1. Pressure Ulcer and Moisture Lesion Prevention and Management
Stuart Elliott
Tissue Viability Nurse

2. Objectives
An understanding of how pressure ulcers and moisture lesions develop and what can be done to prevent and manage them
An understanding of the education and support that can be provided to patients to help them manage their own risk of pressure ulcers and moisture lesions
An understanding of every registered nurse’s professional responsibility in relation to the prevention and management of pressure ulcers and moisture lesions

3. Pressure ulcer definition
Localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful” (NHS Improvement 2018).

4. Moisture lesion definition
‘A lesion being caused by urine and/or faeces and perspiration which is in continuous contact with intact skin of the perineum, buttocks, groins, inner thighs, natal cleft, skin folds and where skin is in contact with skin.’ (All Wales Tissue Viability Nurse Forum and All Wales Continence Forum, 2014).

5. Medical Device related Pressure Ulcer
“Pressure ulcers that result from the use of devices designed and applied for diagnostic or therapeutic purposes” (NHSI, 2018).

6. Pressure Ulcer or Moisture Lesion On admission
A pressure ulcer or moisture lesion on admission to NHS care is defined as “that it is observed during the skin assessment undertaken on admission to that service.” (NHSI, 2018, page 9).
The 72 hour rule which states that pressure ulcers that occur within the first 72 hours of admission to NHS care are not attributable to the setting in which the patient has been admitted is no longer recommended by NHS Improvement and should not be used.

7. Pressure ulcer or moisture lesion developed or deteriorated in NHS Care
NHSI (2018) also set out the definition of a new pressure ulcer or moisture lesion within a setting which is that “it is first observed within the current episode of care.” (NHSI, 2018, page 10).

8. MAIN CAUSES OF PRESSURE ULCERATION.
A perpendicular load of force exerted on a unit of area (this could be a patients body weight bearing down on a hip or sacrum).
It causes local capillary occlusion (reduction in blood supply) and compresses the structures between the skin surface and bone. The damage can often be caused under the skin, but not become obvious until the skin above it has broken down.

9. MAIN CAUSES OF PRESSURE ULCERATION/2.
Shearing.
This is where pushing or pulling the skin means more than one layer of skin slides against each other and this can cause damage to these layers or they may become detached from each other all together.

10. Pressure and shear

11. MAIN CAUSES OF PRESSURE ULCERATION/3.
Friction.
This is where two surfaces rub together, so this could be the skin and bed sheets, or a chair cushion, etc., or poorly fitting clothing or manual handling aids. Hot, moist skin is likely to experience even more damage from friction than more healthy skin.
POOR MANUAL HANDLING TECHNIQUES CAN RESULT IN PATIENTS EXPERIENCING ALL OF THESE FORMS OF PRESSURE AREA DAMAGE.

12. Friction lesions

13. The application of NICE guidelines: CG179
Health professionals are expected to take them fully into account when exercising clinical judgement
NICE guidance does not override individual responsibility of health professionals to make decisions appropriate to the needs of the individual patient
NOTES FOR PRESENTERS
SLIDE FOR CLINICIANS

14. Hints and tips on grading
A pressure ulcer is an ulcer related to some form of pressure and should not be confused with ulcers relating to disease (like cancer), vascular flow (venous or arterial) or neuropathy (like in persons with diabetes)
You should be able to see a “cause and effect” relating to pressure with the ulcer.
Redness or discoloration over a bony area related to sitting or lying
Redness or discoloration on the skin related to pressure from a device such as a brace or a wheelchair pedal

15. Pressure Ulcer Etiology
Pressure exerted by bony prominences on the body that stop capillary flow to the tissues.
Deprives tissues of oxygen and nutrients causing cell death.
Pressure greater than capillary closing pressure exerted by bony prominences to disrupt blood flow.

16. Most Common Sites Sacrum (tail bone)- most common site
-Semi-fowlers’ position
-Slouching in bed or chair
-higher risk in tube fed or incontinent pts.
Heels- 2nd most common
-Immobile or numb legs
-Leg traction
-Higher risk with PVD & diabetes neuropathy

17. Other Bony Prominences
Trochanter (hip bone)
-Side lying
-Highest risk contractured residents
-Ulcers on lateral foot rather than heel itself
Ischium (sitting erect bone)
-highest risk paraplegics

18. Pressure Ulcers from other sources of pressure
Boots/boot straps
Plaster casts
Heel protectors/protector straps
Oxygen tubing
Anti-Embolism Stockings
Compression bandaging
Any device that can lead to pressure induced ischemia on the skin

20. Waterlow scoring points
Intuitive scoring – higher the score, higher the risk (cf Braden for instance)
Problems
Terminal cachexia
Perioperative care
Capacity and compliance of patient

21. Waterlow Reassessment.
After admission to hospital or community nursing caseload, a documented reassessment should occur:
On transfer between ward areas or teams.
During the perioperative period or outpatient procedures
On any change in the patient’s condition which is likely to affect their risk of developing pressure ulceration.
Otherwise weekly.
REMEMBER TO RECORD DISCHARGE STATUS

22. EPUAP categorisation.
Category 1: Non-blanchable erythema of intact skin, warmth, oedema, induration or hardness may be indicators, particularly with darker skin.
Beware BLANCHING erythema
Beware MOISTURE LESIONS
Category 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents as an abrasion or blister.

23. EPUAP categorisation/2.
Category 3:Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Category 4: Extensive destruction, tissue necrosis or damage to muscle, bone of supporting structures.

24. EPUAP categorisation/3.
Unstageable describes those areas of skin breakdown where intact eschar or slough is present and in which the depth is not known.
Suspected Deep Tissue Injury refers to areas of unbroken skin which show signs of discolouration or ischaemia which may have the potential to breakdown as pressure ulcers.

25. EPUAP Category 1: Non-blanching.

26. EPUAP Category 2: Broken skin.

27. EPUAP Category 3: Sub-cutaneous involvement.

28. EPUAP Category 4: Deep tissue involvement.

29. Related concepts McClemont’s cone effect
Unstageable/Deep Tissue Injury

30. Hourglass necrosis development

31. Grading issues
Necrosis/Slough – any pressure ulcer which has necrosis or slough where you cannot assess depth has to be graded as unstageable.
Blisters – blisters obscure the base of the wound. De-roof, treat as a wound, and grade according to the state of the wound bed.
If in doubt, peer review and get two nurses to countersign.
Also, verbal descriptors in documentation and photography are necessary, and part of NICE guidance regarding pressure ulceration.

32. Pressure ulcer or moisture lesion?
Causation: Usually moisture is present.
Location: Less likely over bony prominences
Shape and edge: Usually diffuse edging and shape
Depth: Moisture lesions are rarely more than superficial
Necrosis: Necrosis is never present
Pressure ulcer
Causation: Usually pressure and/or shear are present
Location: More likely over bony prominences
Shape and edge: Usually distinct edging and shape
Depth: Pressure ulcers can be superficial or deep
Necrosis: Necrosis may be present

33. Assessment of pressure ulcer
Assess and document:
cause
site/location
dimensions
stage or grade
necrosis or slough
exudate amount and type
local signs of infection
pain
wound appearance
surrounding skin – including erythema, maceration, moisture damage
undermining/tracking, sinuses, tunnelling or fistulae
odour
Support with photography and/ or tracings
Datix all pressure ulcers acquired or deteriorated under NHS care as a clinical incident, and all coming into care of the Trust.
Pressure ulcers should not be reverse graded
NOTES FOR PRESENTER
SLIDE FOR CLINICIANS

34. As can be seen, the most likely areas of tissue damage are those that are situated over bony prominences. The precise areas that are at risk are dependent upon the position in which the patient remains.
(Diagram courtesy of the Tissue Viability Society.)

35. As can also be seen, patients can be at risk even in a sitting position. We cannot afford to forget patients when they are sitting out – they are still at risk even though they are more mobile.
Patients who have been on bed rest need to have their seating tolerance built up again!!! Do not put patients back out for long periods after bed rest – build them up.

36. Pressure Areas In Wheelchairs

37. Medical devices and equipment

38. NICE Guidelines:
The National Institute for Clinical Excellence recommends the following in terms of pressure ulcer prevention:
Assessment of a patient’s risk of pressure injury within 6 hours of admission to hospital for each episode of care, or on admission to caseload, and regularly thereafter depending upon the severity of the issues identified.

39. Assessment factors/1: Intrinsic factors: Reduced mobility
Sensory impairment
Neuropathy
Acute illness.
Level of consciousness.
Extremes of age.
Vascular disease.
Severe chronic or terminal illness.
Previous history of pressure damage.
Malnutrition and dehydration.

40. Assessment factors/2: Extrinsic factors: Pressure. Shearing. Friction.
Other factors:
Medication.
Moisture to the skin.

41. Care Plans:
Use the body maps in the generic assessment documentation to record where there is skin damage.
Use the daily check charts to record on a daily basis that every area has been checked and if there is a pressure ulcer grade it accordingly.

42. Care Plans/2:
A patient who is unable to reposition themselves MUST have a repositioning plan. Plan on 2 hourly repositioning day and night. Include 30° tilt on bed rest.
Repositioning regimes need to:
Minimise prolonged pressure on bony prominences.
Minimise friction and shear damage – ensure good manual handling with the correct equipment.
Address any incidences of incontinence
Specify that repositioning takes place regularly – even with pressure-relieving devices in situ.
Establish a means of recording when this repositioning takes place – YOU MUST RECORD EVERY INSTANCE OF REPOSITIONING.

43. Care Plans/3:
Any patient with a pressure ulcer which is EPUAP category 2 or higher should have a wound care plan.
Any equipment required, whether it has been already obtained, or, whether it has been requested, when and by whom.
Dates and times should be set for the evaluation of pressure ulcer and wound care plans so that regular updates can take place.

44. Pressure reducing or relieving?
Pressure reducing devices distribute the patient’s weight more evenly across the surface of the device
Pressure relieving devices, such as alternating mattresses, are designed to completely remove the pressure from areas of the patient’s skin

45. Pressure reducing surface
Softform Premier Maxiglide

46. Alternating pressure relief
Huntleigh Nimbus 3

47. Repose

48. Parafricta

49. Pressure ulcer management.
Each pressure ulcer should have an individual care plan detailing the wound care and more general measures to reduce further risk.
Ulcers which develop to EPUAP category 2 or above are NOT TO BE RETRO-GRADED. They become ‘healing category 3 heel ulcers,’ or ‘healing category 4 sacral ulcers.’

50. Pressure Ulcer Care plans.
Pressure ulcer and moisture lesion care plans should detail:
Where the ulcerated areas are.
What measures are currently being used to reduce risk, with special reference to nutrition, continence, pain management and mobility.
If a regime of turning the patient is in place, there must be a means of documenting each time that this is done, and by whom.
These care plans should set up review dates, and these need to be reviewed when indicated.

51. Check Skin
The first step in preventing a pressure sore begins with a complete inspection of the skin. Individuals with spinal cord injury should check their skin in the morning and at night.

52. Patient involvement:
Please encourage patients to maintain their nutrition:
Meat, fish, or alternatives.
Fruit and vegetables.
Bread, potatoes and cereals.
Cheese, milk and dairy products.
Plenty of fluids stop the skin becoming dehydrated and can reduce the risk of ulceration.

53. Advice Regarding Skin Care/1:
Avoid massaging bony parts of the body. This can cause addition damage to skin which may already be delicate.
In bed, your position should be changed every 2 hours. Bed sheets should have no creases.
If you cannot move yourself, ask for help.
Try to avoid dropping crumbs or other food debris in bed which you might lay on.

54. Advice Regarding Skin Care/2:
If you can move around in your chair, try changing position every 15 minutes.
Avoid being dragged when you are lifted – dragging causes friction and increases risk.
Do not use ring cushions as these increase rather than reduce pressure.
Avoid staying in one position for more than 2 hours – try to spread your weight evenly.

55. Advice Regarding Skin Care/3:
Use warm (not too hot) water and mild soap to cleanse. Use a moisturiser to avoid dry skin, and avoid cold or dry air.
If you have a problem with perspiration or incontinence, your skin should be cleansed as soon as you are aware of it. Using a soft cloth or sponge should reduce friction.
Check your skin at least once daily, or ask a carer to help. A mirror will help to see hard-to-reach areas. Attend especially to those areas where pressure is heaviest.

56. Advice Regarding Skin Care/4:
Look out for skin changes:
Reddening on light skin.
Purple or bluish patches on dark skin.
Swelling, especially over bony parts.
Blisters.
Shiny areas.
Dry patches or hard areas.
Cracks, callouses, wrinkles or broken skin.
Let your nurse know if you notice any of these things.

57. Mental Capacity 2 stage process of assessment
If patient has capacity, then their wishes must be respected. In these situations, each and every individual refusal must be recorded.
If patient does not have capacity, care must be provided under ‘best interests’ provision of Mental Capacity Act.

58. Delegating care
Under NMC code, it is the trained nurse’s responsibility to ensure that if we delegate care duties to non-qualified staff, that they are competent and confident to complete the tasks set out to the standard that we require.
This is of particular relevant in primary care when trained nurses are delegating this care to home carers or patient’s relatives…..

59. RCA process
It is now an NHS England requirement that all grade 3 and 4 pressure ulcers, wherever they occur within the Trust, are to be reported on Datixweb and considered as to whether a Serious Incident Investigation should be instigated.
All grade 2 pressure ulcers should be clustered as part of thematic analyses of pressure ulcer causation across all settings.

60. SAFEGUARDING Decision Process
Concern is raised that a person has severe pressure damage
Category/grade 3, 4, unstageable, suspected deep tissue injury or multiple sites of category/ grade 2 damage (EPUAP, 2014)
2. It is the responsibility of the discovering clinician too complete the adult safeguarding decision guide and raise an incident immediately as per organisation policy.
Score 15 or higher?: Concern for safeguarding

61. Adult Safeguarding Decision Guidance – question 1
Has the patient’s skin deteriorated to either grade 3 or 4, suspected deep tissue injury, unstageable or multiple grade 2 from healthy unbroken skin since the last opportunity to assess/visit?
YES, score 5 E.g. evidence of redness or skin breaks with no evidence of provision of repositioning or pressure relieving devices provided
NO, score 0 e.g. no previous skin integrity issues or no previous contact health or social care services

62. Adult Safeguarding Decision Guidance – question 2
Has there been a recent change, i.e. within days or hours, in their / clinical condition that could have contributed to skin damage? e.g. infection, pyrexia, anaemia, end of life care, critical illness
NO, score 5 No change in condition that could contribute to skin damage
YES, score 0 Change in condition contributing to skin damage

63. Adult Safeguarding Decision Guidance – question 3
YES, score 0 Current risk assessment and care plan carried out by a health care professional and documented appropriate to patients needs – state date of assessment and risk score or total
Was there a pressure ulcer risk assessment or reassessment with appropriate pressure ulcer care plan in place and documented? (In line with each organisations policy and guidance)
PARTIAL, score 5 Risk assessment carried out and care plan in place documented but not reviewed as person’s needs have changed
NO, score 15 Risk assessment carried out and care plan in place documented but not reviewed as person’s needs have changed

64. Adult Safeguarding Decision Guidance – question 4
Is there a concern that the Pressure Ulcer developed as a result of the informal carer willfully ignoring or preventing access to care or services
No or Not Applicable, score 0
YES, score 15

65. Adult Safeguarding Decision Guidance – question 5
Is the level of damage to skin inconsistent with the patient’s risk status for pressure ulcer development?
e.g. low risk–Category/ grade 3 or 4 pressure ulcer
Skin damage less severe than patient’s risk assessment suggests assessment is proportional, score 0
Skin damage more severe than patient’s risk assessment suggests is proportional, score 10

66. Adult Safeguarding Decision Guidance – question 6A (PATIENTS WITH CAPACITY)
Was the patient compliant with the care plan having received information about the risks of non compliance?
Patient not followed care plan, score 0
Patient followed some aspects of care plan, but not all, score 3
Patient followed care plan, or not given the information to make an informed choice, score 5

67. Adult Safeguarding Decision Guidance – question 6B (PATIENTS WITHOUT CAPACITY)
Was appropriate care undertaken in the patient’s best interests, following the best interests’ checklist in the Mental Capacity Act Code of Practice? (supported by documentation, e.g. capacity and best interest statements and record of care delivered)
Documentation of care being undertaken in patient’s best interests, score 0
No documentation of care being undertaken in patient’s best interests, score 10

68. If YES
Discuss with the person, family and/ or carers, that there are safeguarding concerns and explain reason for treating as a concern for a safeguarding enquiry has been raised.
1. Refer to local authority via local procedure, with completed safeguarding pressure ulcer decision guide documentation.
2. Follow local pressure ulcer reporting and investigating processes.
3. Record decision in person’s records.

69. IF NO
Discuss with the person, family and/ or carers, and explain reason why not treating as a safeguarding enquiry.
Explain why it does not meet criteria for raising a safeguarding concern with the Local Authority, but then emphasis the actions which will be taken.
1. Action any other recommendations identified and put preventative/ management measures in place.
2. Follow local pressure ulcer reporting and investigating processes.
3. Record decision in person’s records.

70. REFERENCES:
NATIONAL INSTITUTE OF CLINICAL EXCELLENCE (2003) Pressure ulcer risk assessment and prevention, including the use of pressure-relieving devices (beds, mattresses and overlays) for he prevention of pressure ulcers in primary and secondary care. Clinical guideline 7. NICE: London. Also available as a web document from where you will also find a suite of wound care guidelines.
ROYAL COLLEGE OF NURSING (2005) The management of pressure ulcers in primary and secondary care. RCN: London. Also available as a web document from or as an Executive Summary.

71. WEBSITES www.ewma.org www.worldwidewounds.com www.epuap.org