Tissue Viability Team ABUHB
Brief functions of the skin What is a pressure ulcer? Why do they happen? What we can do to prevent pressure ulcers? The way forward
Why do Pressure Ulcers matter? - Human costs Loss of self esteem Painful Loss of independence Life threatening
Regular Repositioning to: Relieve Pressure Restore Blood Supply Reduce Pain and Discomfort Inspect the Skin Relieve Boredom and improve wellbeing
Incorrect Positioning Incorrect use of Equipment Poor Lifting and Manual Handling Techniques - Avoid Dragging the Patient Inappropriate Support Surfaces - Patient Sliding down the Bed or Chair
SKIN Surrounding skin For skin at risk of breakdown or for Category I pressure ulcers, a barrier cream or film may be used to reduce shear forces and minimise the risk of contamination by micro- organisms.
A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are associated with pressure ulcers; the significance of these factors is yet to be agreed. Friction Moisture And intrinsic factors European Pressure Ulcer Advisory Panel (EPUAP) National Pressure Ulcer Advisory Panel (NPUAP 2009)
Pressure damage can occur anywhere on the body but is more likely over a boney prominence. Head Heels Elbows Buttocks Hips Ears Shoulders Ankles Toes Spine Nose
Superficial loss of dermis and / or dermis Loss of epidermis and dermis – with red shiny tissue
Superficial broken skin, which is red and wet with areas of dryness Moisture lesion in the natal cleft
Assessment Reassessment Skin inspection regularly Early recognition Non blanching erythema Blisters Heat Induration
Risk – What risk ? Pressure Shear, friction Immobility Other factors, include age, medication, nutritional and general health status, incontinence, weight.
Significant pain and distress Significant impact on health, Poor quality of life Prolonged hospitalisation Prolonged community care provision Significant financial costs Life threatening
1 Pressure ulcers happen 2 We can stop pressure ulcers from occurring 3 Pressure ulcers should not happen here
All staff involved in patient care should have the appropriate knowledge, skills and resources to reduce the incidence of pressure ulcers in patients admitted to care.
AAssess each patient’s risk of developing a pressure ulcer within 4hours of admission IIndentify intrinsic and extrinsic factors which may influence a patient’s potential to develop pressure damage. SSkin assessment to identify early signs of pressure damage MMUST score RRegular skin reassessment and use clinical judgement and patient’s history DDocument, Document, Document –care plans, skin bundle, wound chart EEvaluate, Evaluate, Evaluate.
Patients with a Waterlow score of 15 and above But Some patients may have a high score but are mobile.... Some patients may score <15 but are clinically judged at risk Apply skin bundle and document any changes Remember
S URFACE K EEP MOVING I NCONTINENCE N UTRITION Is the patient on the right mattress/seating? Patients need to move or be repositioned Skin needs to be kept dry, avoid moisture Keep patient hydrated and well nourished
DATE & Waterlow score ADVISED TIME ACTUAL TIME S URFACE Appropriate mattress in use Appropriate seating K EEP MOVING Patient mobile In bed on back In bed on left side - 30º tilt In bed on right side - 30ºtilt Sat out in chair Stood up from chair Patient sleeping Patient refusing to move Skin checked **Is P.U present? Y or N** Heels checked (Remove T.E.D stockings if necessary) I NCONTINENCE Urine Faecal Continent Catheter Skin moist Washed /dried N UTRITION N.B.M Diet – type Taking fluids only Drink offered Supplements Signatur e **If a pressure ulcer is present, a wound management chart must be used and documented in nursing documentation.
NPSA 2010 recognised that some PUs may be unavoidable MOST PRESSURE ULCERS ARE AVOIDABLE
Person providing care did not do one of the following – Evaluate patient’s condition and risk factors Plan and implement interventions to meet clinical needs and recognised standards of practice Monitor and evaluate impact of interventions Revise interventions as appropriate
Patient developed a pressure ulcer even though the provider of care Had evaluated the patient’s condition and risk factors Had planned and implemented interventions to meet patient’s clinical needs and the recognised standards of practice Had evaluated the impact of interventions and revised as appropriate Patient declined to adhere to care plan
… or ‘ just one of those things ’ ?
Ill-treatment Impairment of, or an avoidable deterioration in, physical or mental health Impairment of physical, emotional, social or behavioural development Grade 3-4 or multiple pressure ulcers
Refer to TVN Enter on DATIX Complete SBAR Inform & discuss with senior nurse - ? Meets POVA threshold If yes – initial POVA strategy meeting
1. Has there been rapid onset and/or deterioration of skin integrity? 2. Has there been a recent change in medical condition e.g. skin or wound infection, other infection, pyrexia, anaemia, high temperature, end of life care that could have contributed to a sudden deterioration of skin condition? 3. Have reasonable steps been taken to prevent skin damage? 4. Is the level of damage to the skin disproportionate to the patient’s risk status for skin damage? e.g. low risk of skin damage with extensive injury 5. Is there evidence of poor practice or neglect?
In order to ensure the patient of concern is made safe In order to keep other patients safe In order to learn lessons and improve practice.
Select pressure redistribution mattress and or cushion based on patients needs and comfort Reassess daily or if patients condition changes Ensure the equipment is functioning correctly Ensure patients with pressure ulcers have access to pressure-relieving support surfaces and strategies Support surfaces alone neither prevent nor heal pressure ulcers. They are to be used as part of a total programme of prevention and treatment
Keep the skin dry and well hydrated Regularly inspect for signs of damage
Mobilising, positioning and re-positioning interventions should be determined by: General health status Location of ulcer General skin assessment Acceptability (including comfort), to the patient Mobilising, positioning and repositioning interventions should be instigated for all individuals with pressure ulcers (including those in beds, chairs and wheelchairs).
During sleep the average person moves times a night with a dozen full turns National Bed Federation 1995
The 30º tilt is a method of positioning the patient/client to decrease the risk of damage. The person is not fully on his or her side, but is placed on pillows positioned to angle the pelvis at approximately 30º to the surface of the bed Frequency of re-positioning should be determined by the patient's individual Needs and recorded – e.g. a turning chart.
Inspect the skin for additional damage each time the individual is turned or repositioned while in bed. Do not turn the individual onto a body surface that is damaged or still reddened From a previous episode of pressure loading, especially if the area of redness does not blanch Do not position on a pressure ulcer Avoid pressure and shear on sacrum and coccyx
Position to minimize pressure and shear Use footstool or footrest if the feet do not touch the floor Limit time in the chair: pressure on ischial tuberosities It is recommended to reduce the duration of sitting to less than two hours at any one time
High-risk groups Immobile legs Peripheral vascular disease impairs reperfusion Diabetic neuropathy
Use urinary or faecal management systems as appropriate Use continence products when required Manage skin temperature and humidity to reduce sweat Keep clean and dry
Assess nutrition status Implement prescribed diet/nutritional supplement Keep well hydrated Refer all individuals with a pressure ulcer to the dietician for early assessment of and intervention for nutritional problems
Provide enhanced foods and/or oral supplements between meals if needed. Provide adequate protein Provide and encourage adequate daily fluid intake for hydration. Provide adequate vitamins and minerals.
Pressure ulcers can have a negative impact on wellbeing and quality of life. It is essential to involve the patient and his/her family in ensuring that individual problems and concerns are addressed
Patients and carers should be informed about any potential risks, and/or complications, of having a pressure ulcer. Patients and carers should be involved in shared decision- making about management of pressure ulcers
Leadership Actions Promote culture of zero tolerance Promote best practice guidance Identify local ‘champions’ Tissue viability nurse specialist Frontline Actions Risk assessment Implement best practice guidelines, skin bundle & safety cross Patient and family education Measurement and data
“Pressure ulcers have a significant impact on health related quality of life and cause substantial burden to patients” (Gorecka et al 2009) Open wounds smell bad I worry about my wound getting worse Pressure ulcers cause a lot of pain
90% of elderly patients who develop a necrotic pressure ulcer on the trunk die within 4 months.
95% of pressure ulcers are avoidable Cost to the patient – financial and personal Cost to the organisation Quality of life Life and Limb threatening
Raise awareness – everyone’s responsibility Education – include patients and carers ( patient information leaflet) Audit – daily data
Its about the WHOLE of the patient !!!
The question must be - Is it worth trying to do, not can it be done? Allard Lowenstein
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009 Clarkson, A. (2007). Are pressure ulcers an act of nursing negligence? Wounds UK. 3(2), Clark, M. (2006). How can we make pressure ulcer prevention and management truly multiprofessional? Journal of Wound Care. 14(5). Fletcher, J Wound essentials. Pressure ulcer management, how to guide. 7(1)