate safeguarding procedures; Discuss with senior manager; and Record decision and reasons for decision. Possibly NOT Safeguardin g at this stage Possibly Safeguarding Definitely Safeguarding 1. What is the severity (grade) of the pressure ulcer? Grade 2 pressure ulcer or below – care plan required Several grade 2 pressure ulcers/ grade 3 to 4 pressure ulcers - consider question 2 Grade 4 and other issues of significant concern 3. Does the individual have mental capacity and have they been compliant with treatment? Has capacity declined treatment Does not have capacity or capacity has not been assessed - continue to question 3 Assessed as NOT having capacity and treatment NOT provided Evidence NOT CLEAR that concerns were raised or support sought in a timely manner. Evidence of partial cooperation or implementation of care plan - some aspects may have been declined e.g. certain equipment. There have been other similar incidents or other areas of concern No support sought If 2 or more of the above apply Safeguarding SAFEGUARDING Has a capacity assessment been completed? 3. Unpaid carer raised concerns and sought support at an appropriate time. 4. Full assessment completed and care plan developed in a timely manner and care plan implemented? 5. This incident is part of a trend or pattern – there have been other similar incidents or other areas of concern and Capacity assessment is recorded. Evidence available to show concerns raised and support sought – e.g. from GP, DN, SW. Evidence available to show unpaid carer cooperated with assessment and has implemented care plan Evidence suggests that this is an isolated incident NOT SAFEGUARDING Pressure Ulcer Prevention and Management Best Practice Guideline NO cooperation and refusal to implement care plan and or purposeful neglect. Evidence demonstrates that this is a pattern or tend. Page 16 of 68 5.0 Skin assessment 5.1 Individuals Vulnerable to Pressure Ulcer Development a. Patients deemed at risk should have their skin assessed regularly with the frequency prescribed and titrated to vulnerability level and in response to any health condition change. On-going assessment is necessary to detect the early signs of pressure damage (EPUAP 2009). Individuals and carers should also be encouraged to inspect the skin and take responsibility for its condition (NICE 2005). b. The signs alerting damage presence include: persistent erythema (reddening); non-blanching hyperaemia (capillaries do not empty and refill); blisters (superficial); localised heat (warm to touch); localised oedema (swelling); Induration (hardness); and purplish/bluish localised areas in those with dark skin. c. Recognising reddened areas of the skin is a significant factor in identifying the earliest signs of pressure damage and is an indication that further action and preventative nursing care is required. Where appropriate, patients should be asked to identify areas of discomfort or pain as this may be a precursor to tissue breakdown. d. Visual skin assessment and additional details such as discomfort or pain should be documented to allow monitoring of the progress of the individual and to aid effective communication between professionals. Patients unable to feel pain due to sensory loss or unable to communicate their pain should be more frequently and closely observed for early signs of damage. Skin assessment is to be undertaken as part of the SSKIN Bundle (see Appendix 5). e. Additionally the skin should be observed for pressure damage created by devices (EPUAP 2009) such as continence care devices. 5.2 Skin care a. Reddened Skin: massage should never be undertaken in the presence of acute inflammation (reddening) due to the risk of increasing the existing damage to underlying blood vessels and potentially separating fragile skin layers. Washing of the area and cream applications should also be undertaken with care. b. Dry Skin: is less tolerant to tissue distortion (stretching) and is thus more vulnerable to breakdown (Allman et al 1995). Emollient should be applied, as available in the Wound Management Formulary to maintain the suppleness of the skin and reduce the risk of breaks/cracks forming. Barrier creams are also available when suppleness and a protective barrier is required. Skin should always be dried thoroughly after washing prior to application of products. c. Excessively Moist Skin: prolonged exposure to excessive moisture (urine, faeces, exudate or sweat) increases the risk of damage from maceration, friction and shear forces (Defloor 1999). Pressure Ulcer Prevention and Management Best Practice Guideline Page 17 of 68 d. Skin that is exposed to or at risk of exposure to excessive moisture should be protected with a barrier forming product as available in the Wound Management Formulary. e. Also refer to Skin Care Tools and Patient/Carer Information leaflets available from Jayne Allchurch on [email protected]. 6. Documentation (initial and on-going assessment) a. Record the risk assessment/paediatric risk assessment and skin assessment fully documenting all relevant factors and any additional information utilising the SSKIN Bundle (see Appendix 5). b. Re-assess patient‟s risk level and skin status on an on-going basis according to individual need and general condition change. This is dependent upon the general condition of the patient and reassessment may be required in as little time as 6 hours. The maximum agreed period before general re-assessment for those on the District Nurse/Paediatric caseload is every 6 months and therefore re-assessment may be up to a maximum of 6 months. 7. Prevention of Pressure Damage a. All patients considered „at risk‟ should have 24 hour access to pressure redistribution/relieving equipment and/or other strategies to relieve pressure such as tilt and turning regimes. 7.1 Positioning and Re-positioning a. Where possible, patients should be encouraged to stand, mobilise, be positioned and repositioned either with assistance, or independently every 2-6 hours to reduce the duration and magnitude of pressure over vulnerable areas of the body (Defloor 2000, Defloor 2001 and EPUAP 2009). The use of re-positioning must be based on the patient‟s risk category the individual‟s skin tolerance of the regime prescribed and take into consideration the support surface in use. b. Positioning on existing pressure ulcer damage or over bony prominences, particularly hips should always be avoided. Avoid turning the individual onto a body surface which remains reddened from a previous turn rota as this indicates the area has not yet recovered from the pressure loading and requires further respite from repeated loading. c. Seating time should always be restricted to less than 4 hours per session for those with intact skin and 2 hours with broken skin, with attention paid to heel and elbow positioning whilst seated. d. The patient needs to be informed of the reasons for re-positioning, their needs and the needs of their carers should also be taken into consideration. Record re-positioning (a re-positioning chart may be used). If the individual is not responding as expected to the re-positioning regime, re-consider the frequency and method of re-positioning and review the skin bundle (see Appendix 5) for a holistic care package. Pressure Ulcer Prevention and Management Best Practice Guideline Page 18 of 68 Figure 2 Semi-Fowler 30°position 30° 30° 30° 30° 30° Figure 3 Lateral 30° position 7.2 Re-positioning and Mobilising a. Re-positioning will contribute to the individual‟s comfort, dignity and functional ability and should be considered in all at risk individuals. b. Mobilising, positioning and re-positioning should be determined by: General health status; Location and category of existing pressure damage; Skin assessment; Acceptability to the patient; The needs of the carer; c. It is important to reposition the individual in such a way that pressure is relieved or redistributed whilst avoiding subjecting the skin to pressure and shear forces; d. When using transfer aids to reduce friction and shear take care to lift and not drag the individual while repositioning; and e. Caution should also be taken to avoid positioning the individual directly onto medical devices, such as tubes or drainage systems. f. Repositioning should be undertaken using the 30 degree Semi-Fowler position or the prone position and the 30 degree-tilted side-lying position (alternately right side, back, left side) if the individual can tolerate this position and her/his medical condition allows. See Figures 2 and 3 above. Any re-positioning should be recorded in the patient‟s documentation. A re-positioning/turning chart may be utilised. Passive movements should always be considered for patients with pressure ulcers who have compromised mobility. g. Advise the patient regarding repositioning, consult the equipment flow chart (see Appendix 7) and deploy the appropriate pressure relieving mattress within 24 hours. Ensure documentation reflects all pressure prevention actions and turning/tilting intervention whilst awaiting any equipment resource. h. If sitting in bed is unavoidable, head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx should Pressure Ulcer Prevention and Management Best Practice Guideline Page 19 of 68 be avoided. The maximum head-of-bed elevation should range from 55 to 80 degrees, sitting time should be limited by the individual‟s skin tolerance and medical status and direct seating position should not exceed 2 hours in a patient with existing damage. When using a profiling bed with the head of the bed elevated utilise the knee break to prevent shear and friction on the coccyx by preventing the patient from sliding down the bed. Pillows beneath the patient‟s arms may improve stability of position and prevent slouching. 7.3 Re-positioning the seated individual a. If a patient has any sign of pressure damage particularly to the sacrum, buttocks or Ischial tuberosity, sitting out time should always be restricted to 2 hours maximum (Defloor 2000). Preference should be given to sitting out at meal times to maximise nutritional support. Seating equipment should be appropriate to the needs of the patient and is in Equipment selection flow chart (see Appendix 7). For chair positioning see Figure 4 and Figure 5 below. b. Key aspects of re-positioning the seated individual: Position the individual so as to maintain his/her full range of activities; Select a posture that is acceptable for the individual and minimizes the pressures and shear exerted on the skin and soft tissues; Place the feet of the individual on a foot stool or foot rest when the feet do not reach the floor because if the feet do not rest on the floor, the body slides forward out of the chair. Caution should be taken to minimise the contact between the heels and foot stool as this can exacerbate the potential for heel pressure damage. Foot rest height should be adjusted to slightly flex the pelvis forward by positioning the thighs slightly lower than horizontally; and Limit the time an individual spends seated in a chair without pressure relief (Gebhardt and Bliss 1994). NICE recommend a maximum „sitting out‟ period of 2 hours if the patient has a pressure ulcer or 4 hours if the skin is intact. These times should always be monitored for individual patients and skin observed for changes and times adjusted accordingly. Figure 4: Sitting upright in an armchair with the feet on the ground Figure 5: Sitting back in an armchair with the lower legs on a rest Pressure Ulcer Prevention and Management Best Practice Guideline Page 20 of 68 c. Record repositioning regimes, specifying the frequency, position adopted and the evaluation of the outcome of the repositioning regime on the individuals skin condition. 7.4 Nutrition a. Nutritional status has been linked to a significant influence on the development of pressure ulceration (Mathus-Viligen 2001 and Clark et al 2004), although the relationship between nutrition and pressure ulcer prevention is unclear (EPUAP 2009). The nutritional status of every individual at risk of pressure ulcers in each health care setting should be screened and assessed. b. Where the Waterlow risk assessment indicates that malnutrition may be present, a Malnutrition Universal Screening Tool (MUST) (www.bapen.co.uk) should be completed and nutritional intervention should be considered (NICE 2006 Nutritional Guideline). c. The primary goal of nutritional intervention is to correct protein-energy malnutrition, ideally through oral feeding (EPUAP 2009). When considering any limitation on normal food and fluid intake, consideration should be given to the ease of access to food, social and functional issues as well as texture of the diet (EPUAP 2009). d. Nutritional supplements/fortified diet should be provided for patients who are unable to tolerate conventional meals or who have an identified deficiency. (Following Trust nutritional guidelines.) e. The success of nutritional intervention should be monitored and documented. f. Decisions about nutritional support should be based on: Assessing weight of individuals to observe for significant weight loss more than 5% in 30 days or 10% in 180 days; Nutritional assessment; Estimation of nutritional requirements compared with nutritional intake; The category of pressure ulcer. Grade 3-4 will be losing high volumes of protein and fluid (EPUAP 2009) this will require replacement; General health status; The appropriate feeding route and the individual‟s ability to eat independently; Patient preference Dietetic/expert input; and Monitoring and evaluation of nutritional outcome. g. The EPUAP recommends referring all individuals with a pressure ulcer to a dietician for early assessment of and intervention for nutritional problems. h. The EPUAP (2009) states that those with a nutritional risk and a pressure ulcer risk should be offered a minimum of 30-35 kcal per kg body weight per day, with 1.25-1.5 g/kg/day protein and 1ml of fluid intake per kcal per day (Mathus-Vliegen 2001, Sauerwein et al 2007 and Wolfe et al 2008). i. Bariatric patients require a dietician referral and review. Care advice related to pressure ulcer prevention/care in the bariatric patient can be seen in Appendix 9. Pressure Ulcer Prevention and Management Best Practice Guideline Page 21 of 68 8. Equipment selection a. This guideline uses the definitions of support surfaces from the NPUAP (2007) which states that a support surface is “a specialized device for pressure redistribution designed for management of tissue loads, microclimate, and/or other therapeutic functions e.g. any mattresses, integrated bed system, mattress replacement, overlay, or seat cushion, or seat cushion overlay”. Therefore health care professionals need to consider all surfaces that the patient may come into contact with e.g. mattresses, cushions, theatre tables, stretchers and chairs. Surfaces offer 3 different characteristics (NICE 2005). 8.1 Support surface characteristics Pressure redistributing Reduce magnitude and/or duration of pressure and shear Pressure redistributing Decrease peak interface pressures by increasing contact area Pressure relieving Effective removal of interface pressure by inflation/deflation of surface a. Surfaces work in two different ways: Continuous low pressure – aim to mould around the shape of the individual, re-distributing pressure over a greater surface area. These include standard foam, visco-elastic foam, air-flotation, air fluidised, low air loss, gel/fluid and combination products (NICE 2005). Alternating Pressure – mechanically vary the pressure beneath the individual by inflating and deflating alternate air-filled sacs. The depth of air cells, mechanical robustness, duration and sequence varies between manufacturers. 8.2 Allocation of support surfaces a. All support surfaces are allocated in Worcestershire Health and Care NHS Trust on the basis of risk assessment, level of mobility and classification of pressure ulceration (NICE 2005). See Equipment flow chart for guidance (see Appendix 7). b. Clinical judgement may override risk assessment but all health care professionals are accountable for their decision-making. Pressure relieving devices should be chosen on the basis of: Risk Assessment; Pressure ulcer assessment (if present); Mobility and ability to move independently; Location and cause of pressure ulcer development; Skin assessment; General health; Lifestyle and abilities; Pressure Ulcer Prevention and Management Best Practice Guideline Page 22 of 68 Critical care needs; Comfort and acceptability to the patient; Availability of carer/healthcare professional; Patient‟s weight; and Height of the bed in relation to bed rails. c. Specific advice is offered by NICE (2005): Patients with a category 1 pressure ulcer are at significant risk of it developing further (NICE 2005) and therefore staff who observe an area of new pressure damage should re-calculate the risk assessment, plan care accordingly and document the findings. Those with category 1 or 2 pressure damage should as minimum provision receive a high specification foam mattress with pressure relieving properties and should be closely observed for skin deterioration. Those with category 3 or 4 pressure ulcers should as a minimum requirement be nursed on an alternating pressure mattress (replacement or overlay) or sophisticated continuous low pressure such as low air loss, air fluidised or viscous fluid. This is as per the equipment flowchart (see Appendix 7). If receiving palliative care and suffering from nausea due to the mattress undulating they should be nursed on a replacement high specification foam mattress, a low air loss system or a Roho Sofflex (see Appendix 7). Patients with sacral or buttock pressure ulcers category 2 or above should not be sat out of bed for longer than a 2 hour period and when sitting out should sit on a high specification foam cushion as a minimum. If bed rails are required the alternating pressure overlay should be placed on a reduced depth foam mattress to maintain safety. Patients undergoing surgery require a high specification foam theatre mattress. Manufactures guidelines to upper and lower weight limits of all support surfaces used need to be considered. 8.3 Support surface for children a. NICE (2005) state that it is essential to ensure: Appropriate cell size of mattress as small children can sink into gaps created by deflated cells causing discomfort and reduced efficacy; Appropriate position of the pressure sensors within the mattress in relation to the child; and Monitoring the use of alternating pressure mattresses with a permanently inflated head in young children to avoid occipital damage. b. Pressure relieving devices should be changed as required in response to changes to the patient‟s level of risk, condition or needs. Pressure Ulcer Prevention and Management Best Practice Guideline Page 23 of 68 9. Management of existing pressure damage a. Patients and their carers should be made aware of the potential risk and/or complications of having a pressure ulcer as well as the NICE (2005) guideline and its recommendations. They should be referred to the information for the public (Nice 2005b) and the public website www.yourturn.org.uk. (See Appendix 10 Your Turn.) Treatment and care should take into account the patient‟s individual needs and preferences and carers and relatives should have the opportunity to be involved in discussions where appropriate. 9.1 Assessment of Pressure Damage a. All patients with pressure ulcers will have a holistic assessment, including environment, nutrition, assessment of the skin as a sensory organ and the patients‟ knowledge and understanding of their wound and general condition. The wound assessment will be documented on an appropriate wound assessment tool, within 24 hours of admission to a hospital setting and within one week of referral to primary care. A multidisciplinary approach is necessary for planning and implementing treatment options. b. Assessment of the individual includes: The individuals and families knowledge and goal of care; A complete health/medical and social history; A focused physical examination including factors that may affect healing (impaired perfusion, sensation or systemic infection); Vascular assessment including ABPI/pulse oximetry in extremity ulcers; Nutritional status; Pain assessment including cause, level, location and management interventions (Hollinworth 2005) using appropriate pain assessment tool available in the Wound Management Guideline; Psychological health, behaviour and cognition; Social and financial support systems; Functional capacity - particularly in regard to positioning, posture and the need for assistive equipment and personnel; The employment and adherence to pressure relieving manoeuvres; and The integrity of support surfaces. c. Assessment of the pressure ulcer includes: CAUSE; Site/location; Dimensions; EPUAP Categorisation (see Appendix 11); Pain; Exudate amount and type; Local signs of infection (EWMA 2005); Pressure Ulcer Prevention and Management Best Practice Guideline Page 24 of 68 Wound appearance/classification; Peri wound/Surrounding skin; Odour; Consider undermining, tracking, sinus or fistula; and Size - length, width and depth. e. This should then be used to plan interventions based upon the assessment and it is recommended to use BASE-LINE PHOTOGRAPHS. f. The documentation of the wound assessment should be supported by photography or tracing, calibrated with a ruler with all patients having their wound size assessed and documented (by centimetre measurement or photography) on initial assessment and as part of the re-assessment. This is to provide a baseline and to monitor improvement or deterioration. g. The pressure ulcer should be categorised according to the Midlands and East modified European Pressure Ulcer Advisory Panel 1 - 4 System. (EPUAP 2009) and should NEVER be reverse graded. (See Appendix 11.) 9.2 Documentation a. Assess the skin using the SSKIN Bundle (see Appendix 5) paying particular attention to reddened areas of skin to prevent any damage occurring. Pressure ulcers should be recorded on the wound management assessment tool. Care Rounds (see Appendix 2) should be undertaken and recorded 2 hourly within community hospital settings and at each district nurse visit. Category 2 should be documented and reported as a Trust clinical incident, and category 3 and 4 should be documented and reported as a serious incident. A root cause analysis will be undertaken to identify the cause and origin. (Appendix 3) All patients with category 2, 3 and 4 should be referred via E health to Tissue Viability Department. (See Appendix 12.) b. An initial and on-going assessment of the wound bed should be undertaken and documented on a Wound Assessment Chart. The assessment should be documented and the use of photography to capture and monitor progress. c. All patients with pressure ulcers will be re-assessed and documented at least weekly. Any alterations to the treatment regime will be discussed with the patient, Healthcare Professional and the rationale for this will be documented. This is to enable the monitoring of the appropriateness of current treatment and to respond to any changes as a result of the reassessment. d. A plan of treatment should be documented on a care plan and an evaluation form completed to monitor progress. 9.3 Treatment of pressure ulcers a. Choice of dressing, method of debridement and the optimum wound healing environment should be created by using modern dressings (NICE 2005). The use of topical agents or adjunct therapies should be based on the current assessment of the wound and Worcestershire NHS Wound Management Formulary: General skin assessment; Treatment objective; Pressure Ulcer Prevention and Management Best Practice Guideline Page 25 of 68 Characteristic of dressing/technique; Previous positive effect of dressing/techniques; Manufacturer‟s indications/contraindications for use; Risk of adverse events; and Patient preference. b. Patients and carers who are willing and able to should be taught how to re-distribute their own weight and utilise a mirror to view any areas difficult to see. c. Passive movements should be considered for patients with compromised mobility. d. Topical and oral anti-microbial therapy should be considered in the presence of systemic and/or local signs of infection. Topical antimicrobials are included in the Worcestershire NHS Wound Management Formulary. e. Referral for surgical/plastics opinion should be made based on the needs of the patient, their health status, their risk (anaesthetic and surgical intervention), previous pressure ulcer history, the assessment of psychosocial factors regarding the risk of recurrence, the failure of previous conservative treatment and positive effect of surgical techniques. f. All patients with pressure ulcers who are transferred to any other care setting will have their treatment regime communicated to the appropriate health care professional prior to discharge. (Transfer of Care Appendix 13). This can contribute to the continuity of patient care. g. Patients with pressure ulcers category 3 and 4 are to be referred to Tissue Viability for consideration of Negative Pressure Wound Therapy (NPWT). This will be supported in line with compliance/concordance to recommended treatment. 9.4 Management of pain a. All individuals should be assessed for pain related to pressure ulceration or its treatment and a number of preventative strategies utilised: Position the individual to avoid the pressure ulcer; Use lifts/transfers to minimise friction and/or shear when repositioning; Avoid posture that increases pressure; Minimise pressure ulcer pain by careful handling of the wound; Organise care so analgesia is provided before procedures; Allow “time out” during dressing change/procedure; Utilise dressings that will minimise pain and trauma; Utilise distracting techniques; Offer appropriate analgesia; or Referral of a patient with chronic pain related to pressure ulceration to the appropriate pain clinic for assessment and management. Pressure Ulcer Prevention and Management Best Practice Guideline Page 26 of 68 b. This should be carried out utilising the appropriate pain assessment tool for the client group involved. 9.5 Consent a. Patients have a fundamental legal and ethical entitlement to determine what happens to their bodies (Beauchamp and Childress 2001 and Edwards 1996). Valid consent to treatment is central to all forms of healthcare. Consent is a patient agreement for a health professional to provide care. Patients may indicate non-verbally (by turning over to expose the area of pressure damage), orally, or in writing. For consent to be valid the patient must be competent to take that decision, be fully informed of the action and its consequences, and not be under duress. b. Consent should be sought verbally and where possible in writing prior to sharp debridement of dead tissue and for photography to monitor progress of the wound (see Consent to Treatment Policy.) c. If a patient declines treatment or equipment recommended by the healthcare professional, that may be detrimental to the health and wellbeing of the patient, this should be documented in accordance with the consent policy. The aim of pressure ulcer assessment is to establish the severity of the pressure ulcer, assess for complications and develop a plan of care which is communicated to those involved in care. 10.0 Clinical Audit and Safety Thermometer a. Safety Thermometer is the point prevalence audit tool that senior clinical staff are required to complete monthly. The objectives of the Safety Thermometer are to measure, monitor and track 'harm free' care ensuring organisational accountability, system learning and triangulation of data, thereby raising the profile of the ambition. b. All patients with a category 2, 3 or 4 pressure ulcer will have this recorded as a clinical incident on incident reporting system. The Patient Safety Report on this is presented quarterly to the Quality and Safety Committee. This information will be analysed with the usage of equipment through central equipment services. This will include: Number of patients with pressure ulcers; Number of patients with pressure ulcers acquired within establishment; Number of patients admitted/admitted onto caseload with pressure ulcers; Number of patients on mattresses that met their clinical need; Categories of pressure damage; Treatment regimes; and Presence of documentation for risk, wound assessment, and treatment care plans. Pressure Ulcer Prevention and Management Best Practice Guideline Page 27 of 68 11.0 Pressure Ulcer Prevention and Management Algorithm Patient at risk of or presents with a pressure ulcer? Waterlow assessment, Holistic assessment and assessment of SSKIN Conducted by a competent healthcare professional and recorded every week in Community Hospital and every month on Community Nursing caseload for those at risk. Contributory risk factors/factors that delay healing or cause complications Skin Assessment and Ulcer assessment with tracings/photographs Health status (acute, chronic, terminal) Previous pressure ulcer history Co-morbidity Cognition Sensory impairment Conscious level Nutritional status If Bariatic refer to dietician Psycho-social factors Continence status Tissue perfusion Medication Access ulcer weekly and document Base line photo and refer to Tele-health ABPI in extremity ulcers Cause Site/location Dimensions of ulcer Category (E.P.U.AP) Tissue type Infection/inflamation Exudate (type, amount Odour) Undermining/tracking (sinus, fistula) Edge of wound Surrounding skin Pain Prevention/treatment plan should address all aspects of assessment Provide patient information Patient at risk of or who have pressure damage should be actively encouraged to mobilise, change position or be re-positioned frequently Relieve the Pressure Patients at risk of pressure damage should not sit for intervals greater than 4 hours (2 hours with pressure damage) Patient management should be multi-interventional and an inter-disciplinary team approach Patients at risk of/who have pressure damage have access to appropriate pressure redistributing support surfaces (mattresses and cushions) 24 hours a day Category 3 and 4 to be reported as SIs and RCA on all Category 3 and 4 Pressure Ulcer management options Surface Skin Keep moving Incontinence Nutritional Support Wound management Debridement Dressing Selection Adjunct therapy Evaluate impact of prevention/treatment intervention by regular re-assessment No improvement Improvement Pressure Ulcer Prevention and Management Best Practice Guideline Page 28 of 68 12.0 References Allman R, Goode P, Patrick M, Burst N, Bartolucci A. (1995) Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA.273 (11):865-70. Beauchamp, T.L & Childress, J.F. (2001) Principles of Biomedical Ethics, 5th ed. Oxford: Oxford University Press Beldon, P. 2008 Moisture lesions: the effect of urine and faeces on the skin. Wound Essentials. Vol 3, pp. 82-87 Bennett, G., Dealey, C. & Posnett, J. (2006) the cost of pressure ulcers in the UK. Age and Ageing. 33: 230-235. Braden, B & Bergstorm, N. (1987) a conceptual scheme for the study of the aetiology of pressure sores. Rehabilitation Nursing; 12: p8-16 Bradley, M. Cullum, N. Nelson, E. Petticrew, M. Sheldon, T. and Torgerson, D. ( 1999) Systematic reviews of wound care management: (2) Dressings and topical agents used in the healing of chronic wounds. Health Technology assessment. 3 (17) pt 2. Bridel, J. (1993) The aetiology of pressure sores. Journal of Woundcare. 2, 94) pp230-238 Butcher, M (2004) NICE Guidelines: Pressure ulcer risk assessment and preventiona review. World Wide Wounds Callaghan, R. (2009) Pressure ulcer prevalence in a UK PCT. EWMA poster. Helsinki. Clarke M Cullum N (1993) Matching the needs of pressure sore prevention with the supply of pressure relieving mattresses. Journal of Advanced Nursing. 17. 310-316 Clarke, M. Schols, J. Benati, G. (2004) Presure ulcers and Nutrition: a New European Guideline. Journal of Woundcare 13, (7) p267-272 Cooper, P. Gray, D. (2001) Comparison of two skin care regimes for incontinence. British Journal of Nursing, 10 (6 Supplement) S6, S8 S10. Dealey, C. (1994) Monitoring the pressure sore problem in a teaching hospital. Journal of Advanced Nursing . Oct;20(4):652-9 Defloor T. (1999)The risk of pressure sores: a conceptual scheme. J Clinical Nurs. Mar; 8(2):206-16. Defloor, T and Grypdonck, M. (1999) Sitting posture and the prevention of pressure ulcers. Applied Nursing Research. 12, 3 pp136-142 Defloor, T. (2000) Does turning patients really prevent pressure ulcers. PhD thesis, Ghent University, Ghent. Defloor, T. (2001) Manual repositioning of patients. Journal of Tissue Viability. 11, 3 p117 DoH First assessment (1999) Department of Health. London. Pressure Ulcer Prevention and Management Best Practice Guideline Page 29 of 68 DoH (1990) National Health Service and Community care act.DoH. HMSO. London. Department of Health (1992) the health of the nation. A strategy for health in England. HMSO. London Dept of health (2001) the essence of care, Patient focused benchmarking for health care practitioners. HMSO: Department of Health (2005) Consultation document. Arrangements for the provision of dressings, Incontinence appliances, stoma appliances, chemical reagents and other appliances to Primary and secondary care. Published 24th October 2005 Edwards, M. (1994) Rationale for the use of risk calculators in pressure sore prevention, and the evidence of the reliability and validity of published scales. Journal of Advanced Nursing. 20:p288-96 Edwards, S. (1996) Nursing Ethics. A principle Based Approach. Wiltshire: Macmillan EPUAP (2009) Pressure ulcer prevention guidelines. www.epuap.org EPUAP (2009) Pressure ulcer treatment guidelines. www.epuap.org EPUAP- NPUAP (2009) Quick version guide. OR www.npuap.org or www.epuap.org Evans, J. and Stephen-Haynes, J. (2007) Identification of superficial pressure ulcers. Journal of Wound Care. 16(2), pp. 54–6 EWMA (2006) Position document. Management of infection. London. MEP Ltd 2006. Topical management of infected grade 3 & 4 pressure ulcers. Moore, Z. & Romanelli, M. p11-13 Fox, C. (2002) living with a pressure ulcer: a descriptive study of patients‟ experiences. Wound Care. British Journal of Community Nursing. June Gebhardt K, Bliss MR. Preventing pressure sores in orthopaedic patients. Is prolonged chair nursing detrimental? J Tissue Viability 1994;4:51-4. Hibbs, P. (1988) Action against pressure sores. Nursing Times 84, 13 p 68-73 High Impact Intervention: Reducing the risk of infection in chronic wounds care bundle. 2007. Clean Safe Care [Online]. Available from: http://www.clean-safecare.nhs.uk/Documents/HII_-_Chronic_Wounds.pdf accessed on 02.04.11. [Accessed: 02 April 2011]. Hollinworth, H. (2005) Pain at wound dressing-related procedures: a template for assessment. World Wide Wounds. WWW.worldwidewounds.com Accessed 30th September 2005 Keelor, D. (2005) Paeditric risk assessment. Taken from original by S. Barnes of Leicester Royal Infirmary Children‟s Hospital (April 2004) Mathus-Vliegen (2001) nutritional status, Nutrition and pressure Uclers. Nutrition in Clinical practice. 16, p286-291 Maklebust, J. (1987) pressure ulcers, aetiology and prevention. Nurs Clin North America: 22(2) p359 -77 Pressure Ulcer Prevention and Management Best Practice Guideline Page 30 of 68 Maklebust J, Sieggreen M (1995) Pressure ulcer guidance for Prevention and Nursing Management. Pennsylvania, Springhouse Corporation Malnutrition Universal Screening Tool (MUST) Nutritional assessment tool (www.bapen.co.uk). Mathus-Vliegen E. (2001) Nutritional status, nutrition and pressure ulcers. Nutr Clin Practice. 16:286-91. Nice (2005) Pressure ulcers: the management of pressure ulcers in primary and secondary care.http://www.nice.org.uk and http://www.doh.gov.uk/ Quick reference guide: Summary of recommendations for health professionals www.NICE.org.uk/c G029Quickrefguide. or hard copies on 0870 1555 455 Nice (2005b) Patient information leaflet for pressure ulcer prevention and treatment. www.nice.org.uk/cg029publicinfo NICE (2006) Nutrition guidelines http://www.nice.org.uk and http://www.doh.gov.uk/ Nursing and Midwifery Council (2002) Code of Professional Conduct. London. NMC O‟Dea K (1993) Prevalence of pressure damage in hospital patients in the UK. Journal of Wound Care 2. 4. 221 – 225 National Pressure Ulcer Advisory Panel Support Surface Standards Initiative. Terms and Definitions Related to Support Surfaces. Washington, DC: National Pressure Ulcer Advisory Panel; 2007. National Patient Safety Agency (2010) NHS to adopt zero tolerance to pressure ulcers. (www.npsa.nhs.uk/nrls). Posnett, J.and Franks, P.J. (2008) the burden of chronic wounds in the UK. Nursing Times. Jan 22-28; 104(3):44-5. Preston, K. (1988) Positioning for comfort and pressure relief. The 30 degree alternative. care, science and practice. 6, 4 p 116-119 Sauerwein HP, Strack van Schijndel RJ. (2007) Perspective: How to evaluate studies on peri-operative nutrition? Considerations about the definition of optimal nutrition for patients and its key role in the comparison of the results of studies on nutritional intervention. Clin Nutr 2007 Feb; 26(1):154-8. Wolfe RR, Miller SL, Miller KB. (2008) Optimal protein intake in the elderly. Clinical Nutrition Oct; 27(5):675-84. Rycroft Malone, J. (2001) Pressure ulcer risk assessment and prevention recommendations. London: Royal College of Nursing. RCN. Waterlow, J. (1985) Pressure sores: a risk assessment card. Nursing Times 81 (48): p49-95 Waterlow, J. (2005) Pressure ulcer prevention manual. Revised. Taunton. www.judy-waterlow.co.uk Pressure Ulcer Prevention and Management Best Practice Guideline Page 31 of 68 13.0 Links to National and Local Standards and Guidelines NICE Pressure Ulcer Prevention 2005. NICE Diabetic Foot 2007. NICE Nutrition 2006. European Pressure Ulcer Advisory Panel 2009. National Pressure Ulcer Advisory Panel 2009. National Patient Safety Agency 2010. Clean Safe Care 2007. High Impact Actions 2009. Midlands and East Prevention of “Avoidable” Pressure Ulcers 2012. Midlands and East Safeguarding 2011. Wound Management Formulary. Wound Assessment and Management Guideline . Infection Prevention Policy. Consent to Treatment Policy. Nutritional guidelines. Record Keeping. Equipment Selection Flowchart. Safeguard Adults Policy. Pressure Ulcer Prevention and Management Best Practice Guideline Page 32 of 68 Appendix 1 HIA AMBASSADORS • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Alison Want, District Nurse Elbury Moor Annie Allsopp, Invacare Ann Lofthouse, District Nurse T/L Catshill Clinic Caroline Gaynor, Practice Nurse Spa Medical Cath Crook, Molnlycke Claire Stephens, Independent Consultant Dee Davies, District Nurse T/L Knightwick Surgery Dev Mooten, Clent Ward Gail Jackson, Team Lead Orchard Service Geraldine Stanton, District Nurse T/L Redditch Ian Siddall Smith, and Nephew Jane Gardener, DN Crabbs Cross Redditch Jane Hipwell, DN Team Manager, Crossgates House Jayne Collins, Team Leader Wyre Forest Child Development John Hannah, Urgo Julie Money, Elbury Moor Juliet Shaw ,District Nurse Stourport Health Centre Kathryn Greenwood, Lead Nurse, Evesham Hospital Kellie Eastlake, Hartmann Linda Green, Community Staff Nurse, Church Street Surgery Lisa Battersby, Smith and Nephew Lisa Taylor, Aspen Medical Europe Liz Nutland, Witley Ward, Mental Health Louise Morton, Honorary Contract TVN and ConvaTec Mandy Lawrence, Abbott Ward, Evesham Maria Wilday, Matron/Hospital Manager POWCH Mark Addy, Medi Mary James Elbury Moor Reuben Snaith 3M Rosie Callaghan, TVN Sarah Lahert, Sumed Sarah Winfield, Community Staff Nurse Pershore Sue Jones, Warndon Clinic Sally Pumfrey, Seating therapist , Central Equipment Services Pressure Ulcer Prevention and Management Best Practice Guideline Page 33 of 68 Appendix 2 Daily In-Patient Care Rounding Patients Name: NHS No: 00:0002:00 02:0104:00 04:0106:00 Date: 06:0108:00 08:0110:00 10:0112.00 Ward/ Address: 12:0114:0114:00 16:00 16:0118:00 18:0120:00 20:0122:00 22:0123.59 Comfort Safety Emotional Wellbeing Nutrition & Hydration Is there anything else that I can do for you? Time and Signature. Instructions for completion: Initial and comment in each box after each care round. This document does not replace the need for ongoing assessment and care planning. If the patient is not on the ward for the care round ensure you are aware of where the patient is and that the absence is acceptable, safe & appropriate. Please be sure to record specifically the patient‟s whereabouts clearly in the time slot box. Focus of Care: Comfort Safety Emotional Wellbeing Nutrition & Hydration Pressure Ulcer Prevention and Management Best Practice Guideline Page 34 of 68 Guidelines for use When completing the Care Round please consider the following areas; this is not an exhaustive or mandatory list and when completing a care round your observations and interactions must be guided by your knowledge of that patient & their needs, understanding that the intention of the care round is to improve the quality of patient care through observation & interaction. Comfort Safety Refer to SSKIN Tool for those with issues related to tissue viability Is the patient in any pain? Consider Environmental factors e.g. – too hot / cold / dark / bright / noisy Consider if the patient‟s clothing is suitable, appropriate, e.g. consider dignity Consider the patient‟s ability to access help or assistance Consider the patients position i.e. does the patient need to be moved? Communication: Is the patient able to articulate needs? Is the patient able to understand what you are asking? Are there sensory needs? Are hearing aids in place and functional? Are spectacles clean and being worn when needed? Other sensory aids? Does the patient need to go to the toilet? Does the patient need help to attend to other personal hygiene needs? Emotional Wellbeing Consider the risk of pressure ulcers / ability to move unassisted Can the patient access their call bell or help easily? To reduce falls – „think‟ footwear, glasses, lighting, hazards Does the patient use walking aids? Are these accessible / functioning / safe Have observations been carried out according to plan? Consider AWOL / Absconding risk Are medical devices functioning / well maintained / correctly positioned? Is the ward environment therapeutic? Is the patient vulnerable? Can the patient be identified / seen or their current whereabouts known? Nutrition & Hydration Is the patient showing signs of or expressing feelings of anxiety? Is the patient showing signs of or expressing feelings of distress? Ask the patient “are you okay / is there anything I can do for you?” Is the patient engaged in meaningful activity / occupation? Is there any indication the patient may have a problem with their mood or thoughts? Does the patient have access to an appropriate diet? Ask and check, include culture choice etc. Has an appropriate diet been taken since the last care round? Ask and check, include culture choice etc. Does the patient have easy access to fluids? Does the patient need assistance to choose meals or drinks? Does the patient require oral hygiene care? Are dentures in place? Pressure Ulcer Prevention and Management Best Practice Guideline Page 35 of 68 Appendix 3 ROOT CAUSE ANALYSIS FOR PRESSURE ULCERS Please complete all sections fully Name and designation of individual completing RCA PATIENT NAME Locality DOB Contact Number/ email Date of referral to the Team/Ward NHS NUMBER Date pressure(s) ulcer identified Where was patient from? Please name the residential or nursing home/ward/hospital Own Home Residential Home Nursing Home Hospital (Name) Other Does the patient have formal carers? Yes No Relevant medical history, including medication Site (e.g. Sacrum) Wound Size please stated 1. 2. 3. 4. 5. st Informal carers e.g. family? Yes Right Left No Ulcer category 1 2 3 4 st Right Please number sites Date of 1 Waterlow score when patient was admitted onto the caseload/Ward 1 Waterlow Score Where was it carried out? Date of most recent Waterlow Most recent Waterlow Score Where was it carried out? Pressure Ulcer Prevention and Management Best Practice Guidance Page 36 of 68 How often was the Waterlow score carried out before the incident was reported and by whom? Daily Alternate days every 72 hours weekly monthly other (give details) Person completing Waterlow How often is Waterlow score carried out now and by whom Daily Alternate days every 72 hours weekly Monthly other (give details) Person completing Waterlow SSKIN assessment S Skin Inspection Yes Yes Yes Yes Is a skin inspection now carried out at each visit? No No No No Yes Have any skin conditions been identified? Appropriate skin barrier used Appropriate skin care given? SSKIN bundle completed? No Frequency K Keep Moving Level of Mobility: Independent Assistance of : 1 Approximate daily length of time in bed 2 Bedbound Chair bound Approximate daily length of time in chair Advice given (e.g. Turning regime, pressure relief care) Patient‟s compliance to advice: Yes No I Incontinence Continent Moisture damage? Yes Elimination: Catheter No Incontinent of: urine faeces both Continence aids – describe N Nutrition and Hydration: MUST assessment completed and documented? Yes No Date: MUST score Advice given: Peg Feeding Yes No Has appropriate care plan been completed? Yes No Dietician referral Yes Review Date No Date: Patient Information Leaflet given: Yes No Please explain the causes of the pressure ulcer e.g. discharge planning, staff knowledge and training, communication, equipment, change in patient’s medical condition, end of life Pressure Ulcer Prevention and Management Best Practice Guidance Page 37 of 68 Lessons learnt Actions taken Patient outcome at time of RCA Transferred Stayed at home TVN to complete if involved with patient. Was the pressure ulcer: avoidable Died Other Team Leader /Manager to complete if no TVN involvement unavoidable Incident Form completed Date Completed STEIS Number Signature: Date Completed Print Name: Designation: Date: Pressure Ulcer Prevention and Management Best Practice Guidance Page 38 of 68 Appendix 4 Waterlow Pressure Ulcer Risk Assessment (2005) SKIN TYPE VISUAL BUILD / WEIGHT RISK AREAS FOR HEIGHT Average 0 Healthy BMI=20-24.9 Tissue Paper Dry Above average 1 Oedematous BMI= 25-29.9 Clammy (Temp) Obese 2 Discoloured BMI>30 Grade 1 Broken/Spots Below average 3 Grade 2-4 BMI<20 SEX AGE 0 1 1 1 1 Male Female 14 – 49 50 – 64 65 – 74 75 – 80 2 81+ 3 SPECIAL RISKS 1 2 1 2 3 4 5 TISSUE MALNUTRITION Terminal Cachexia Multiple organ failure Single organ failure Peripheral Vascular Disease Anaemia Smoking 8 8 5 5 2 1 BMI=wt (kg)/ Ht (m²) CONTINENCE MOBILITY MST Complete/ Catheterised Occasional Incont Cath/Incontinent of Faeces Double Incont. Fully 0 Restless/ Fidgety 1 Apathetic Restricted 2 Inert/Traction 3 Chairbound 0 1 2 3 4 5 Lost weight Yes go to B No go to C Unsure go to C and add score 2 B Weight loss score 0.5 – 5 kg 5 kg – 10 kg 10 kg – 15 kg >15 kg Unsure C Patient eating poorly or lack of 1 appetite 2 No 3 Yes 4 2 Nutrition score If > 2 refer 0 for nutrition 1 assessment /intervention NEUROLOGICAL DEFICIT Diabetes, C.V.A Motor / Sensory Paraplegia MAJOR SURGERY / TRAUMA 2 Orthopaedic/ Spinal On table > 2 hours On table > 6 hours Scores to be discounted after 48 hours if patient recovering Medication Cytotoxic High dose steroids Anti-inflamatory 4-6 5 5 8 Max of 4 10+ AT RISK 15+ AT HIGH RISK 20+ AT VERY HIGH RISK Pressure Ulcer Prevention and Management Best Practice Guidance Page 39 of 68 Patients name: Date of admission: Hospital No: SCORE: 10+ at risk SCORE: 15+ high risk SCORE: 20+ very high risk DATE: Date: 0 Total brought forward Nutrition Score If > 2 refer for nutrition assessment/intervention 1 SPECIAL RISKS 2 3 TISSUE MALNUTRITION BUILD/WEIGHT FOR HEIGHT Average BMI = 20-24.9 Above Average BMI = 25-29.9 Obese – BMI >30 Below Average BMI < 20 Terminal Cachexia BMI = Wt (Kg)/Ht (m)² Multiple organ failure CONTINENCE Single organ failure (Resp. Renal, Cardiac) Peripheral vascular Disease Anaemia (Hb < 8) Complete/catheterised 0 Urine incontinence 1 Faecal incontinence Doubly incontinent 2 3 5 2 1 NEUROLOGICAL DEFICIT Smoking Diabetes, MS, CVA SKIN TYPE (VISUAL AREA) 8 8 5 46 46 46 Healthy 0 Motor/sensory Tissue paper 1 Paraplegia (MAX 6) Dry 1 1 1 2 3 MAJOR SURGERY or TRAUMA Orthopaedic/spinal 5 On Table > 2 HR# 5 On Table > 6 HR# 8 Oedematous Clammy (raised temp) Discoloured Broken/spot MEDICATION Cytotoxics, 4 0 1 Anti-Inflammatory 4 Long term/High dose steroids 4 Apathetic 2 OVERALL TOTAL Restricted 3 4 MOBILITY Fully Restless/fidgety Bed bound eg Traction Chair bound eg Wheelchair 5 Is wound chart in use SEX/AGE Male Female 14-49 50-64 65-74 75-80 81+ Is pressure ulcer present If yes state grade 1 2 1 2 3 4 5 Nurse/assessors signature MALNUTRITION SCREENING TOOL (MUST) (Nutrition Vol.15, No.6 1999-Australia) A. Has patient lost weight recently? Yes Go to B No go to C Unsure go to C and score 2 2 B.Weight Loss 0.5-5Kg 5-10Kg 10-15 Kg >15Kg 1 2 3 4 Unsure C. Patient eating poorly Or lack of appetite ‘NO = 0; YES = 1 2 ACTION SIGN AND DATE WHEN INFORMATION GIVEN Assessment and treatment has been discussed with patient/carer Verbal information on positioning given Written information given Patient/carer understands equipment Comments on your decision re. Risk to patient Pressure Ulcer Prevention and Management Best Practice Guidance Page 40 of 68 Item Supplier Date referred Sign Date Sign received Pressure Ulcer Prevention and Management Best Practice Guidance Date Sign returned Page 41 of 68 Appendix 5 SSKIN Bundle/Skin Assessment Patient’s Name: Date of Birth: Waterlow Score: NHS Number: Date: Time: Mark each area of pressure damage with an ‘X’ on the body map and number and date each area of damage/pressure ulcer Common location of pressure ulcers 1. Back of head 2. Ears 3. Shoulders 4. Elbow 5. Lower Back 6. Sacrum 7. Ischial Tuberosities 8. Hips 9. Between knees 10. Malleolus 11. Heels Signs to look for: Red area Purplish/bluish area Area of discomfort/pain Cracks, Calluses Patient assessed – Skin intact Focus of Care Surface Skin Keep moving Incontinence Nutrition Comments ………………………………… Signs to feel for: Localised Oedema Blisters Shiny areas Dry patches Patient information: Skin Care Hard areas Warm areas Localised coolness if tissue death occurs Swollen skin over bony points Patient information: Pressure Ulcers Pressure Ulcer Prevention and Management Best Practice Guidance Page 42 of 68 Date Number of area of damage or pressure ulcer/s Signs or categorisation (EPUAP 2009) Action Pressure Ulcer Prevention and Management Best Practice Guidance Signature and designation Page 43 of 68 Appendix 6 Wound Assessment Chart Pressure Ulcer Prevention and Management Best Practice Guidance Page 44 of 68 Pressure Ulcer Prevention and Management Best Practice Guidance Page 45 of 68 Appendix 7 Equipment Selection Flow Chart Pressure Ulcer Prevention and Management Best Practice Guidance Page 46 of 68 Pressure Ulcer Prevention and Management Best Practice Guidance Page 47 of 68 Pressure Ulcer Prevention and Management Best Practice Guidance Page 48 of 68 Pressure Ulcer Prevention and Management Best Practice Guidance Page 49 of 68 Appendix 8 Children’s Pressure Ulcer Risk Assessment and Intervention plan (Developed by Stephen-Haynes and Courts) 1 2 3 Date Date Date Date Date score A B Category Weight based on Centile Nutrition Normal Overweight Underweight Normal •TPN •Enteral •Poor intake Assistance required to change position •NMB •IV C •Totally dependent to reposition •Repetitive movement •Shear/ friction Continent •Occasionally •Faecal Continence urinary incontinence appropriate incontinence or •Wears to age •wears nappies nappies (under 5) (Over 5 years) •Urinary incontinence Pain Free Intermittent pain Continual Pain •with movement pain/ •without discomfort movement Intact •Redness Deep or Skin •Superficial extensive •Broken area damage Intact Impaired Significant Sensation deficit Normal Mild asymmetry Severe Posture (e.g head asymmetry position) (e.g. Scoliosis) General issues: add 2 points for each of the following : • Radiotherapy • Chemotherapy • Steroid therapy • SATS monitor • Infusion line ( e. g S/C) • Temp over 38 degrees Mobility appropriate to age D E F G H I Mobile Any other problem that puts the child at risk please state: ............................................................................................. Pressure Ulcer Prevention and Management Best Practice Guidance Page 50 of 68 <8 Low risk 8 to < 14 medium risk > 14 high risk Please supply patient information leaflet: Pressure ulcers Skin care Use of Sorbaderm Potential Interventions Category Score 2 Score 3 A Weight Health Promotion Health Promotion Consider oedema Consider oedema Refer to dietician Refer to dietician B Nutrition Ensure tubing secured appropriately Ensure weight is monitored: weekly/ monthly C Activity Regular turning & re-positioning Ensure appropriate use of manual handling aids Ensure appropriate use of pressure reducing equipment including bed bases, mattresses, cushions and gel pads D Continence assessment Continence Ensure skin is kept clean and dry Ensure nappies have fluid retention crystals Regular nappy/pad changes Consider regular toileting programmes E Pain F Skin G Sensation H Posture G Other Pain assessment Consider the cause of pain Implement management strategies including distraction and medication Consider referral to appropriate specialist Skin assessment Keep skin clean and dry Appropriate use of barrier cream/ film/ moisturiser Use of Aderma/Parafricta Refer to Orchard service (CCN team) Patient information Sensation assessment Skin assessment Appropriate linen/ clothing/ set covers As in C Activity As in C Activity There are many interventions, these should be acted upon and recorded in the care plan Ensure tubing secured appropriately Ensure weight is monitored: weekly/monthly Seating assessment for the chair bound Regular turning & re-positioning Ensure appropriate use of manual handling aids Ensure appropriate use of pressure reducing equipment including bed bases, mattresses, cushions and gel pads Continence assessment Ensure skin is kept clean and dry, particularly after soiling Ensure nappies have fluid retention crystals Regular nappy/pad changes Consider regular toileting programmes Pain assessment Consider the cause of pain Implement management strategies including distraction and medication Consider referral to appropriate specialist Skin assessment Keep skin clean and dry Appropriate use of barrier cream/ film/ moisturiser Protect high risk areas with film Use of Aderma/Parafricta Patient information Refer to Tissue Viability Sensation assessment Skin assessment Appropriate linen /clothing/ set covers As in C Activity As in C Activity There are many interventions, these should be acted upon and recorded in the care plan Pressure Ulcer Prevention and Management Best Practice Guidance Page 51 of 68 Appendix 9 Bariatric Care: Pressure Ulcer Prevention. Introduction Bariatric patients have complex needs that require a multi-disciplinary approach throughout their journey. The bariatric population is increasing at an alarming rate, if the upward trend continues almost one third of the population are likely to be obese (BMI greater than 30) by 2010. This presents an organisational challenge to the National Health Service to deliver a safe dignified experience for the patient as well as safe systems of work for staff. Clinicians encountering bariatric patients should be aware of their special needs and maintaining skin integrity is one of the challenges that nurses will encounter, as bariatric patients are at increased risk of pressure ulcers due to skin physiology changes, resulting in poor wound healing. Krasner et al (2001) article highlights the need for advance wound management for bariatridc patients they identify that they not only are they at high risk for acute wounds, most notably non-healing surgical wounds due to dehiscence or infection, but the risk is higher risk for chronic wounds, such as pressure ulcers, venous ulcers, and diabetic foot wounds. Holistic assessment and the means to source appropriate intervention are other contributing factors that need to be addressed through education programs, as lack of knowledge poor staffing and unsafe handling techniques contribute to tissue damage. Risk Factors/Complications Obesity in itself places extra strain on the heart and lungs to distribute oxygen and nutrients around the body. Krasner et al (2006) identify that chronic impairment of the systemic perfusion frequently results in chronic skin and wound problems for bariatric patients. Personal hygiene (Picture 1) is problematic for most bariatric individuals as the majority of th em are unable to access the bath and a shower may not be available, Washing underneath the skin folds abdominal fold, and groin area, is a difficult task for bariatric patients since the weight of the folds is too heavy for the individual to lift and wash underneath. Individuals often suffer skin breakdown, rashes intertrigo and eczematous lesions resulting from perspiration, friction and lack of cleanliness. All of these require careful intervention to prevent bacterial or fungal growth. Profuse sweating is also experienced due to increased adipose tissue preventing heat loss and body mass area ratio. Picture 1 Wound healing is slower which is thought to be associated with decreased wound collagen deposition, which causes structural changes in adipose tissue (Pokorny 2008). It is not uncommon for bariatric patients to have pressure ulcers under the pannus ( Picture 2), in one particular case I dealt with the patients pannus touched the floor as they walked and as a consequence the lower pannus developed pressure ulcers which resulted in a hospital admission and ultimately an apronectomy because the pannus had become necrotic due to restricted blood supply. Pressure Ulcer Prevention and Management Best Practice Guidance Page 52 of 68 Picture 2 Gallagher (2006) identified that pressure ulcer development seriously related to bariatric patients immobility, patients had difficulty in repositioning themselves and nurses were reluctant to turn and reposition the patient, causing shearing damage and atypical pressure ulcers in the skin folds from tubes or catheters than have burrowed into the soft tissue. Skin often breaks down at the occiput due to the bull-head configuration of the head and neck (picture 3). The weight of the skin folds and skin to skin can create forces that enable pressure ulcers to develop in areas that are not considered to be high risk. Picture 3 In some cases inappropriate equipment provision is a contributory factor to pressure damage in unusual places patient hips, this is caused by inappropriate seating provision chair too narrow and bed rails due to bed width being too small. Solution Preventive measure for bariatric patients can be difficult for nurses to implement, and solutions should be implemented that meets the needs of the individual through management strategies that includes multi-disciplinary involvement, equipment provision that prevents or is part of the management of a pressure ulcer. At an Organisation level systems should be in place that minimise the risk of pressure damage occurring enabling nurses to deliver effective care. Solutions should be provided that enable effective equipment provision, education and resources as and when required with a named coordinator to implement when the patient presents within the acute or primary setting. Nurses should be vigilant, and undertake a holistic assessment that encompasses and identify all high risk breakdown areas for careful monitoring, including buttocks, heels, sacrum, occiput, skin fold area including skin to skin areas and thigh folds, and the health and safety aspects (risk assessment) reducing the risk of caregivers sustaining injury due to unsafe manual handling techniques. The assessment should also include the co-morbities of the patient and their effects on the patient to include pain thresholds; pain is known to interfere with patient‟s mobility, and nutritional needs. A dietitian should be an active member as they can assist on food choices during the catabolic process, if this need is met the bariatric patient is less likely to acquire pressure damage Mastrogiovanni (2003). Pressure Ulcer Prevention and Management Best Practice Guidance Page 53 of 68 Pressure Ulcer prevention is always one of the first goals of skin care and intervention will vary according to the patients mobility, When assisting or undertaking personal hygiene it is essential that the skin folds are kept clean and dry to minimise the amount of mo isture build up this might need to be undertaken several times a day, each time this task is undertaken a change of clothing might also be required. The use of harsh soap, alcohol based lotions and talc powders should be avoided at all cost if cream is required then a good moisturizing cream to lubricate the skin is the preferred option. Drying the skin under the folds is critical; leaving the skin underneath the folds wet encourages fungal and bacterial growth. In some circumstances, leaving a soft cloth between the skin folds would reduce friction and absorb moisture. In females wearing a bra might not be an option as it could further aggravate any skin problems. Another goal in preventing pressure damage and is a challenge in itself if the choosing and implementing of bariatric equipment. The right equipment can facilitate independence rather than dependence and although there is equipment off the shelves available the majority will be specialist equipment and require training on its use. Although the skeletal body stays the same the increased body tissue will require wider beds, and dynamic mattress, hoist that take have a higher weight capacity and slings that are wide enough with long legs to encompass the patient heavy legs to avoid skin tears on the legs when hoisting. Moving bariatric patients around the bed is a challenging task and will often take up to three or more persons, whilst doing this task it is important to miminise friction and shear when positioning the patient correctly Mastrogiovanni et al (2003). Bariatric patient can be positioned using different types of equipment sliding sheets being one option but nurses should be aware and trained in the use of sliding sheets ensuring that the right size is used as they come in several shapes and sizes, too big or too small will not work and increase the risk to staff. Hoist and slings are a further option overhead gantries being the preferred method of hoisting than a mobile hoist. The use of hoist of slings will reduce the number of nursing staff required and enable position changes that would reduce the risk of friction injuries to bariatric patients. Kirton (2007) identified that the positioning of patients using a repo sheet (Picture 4) reduces the risk further of the patient sustaining tissue damage and nursing staff sustaining injury. Picture 4 External pressure will cause capillary occlusion which decreases the oxygen to the available distal pressures Porkorny (2008). To minimise the risk of pressure damage the full functionalities of the bed should be used when a patient is in a seated position. Beds provided should support the weight of the patient be wide enough to enable independent or nursing staff movement and positioning within the bed and accessories that will not inflict harm on the patient through the bed being too narrow. To avoid shearing the bed should not be angled at more than 30º however if a bed cannot achieve a 30º angled pillows can be used for support which will reduce friction and shear, to reduce the effects of gravity the knee break (commonly known as gatching) this will also reduce the pressure on the heals, but this will increase abdominal pressure which could in turn inhibit the patients breathing. It is the increased body fat on the chest and intra-abdominal area that makes breathing more strenuous with poor oxygen intake and gas exchanges, and lead to the inability to lie down. Mattresses are a requisition to preventing tissue damage, but mattresses only will not prevent pressure ulcers, finding a mattress for bariatric patients is problematic and the width of the bed and weight of the patient could be a limiting factor. There are only two ways associated with pressure in which a support surface can operate in order to reduce the probability of developing a pressure ulcer. First there are static systems which including your static foam mattress or overlay mattress which seek to minimise the interface Pressure Ulcer Prevention and Management Best Practice Guidance Page 54 of 68 pressure by increasing the contact area. The second a dynamic system which produces an alternating action which subject the tissues of the body through periods of high pressure followed by periods of low pressure during which it is anticipated that the pressure is sufficiently low to enable blood flow to return. These mattresses are commonly seen both in the hospital and at home where they have a pump visible, (Swain 2004) “the difference lies in the measured ability of the support surface to lower interface pressure to below capillary closing levels”. Foam mattresses allow individuals more independence as they are able to assist with turning and getting in and out of bed. Dynamic mattresses can make individuals dependent as getting in and out of bed and moving around in bed is more difficult than with foam. The mattress needs to accommodate the patient‟s weight and to work in conjunction with the bed it is supplied with. The combination of bed, mattress, bed rails, bumpers and hoists must be a match. If the bed does not go low enough and the hoist high enough then the individual will not clear the bed to be transferred to another piece of equipment. Mismatch of equipment is common so careful consideration should be given to the types of equipment that are being used in conjunction with each other Most bariatric patients sleep in chairs because they cannot lie flat or ra ise their legs into bed. Therefore, in preference to a single motor a dual motor chair should be provided. This will enable the patient to change position. The chair also requires pressure-relieving properties so as to obviate the need for a cushion. Weight shifting is essential to avoid pressure damage whether the patient is in bed chair, or wheelchair. Bariatric persons find elimination difficult, due to their relative immobility and size. The size and safe working load of the toilet inhibit normal elimination when using a commode the width may inhibit the use of the bathroom, personal care tasks could be easier for pressure ulcer prevention by allow better access to the sacrum, but in some cases when the patient is self caring they may have problems with cleaning themselves after toileting which will increase their risk to tissue damage, to maintain skin integrity where possible the installation of a closimat toilet, would maintain skin integrity in that it would wash and dry the patient before they got up from the toilet. Conclusion Butler (2008) reviewing the Essence of Care the pressure ulcer benchmark discussed the financial cost of pressure ulcers to the NHS, the cost of healing a pressure ulcer for bariatric patients is increased due to the extended time span for the wound to heal, dressing provision, equipment provision, and the quality of life for the patient Educating staff on bariatric management is the key to eliminate the nursing staff fears of being injured whilst providing care to bariatric patients, it should be part of organisation education program empowering nurses to provide the high level of care that prevents tissue damage and reduce the inherent risks associated to handling bariatric patients. Pressure ulcer prevention is part of the holistic care management pathway for bariatric patients and to effectively manage skin integrity is a challenge for all nurses but we should be empowering our patients and their families to work in collaboration with a multi-disciplinary team to prevent pressure ulcers and achieve optimal outcomes References Butler F (2006) Essence of Care and the pressure ulcer benchmark – An evaluation Journal of Tissue Viability published by Elsevier Ltd. 17 pages 44-59 Gallagher Camden S (2006) Does Skin Care for the Obese Patient Require a Different Approach? Roundtable Discussion Bariatric Nursing and Surgical Patient care Vol 1 3 page 158 Kirton H (2007 Conference Presentation Tissue Viability and the Bariatric Patient sponsored by KCI Krasner D.L et al (2006) Bariatric Would Care: Common Problems and Management Strategies Bariatric Times - ISSN: 1044-7946 - Volume 03 - Issue 05 - June 2006 - Pages: 26 – 27 Pressure Ulcer Prevention and Management Best Practice Guidance Page 55 of 68 Krasner DL, Rodeheaver GT, Sibbald RG(eds). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition. Wayne, PA: HMP Communications, Inc., 2001:575�82. Mastrogiovanni D., Phillips E.M Fine CK (2003) Spinal Cord Injury Rehabilitation The Bariatric Spinal Cord-Injured Person: Challenges in Preventing and Healing Skin Problems. 9 (2) 38-44 Thomas Land Publishers Inc Pokorny M.E. (2008) Bariatric Nursing and Surgical Patient Care Lead In: Skin Physiology and Diseases in the Obese Patient. Vol 3 (2) Mary Ann Liebert Inc. Rush (2002) A Study to investigate Bariatric Care in the Community submitted to Robens Centre for Health Ergonomics in part fulfilment of Master of Science in Health Ergonomics Swain I. Bader D (2004) The Measurement of Interface Pressure and its role in Tissue Breakdown cited in Pressure Ulcers recent advances in Tissue Viability pages 39-55. Pressure Ulcer Prevention and Management Best Practice Guidance Page 56 of 68 Appendix 10 Patient Information Leaflet Pressure Ulcers A pressure sore (sometimes called a bedsore or pressure ulcer) is when your skin and underlying tissue gets damaged causing a painful sore. For more information visit the government‚ NICE guidelines at http://www.nice.org.uk How does the skin get damaged? The damage is usually caused by one of 3 main things: Pressure – the weight of the body pressing down on the skin Shear – when layers of skin are forced to slide over one another, for example when you slide down or are pulled up a bed or chair Friction – rubbing of the skin How can your spot one? The first sign that a pressure sore might be forming is a change in the colour of the skin. This can then get progressively worse and can lead to an open wound. Where do they usually appear? The most common places for pressure sores are over bones that are close to the skin like the bottom, heal, elbow, ankle, shoulder, back and back of the ear. Pressure Ulcer Prevention and Management Best Practice Guidance Page 57 of 68 Q - What are the symptoms of a pressure sore? A – A pressure sore may initially appear as a red area of skin that does not disappear after a few hours and it may feel tender. The area may become painful and purple in colour. Continued pressure and poor circulation can cause the skin and tissue to break down. Q – Who is affected? A – Pressure sores can affect people of any age, particularly those with poor mobility who spend prolonged periods in bed or in a chair or are unable to change their position. Older people are more likely to develop pressure sores which can also be caused by poor nutrition, anaemia, recurrent infection and poor circulation. Q – How do you treat pressure sores? A – Treating a pressure sore is much more difficult than preventing one. Treatment of pressure sores includes relieving pressure and keeping the sore clean. Dressings are used to encourage healing and antibiotic therapy can treat infection.The removal of dead tissue, skin grafting and plastic surgery may also be required. It‟s important to improve nutrition and to treat any underlying condition that‟s contributing to the problem. Q – Can pressure sores be prevented? A – In many cases, yes. The most important factor in preventing sores is avoiding prolonged pressure on an area of the skin. This can be achieved by encouraging a person to change their position regularly throughout the day, such as moving, standing or turning. Those unable to do this themselves should be moved at appropriate intervals – at least every two hours. Do not sit for longer than 2 hours without relieving pressure Special mattresses, such as air filled alternating pressure mattresses and cushions that redistribute pressure help reduce pressure on sensitive areas. Regular inspection of high risk pressure areas is important to detect early signs and prompt medical care should be provided. It is also important to keep skin healthy, clean and dry. Use a mild soap and warm (not hot) water. Apply moisturisers so the skin doesn‟t get too dry. If you must spend a lot of time in bed or in a wheelchair, check the whole body every day for spots, colour changes or other signs of sores. Reduce or stop smoking. Q – Can diet prevent pressure sores? A – A healthy diet is vital in preventing and healing pressure ulcers. If you do not get enough calories, protein, vitamins and fluids you may develop a pressure ulcer or your pressure ulcer may fail to heal. Q – What are the risk factors associated with pressure sores? A – There are a number of risk factors including age, mobility, incontinence, malnutrition and dehydration, diseases and disorders such as confusion or dementia that lessen mental awareness and may prevent a person from feeling the discomfort of a harmful body position. There are also medications such as sedatives that may lessen a person‟s sensitivity to pain. Q – How can infected pressure sores be treated? A – The treatment of an infected pressure sore depends on the severity of the infection. If only the sore itself is infected, a dressing that promotes wound healing and helps to reduce bacteria can be put on the sore. When bone or deeper tissue is infected, intravenous antibiotics (given through a needle in a vein) are often required. Q – How can I tell if a pressure sore is getting better? A – As a pressure sore heals, it slowly gets smaller. Less fluid drains from it. New healthy skin starts growing at the bottom of the sore. This new skin is light red or pink and looks lumpy and shiny. It may take two to four weeks of treatment before you see these signs of healing. www.your-turn.org.uk Pressure Ulcer Prevention and Management Best Practice Guidance Page 58 of 68 Appendix 11 EPUAP Pressure Ulcer Classification System Pressure Ulcer Prevention and Management Best Practice Guidance Page 59 of 68 Patient Name DOB NHS No. Date of referral to team or ward Date pressure ulcer identified Team or Ward Locality Name and designation of person completing RCA and their phone number and email address Where was the patient from? Please enter yes or no Own home Nursing home Hospital Residential home Other Name the nursing or residential home or hospital Does the patient have formal a carer? [yes or no] Does the patient have an informal carer e.g. family? Please describe in full any relevant medical history, including medication in the box below Ulcer category Site [e.g. sacrum] Right Left Right Please state wound size 1 2 3 4 1 2 3 4 5 Please number sites st st Date of 1 Waterlow score when patient was admitted onto the caseload or the ward 1 score Where was it carried out? Date of most recent Waterlow assessment Recent score Where was it carried out? Pressure Ulcer Prevention and Management Best Practice Guidance Page 60 of 68 How often was the Waterlow score carried out before the incident was reported and by whom? Alternate days Daily Every 72 hours Weekly Monthly Other [give details] Weekly Monthly Other [give details] Person completing Waterlow How often is Waterlow score carried out now and by whom Alternate days Daily Every 72 hours Person completing Waterlow SSKIN Assessment S = Skin Inspection Question Yes or No Frequency Is a skin inspection now carried out at each visit? Have any skin conditions been identified? Was the appropriate skin barrier used? Was the appropriate skin care given? Was the SSKIN bundle completed? K = Keep Walking Level of Mobility Independent Assistance of 1 Bedbound Chairbound Approximate daily length of time in bed of 2 Approximate daily length of time in chair Advice given (e.g. turning regime, pressure relief care) Was the patient compliant to the advice given? [Yes or No] I = Incontinence Elimination Incontinent of faeces Continent Catheter Incontinent of urine and faeces Pressure Ulcer Prevention and Management Best Practice Guidance Incontinent of urine Moisture damage [Y or N] Page 61 of 68 Please describe the continence aids used? N = Nutrition and Hydration Has a MUST assessment been completed and documented [Y or N] What was the MUST score? Date Peg feeding [Y or N] Referral to Dietician [Y/N] What advice was given? Care Plan Has an appropriate care plan been completed [Y or N] Patient Information Date Was the patient given a patient information Leaflet [Y or N] Please explain the causes of the pressure ulcer [e.g. discharge planning, staff knowledge and training, communication, equipment, change in patient’s medical condition and end of life] FAMILY AND CARERS INVOLVEMENT AND SUPPORT Did the care team triggered the being open process Names and relationship Support offered by investigating officer Was support accepted Involvement in the investigation MULTIDISCIPLINARY ROOT CAUSE ANALYSIS MEETING A serious incident multidisciplinary meeting must be held and it is an expectation of the trust that those involved attend Independent chair [name & designation] Independent clinician [name & designation] Name of minute taker People present at the meeting [Name & Designation] People invited who did not attend [Name & Designation] SAFEGUARDING AND CAPACITY Did the investigation identify safeguarding adult issues Was a referral made prior to the incident Did the investigation identify capacity issues Was a Mental Capacity Act assessment undertaken prior to the incident CONTRIBUTORY FACTORS Pressure Ulcer Prevention and Management Best Practice Guidance Page 62 of 68 Patient Staff Team Communication Task Education Resources Environmental Organisational AVOIDABLE OR UNAVOIDABLE According to the Department of Health definition [2010] was the pressure ulcer avoidable? Avoidable means that the person receiving care developed a pressure ulcer and the provider of care did not do one of the following: evaluate the person’s clinical condition and pressure ulcer risk factors; plan and implement interventions that are consistent with the persons needs and goals, and recognised standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Unavoidable means that the person receiving care developed a pressure ulcer even though the provider of the care had evaluated the person’s clinical condition and pressure ulcer risk factors; planned and implemented interventions that are consistent with the persons needs and goals; and recognised standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate; or the individual person refused to adhere to prevention strategies in spite of education of the consequences of non-adherence. Avoidable Unavoidable RECOMMENDATIONS/LESSONS LEARNED/ACTIONS TO BE TAKEN 1 2 3 4 5 6 CLOSURE OF THE INVESTIGATION FOR THE TRUST Pressure Ulcer Prevention and Management Best Practice Guidance Page 63 of 68 The closure of an investigation can only be undertaken by the Quality Governance Manager or their nominated representative Name Job title Date SERIOUS INCIDENT FORUM The monthly Serious Incident Forum reviews investigations, agrees the recommendations the Trust will take forward. Forum membership: Director of Quality and Executive Nurse, Medical Director, Quality Governance Manager, Patient Safety manager and Senior Clinicians Date of meeting Chaired by Comments Feedback to SERIOUS INCIDENT FORUM FINAL RECOMMENDATIONS 1 2 3 4 5 6 CLOSURE OF THE INCIDENT FOR THE TRUST The closure of an investigation can only be undertaken by a HACW Director or their nominated representative Name Job title Pressure Ulcer Prevention and Management Best Practice Guidance Date Page 64 of 68 Pressure Ulcer Prevention and Management Best Practice Guidance Page 65 of 68 Appendix 12 Additional website links and Information Sources Harmfreecare.org HIA‟s Calculator Telehealth : [email protected] Tissue Viability website: www.hacw.nhs.uk/tissueviability Skin Care – A guide for Patients and Carers (leaflet) Pressure Ulcer Prevention - A guide for Patients and Carers (leaflet) www.stopthepressure.com Tissue Viability Department Jackie Stephen Haynes Professor and Consultant Nurse in Tissue Viability Stourport Health Centre Worcester Street Stourport Worcestershire DY13 8EH Email: [email protected] Mobile: 07775 792775 Rosie Callaghan Tissue Viability Nurse Stourport Health Centre Worcester Street Stourport Worcestershire DY13 8EH Email: [email protected] Mobile: 07717 543046 Jayne Allchurch Secretary, Tissue Viability Stourport Health Centre Worcester Street Stourport Worcestershire DY13 8EH Email: [email protected] Phone No: 01299 879453 Pressure Ulcer Prevention and Management Best Practice Guidance Page 66 of 68 Appendix 13 Pressure Ulcer Discharge/Transfer Information List This chart is designed to assist nurses with the discharge of patients with Tissue Viability needs. Patient Details DoB Pt Number Length of time wound present _____________ Clinical Incident Form completed? Does the patient have a wound? Yes / No (circle) Location______________________ Classification Necrotic Sloughy Infected Granulating Epithelialising Depth of Wound / Grade of Ulcer (tick) (tick) Blanching / non blanching hyperaemia or grade 1 pressure ulcer Superficial tissue loss or grade 2 pressure ulcer Wound extends to subcutaneous tissue or grade 3 pressure ulcer Wound extends to bone or joint capsule or grade 4 pressure ulcer Investigations carried out in hospital: Wound Swab MSU FBC U+E’s XR ABPI Tissue Biopsy Y/N Findings Has the patient had antibiotics whilst in hospital? Has the patient been seen by / referred to a specialist? Vascular Surgeon Dermatologist Yes / No Yes / No Dietician Tissue Viability Nurse Chiropodist Other Referral/ Appointment Date Current Dressing Regime Primary Dressing Secondary Dressing Bandage Frequency of Application Ordered as TTOs? Yes / No (circle) Name of Discharging Nurse Signature (print) Equipment Is patient using specialised equipment for the prevention and management of pressure ulcers? Name of Mattress Name of Cushion Both Ordered for Discharge? Date of Delivery Delivery Location Yes / No (circle) Yes / No (circle) Designation Date Pressure Ulcer Prevention and Management Best Practice Guidance Page 67 of 68
