PRESSURE ULCER PREVENTION: refresher training Tissue Viability Service 0113 2069207 Leedsth-tr.tissue-viability@nhs.net
Causes of Pressure ulceration Immobility ** Existing /Previous PU Vulnerable skin Perfusion Sensory perception Hydration/ nutrition Moisture Pain As defined by systematic review and expert consensus group. Immobility is the main factor.
Assessing risk: When & how PURPOSE T
Normal skin/Blanching erythema
Category 1 Report to Staff Nurse immediately If you identify a Category 1 Report to Staff Nurse immediately Review 2 hourly and increase repositioning to 2 hourly Discuss with Link Nurses If no improvement in a couple of days then refer to Tissue Viability
Category 2
Category 3
Category 4
Category U (unstageable)
Incontinence Associated Dermatitis (IAD) IAD is superficial and are associated with redness, rash or vesiculation – can get deeper if infection present Examples of IAD: Other moisture lesions: Combined pressure and moisture lesion Sweat/moisture rash, possibly fungal Moisture “kissing lesion”
Planning Care Care plan should: address the patient’s risk profile (factors) consider patient preferences & ability to self-care Patients should be involved in decisions about their care Essential Elements of Care include: promotion of movement re-positioning support surface provision Active monitoring of skin response
Keep Moving/2 hourly If a patient is moving they wont develop pressure ulcers
Beds & Surfaces
Alternating cell
Seating Chairs with integral pressure relief? Pressure relieving cushions Wheelchair cushions
Heels (& other body areas) Aderma
Planning Care Other aspects of care may include management of: Moisture Diabetes Poor perfusion Nutrition Pain Skin Poor sensory perception & response
New Proposed Pressure Ulcer Prevention Pathways: PUPPs PURPOSE T Assessment Existing PU/scar Secondary Prevention & Treatment Pathway No PU but at risk Primary Prevention Pathway Not currently at risk Re-assess If condition changes Continuous Active Monitoring of Skin Response Deterioration Prompts Action
The patients perspective Involve the patient PRESSURE ULCERS The patients perspective Involve the patient Patient information leaflets http://nhslocal.nhs.uk/story/i-think-about-pressure-ulcers-every-day
Summary The development of a pressure ulcer indicated a patient has suffered HARM whilst in our care. The key to preventing HARM is recognising VULNERABLE SKIN and ACTING on it. Any vulnerable skin or pressure damage should be seen per shift by the RN responsible for that patients care and not just by a non-registered nurse.