Special thanks are due to Mrs Heather Reid for the major contribution which she made to the production of these booklets.

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2 These guidelines have been prepared by CREST CREST is a small committee of doctors established under the auspices of the Central Medical Advisory Committee, to promote clinical efficiency in the health service in Northern Ireland while ensuring that the highest possible standard of clinical practice is maintained. CREST wishes to express its appreciation to Mrs Mary Waddell and the working group for producing this guidance, to all the members of the sub-groups and to all those who contributed in any way to the development of these guidelines. Special thanks are due to Mrs Heather Reid for the major contribution which she made to the production of these booklets. Further copies may be obtained from: CREST Secretariat Room 517 Dundonald House Upper Newtownards Road Belfast BT4 3SF Tel: CREST Website

3 PRESSURE SORES Table of Contents Foreword Page 1. Summary of Conclusions and Key Recommendations 3 2. Introduction 5 3. Pressure Sore Risk Assessment Tool 8 4. Pressure Sore Classification Providing Pressure Reduction/Relief Monitoring Pressure Sores Discharge Arrangements Developing a Pressure Sore Prevention Policy Audit 20 Appendicies 1. Braden Risk Assessment Tool Equipment Choice Flow Chart Guideline Development Sub-Group CREST Wound Management Group 25 Glossary 27 References: A full list of references and further reading may be obtained by contacting the CREST Secretariat.

4 Foreword Guidelines and recommendations for practice are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. This document is targeted for use by nursing and medical staff and professions allied to medicine. This document discusses the prevention and management of pressure sores, however, the main focus is on prevention. Further information on managing pressure sores is contained in the CREST document Guidelines on the General Principles of Caring for Patients with Wounds Diagnostic acumen is not measured by the ability to recognise a pressure sore once it has developed: it is the recognition of the early warning signs of potential skin breakdown and prevention of any further progression. Edberg et al 1973

5 1. SUMMARY OF CONCLUSIONS AND KEY RECOMMENDATIONS A number of key recommendations highlighted throughout the report are listed below. Each recommendation is graded so as to give the reader an indication of the type of evidence supporting it. GRADE A GRADE B GRADE C Requires at least one randomised controlled trial as part of the body of literature of overall quality and consistency addressing the specific recommendation. Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation. Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality. Minimise pressure through the immediate use of pressure relieving/reducing equipment and/or a repositioning schedule. When patients are in bed maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions to reduce shearing forces. Correct lifting and handling reduces friction. All staff and carers should be trained in the moving and handling of patients. A risk assessment tool should be used as an aid to professional and clinical judgement. Scores should be interpreted within the context of the full patient profile. On the basis of the available evidence, the Braden risk assessment tool should be adopted. Acutely ill unconscious, sedated and immobile patients are all high risk All individuals at risk of developing pressure sores should have a systematic skin inspection of their pressure points at least once a day. Avoid massage over bony prominences, as this can cause skin damage. Pressure sore risk assessment is concerned with clinical judgement. This document advocates the use of the NPUAP grading tool (National Pressure Ulcer Advisory Panel) When eschar or necrotic tissue and/or black discoloured tissue is present it is impossible to grade the pressure sore until the eschar is removed and/or the black discoloured tissue breaks down. Treat as a Grade 4 sore until grading can be carried out. Grade See Section C 2.1 C 2.1 C 2.1 C 3.1 C 3.2 C 3.2 C 3.3 B 3.3 C 3.3 C 4 C 4 3

6 The use of a grading tool requires a clear understanding of the anatomy and physiology of the skin. Establishing a written repositioning schedule is part of a pressure prevention programme. No patient at risk of a pressure sore should be nursed on a NHS standard mattress. A high density foam/low interface mattress should be used. A pressure reducing foam mattress in conjunction with a repositioning turning programme should be used to prevent pressure sores in moderate to high risk patients. At risk acutely ill patients should be placed on an alternating overlay in the first instance. At risk, acutely ill patients and immobile patients, with or without pressure sores should be considered for an alternating mattress replacement. Patients unable to tolerate an alternating pressure system could be tried on a low air loss system. Air fluidised beds should be reserved for patients with specialised problems i.e. burns, exudating wounds or intractable pain. Patients should be referred to occupational therapy for a seating assessment and further advice, especially when they have special needs. Advance notice should be given when transferring a patient from hospital to home/nursing home/hospice/residential care if pressure relieving equipment is required. Guidelines are more likely to be effective if they take into account local circumstances and are disseminated by an active educational and training programme. C 4 C 5.1 A 5.2 C 5.2 B 5.3 B 5.3 C 5.4 C 5.4 C 5.6 C 7.2 C 8 4

7 2. INTRODUCTION Until recently, pressure sores were considered to be a nursing problem and of little interest to other health care professionals. Today, they are deemed to be an indicator of the quality of care provided by a hospital or unit and have been the subject of debate in the House of Lords (Hansard1993). Pressure sores are thought to be 95% preventable (Waterlow 1994). Pressure sores have been defined as: skin discolouration or damage which persists after the removal of pressure and which is likely to be due to the effects of pressure on the tissues. (Department of Health 1994.) O Dea (1993) surveyed 3213 patients in a number of hospitals in the UK and found a prevalence of pressure sores (Inclusive of Grade I) of 18.6%. A study by Clarke and Cullum (1992) revealed a prevalence of pressure sores in an orthopaedic unit of 10.3% (Exclusive of Grade I). Incidence of pressure sores in an orthopaedic unit was studied by Versluysen (1986). 100 consecutive patients over 70 years of age admitted to a teaching hospital with a fractured neck of femur were studied. Incidence figures were 66% over an 18 month period. Clarke and Watts (1994) found an annual incidence of 4.03% ranging from 1.8% in surgical wards to 10.3% in orthopaedic wards. This emphasises the differences that can occur in different patient groups. The development and treatment of pressure sores has considerable implications for both patients and the health service: the most significant being a longer hospital stay or community care provision with consequent cost to the patients increased pain and discomfort and a predisposition to systemic illness. Hibbs, (1988) calculated the cost of hospital care for one patient with a pressure sore to be 25,905. The Nursing Practice Research Unit (1992) studied one district general hospital to determine the annual costs of management and prevention of pressure sores. They suggested that the total cost was 408,311.05, of which 83, was incurred by the two orthopaedic wards. The authors consider that pain and suffering to patients are difficult to quantify financially and should play a major part in any discussion of the merits of pressure area care. Furthermore, hospitals may be exposed to litigation if poor standards of care are shown to be responsible for the development of pressure sores. Damages of 100,000 have been awarded to one successful claimant in England. 5

8 2.1 Pressure Sore Development [a] Extrinsic Factors Dealey (1997) stated that a pressure sore is damage to the skin caused by pressure, shearing forces or friction, or a combination of any of these. These variables are commonly known as EXTRINSIC FACTORS. Pressure: The most important factor in pressure sore development is pressure, in particular over a bony prominence or pressure area. External pressure over the tissues causes compression and distortion. If the pressure is higher than capillary closing pressure it will result in occlusion of blood vessels. Minimise pressure through the immediate use of pressure relieving / reducing equipment and/or a repositioning schedule. Shearing: Shearing occurs if the patient slides down in the bed or chair. The shear forces cause small blood vessels to be kinked, stretched or torn leading to disruption of the local blood supply and subsequent ischaemia. If ischaemia is prolonged endothelial damage and thrombosis occurs leading to cell death. When patients are in bed maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions to reduce shearing forces. Friction: Friction can be described as the force generated when two surfaces move across one another. It most often causes superficial damage, such as stripping of the epidermis. Correct lifting and handling reduces friction. All staff and carers should be trained in the moving and handling of patients. 6

9 [b] Intrinsic Factors Although pressure is the major cause of pressure sores, the patient s potential to develop sores may be influenced by other factors. These variables are known as INTRINSIC FACTORS and are listed in the table following. Problem Example Rationale Acute Illness Acute infection Trauma Associated dehydration and circulatory fracture Age > 70 years 70% of pressure sores occur in this age group due to a combination of age related skin changes and increased co-morbidity factors Incontinence Bladder or bowel Damp skin increases friction and skin maceration Poor nutritional status Emaciated patients High association with acute and chronic illness Vascular disease Peripheral vascular insufficiency Decreased blood flow and microvascular reflexes Neurological disease Multiple sclerosis Stroke Reduction in sensory perception and mobility Immobility Parkinsons disease Reduced ability to relieve pressure Loss of sensation Diabetes Reduced awareness of pressure Drug therapy Sedatives Reduced mobility Reduced awareness of pressure and pain Debilitating disease Rheumatoid disease Terminal illness Multiple associated factors 7

10 3. PRESSURE SORE RISK ASSESSMENT TOOL RISK ASSESSMENT 3.1 Information One of the first activities in preventing pressure sores is the early identification of patients who are at risk of developing pressure sores. Various scales have been developed to identify those patients at risk of developing a pressure sore. Most scales have been developed in an ad hoc fashion, based on opinions of the relative importance of possible risk factors such as mobility, incontinence and activity; the total score is compared to a standard reference value to classify level of risk. Potential applications of risk assessment scales: to identify the risk status of individual patients; to structure patient assessments and act as an aide-memoire of risk factors; to aid the rational allocation of limited resources to those who are likely to benefit most; to facilitate clinical audit of patient management and outcomes; to facilitate comparisons of the prevalence and incidence between units with differing populations. A risk assessment tool should be used as an aid to professional and clinical judgement. Scores should be interpreted within the context of the full patient profile 3.2 Guidance For Practice It is important when choosing a tool the following questions are asked: Does the tool take into consideration the specific needs of your patients? Which clinical setting was the tool originally designed for? Is it easy to use and understand? 8

11 The Braden Risk Assessment Tool is one of the few tools which has been assessed in a variety of settings i.e. nursing homes and hospitals. While it is advocated that this tool is used, it should be remembered that the issue of risk assessment is an evolving clinical activity and practitioners should be aware of any new and updated research findings in this field, and adapt their clinical practice accordingly. On the basis of the available evidence the Braden Risk Assessment Tool should be adopted. The patients who should have their risk of developing pressure sores calculated include: (i) Emergency Medical and Surgical Admissions These patients should have a risk assessment carried out within two hours of admission. Note: Acutely ill patients may have other clinical priorities before this assessment is carried out. Pressure reducing interventions should not be withheld. Acutely, unconscious, sedated and immobile patients are all high risk. (ii) Elective Admissions These patients should have a risk assessment carried out if they have one or more of the recognised intrinsic factors present or if they have a history of pressure sores. Note: (iii) Any patient, regardless of admission status, could become an at risk patient during the course of their stay. Care in the Community All patients in the community who develop an acute illness or who have decreasing mobility, neurological conditions and/or a history of pressure sores should have a risk assessment for pressure sore development carried out by the district nurse or other health professional. 9

12 3.3 At Risk Patients All individuals at risk of developing pressure sores should have a systematic skin inspection of their pressure points at least once a day. Any skin damage should be recorded using the recommended pressure grading tool. It should be noted that in the earliest phases of deep pressure sore development there may be no outward visible evidence of the pressure damage. It is therefore important that at risk patients have immediate pressure relieving interventions. Avoid massage over bony prominences as this can cause skin damage. When patients are lying on their side, avoid positioning directly on the trochanter. The frequency of reassessment depends on the clinical status of the patient. It is not possible to be prescriptive about this except to say that when there is a deterioration in the clinical status of a patient reassessment should be mandatory. Providers of care should : advocate the use of one tool within a care setting; ensure staff receive training on use of the selected tool; provide guidance on when and who to assess; audit the use of the tool and patient outcomes. Pressure sore risk assessment is concerned with clinical judgement. 10

13 4. PRESSURE SORE CLASSIFICATION Pressure sores can be classified, graded or staged. A standardised classification system for pressure sores is desirable as: it improves communication and enables clinical staff from different disciplines to record and review progress of a pressure sore without ambiguity; it facilitates audit so that comparisons can be made between different clinical settings; it allows comparisons to be made in clinical trials of interventions for the prevention and treatment of pressure sores. There are at least 17 different pressure sore classification scales with multiple variations in local use. There has been no national consensus reached regarding which tool to use. This document advocates the use of the following grading tool - NPUAP, (NATIONAL PRESSURE ULCER ADVISORY PANEL 1989) which is a simple, reliable and easy tool to use. 11

14 NPUAP Classification of Wounds GRADE 1 Non blanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discolouration of the skin, warmth, oedema, induration or hardness may also be indicators. GRADE 2 Partial thickness skin loss involving epidermis, dermis or both. The ulcer is usually superficial and presents clinically as an abrasion, blister or shallow crater. GRADE 3 Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. GRADE 4 Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures eg. tendon joint capsule. Undermining and sinus tracts may also be associated with stage 4 ulcers. When eschar or necrotic tissue and/ or black discoloured tissue is present it is impossible to grade until the eschar is removed and/or the black discoloured tissue breaks down. Treat as a Grade 4 sore until grading can be carried out. However as outlined in the CREST General Management Principles Document, it may not always be appropriate to remove necrotic tissue/eschar. Please follow the guidance provided in this document and if debridement is appropriate then grade accordingly. 12

15 Successful introduction of a Pressure Sore Grading Tool such as NPUAP requires: staff training on the use of the tool; audit of the use of the grading tool. The use of a grading tool requires a clear understanding of the anatomy and physiology of the skin Grading a pressure sore classifies tissue damage there is also a need to describe the nature of the wound: Necrotic Wounds Necrosis is a term used to describe dead (ischaemic) tissue, e.g. Eschar and Slough. However, within the field of wound care the term tends to be used to describe dead tissue which is black/brown in colour. Note: Hard, black, dehydrated, leathery necrosis is known as ESCHAR Sloughy Wounds Slough is a term used to describe the accumulation of dead cellular debris on the wound surface. It tends to be yellow in colour due to the large amounts of leucocytes present. Its presence will delay healing. Warning! Yellow tissue is not always indicative of slough. You may be looking at subcutaneous tissue, tendon or bone. Granulating Wounds Granulation is the process by which the wound is filled with highly vascular connective tissue. Granulation tissue is usually red and moist and has an uneven granular appearance. Unhealthy infected granulation tissue often looks dark and bleeds very easily. Epithelialising Wounds Epithelialisation is the process by which wounds are covered with epithelial cells. This process can be recognised by the presence of pink-purple tissue which migrates from the wound edges and/or the remnants of hair follicles in the wound bed. 13

16 5. PROVIDING PRESSURE REDUCTION/ RELIEF The initial emphasis for the acutely at risk patient is the management of the acute illness, relief of dehydration and the correction of underlying illnesses. These patients should mainly be nursed in bed to assist in reduction/relief of pressure. This prevents postural hypotension; improves peripheral blood flow and reduces leg oedema. Bed rest also improves sleeping and reduces exhaustion. Ill patients should be sat out in chairs for short periods only e.g. for meals. 5.1 Repositioning Written repositioning schedules should be developed even when at risk patients are using a pressure reducing/relieving support surface. Establishing a written repositioning schedule is part of a pressure prevention programme. 5.2 Static Mattresses A Department of Health funded study in 1993 demonstrated that the modern pressure-reducing mattresses give lower interface pressures than the conventional standard NHS mattress which gives very high pressures. Evidence exists to support the use of static pressure reducing foam mattresses over standard NHS mattresses. No patient at risk of a pressure sore should be nursed on a NHS standard mattress. A high density foam/low interface mattress should be used. Pressure reducing foam mattresses, in conjunction with a repositioning turning programme should be used to prevent pressure sores in moderate to high-risk patients. 5.3 Alternating Air Pressure Systems - overlays, mattresses and beds (i) Overlays Overlays are electronically powered, air-filled mattresses with large cells which inflate and deflate in a 5-10 minute cycle. They thereby continually alter the high pressure points under a recumbent patient allowing constant restoration of blood flow and relief of ischaemia. Cycle time, number, shape and size of cells vary between manufacturers. At risk acutely ill patients should be placed on alternating overlays in the first instance. 14

17 (ii) Mattresses/Beds these mattresses and beds are more sophisticated systems with either figure of eight shaped cells or a double layer of cells. Inflation pressures are automatically adjusted and pressure sensors prevent bottoming out. They may also have facilities to switch to a static mode for transferring patients and performing procedures. There is little to choose between the various models. There is good evidence to support their use in pressure sore prevention when compared to standard NHS mattresses or pressure reducing foam mattresses. At risk, acutely ill patients and immobile patients - with or without pressure sores, should be considered for an alternating mattress replacement. 5.4 Constant Low Air Pressure and Air Fluidised Systems overlays, mattresses and beds (i) Low Air Loss Systems these systems range from simple air flotation overlays to expensive low air loss beds. They are described as soft support systems designed to prevent capillary occlusion and ischaemia by a wider distribution of body weight. Air is constantly pumped into the cells and then slowly lost through the vapour permeable cell material. The beds can be very sophisticated with pressure adjustments for individual groups of cells and electronically powered sections for changing position. Patients unable to tolerate an alternating pressure system could be tried on a low air loss system. (ii) Air Fluidised Beds These beds use air pumped through ceramic microspheres to produce a dynamic non-alternating support system. The patient is separated from the microspheres by a semipermeable filter sheet. The beads clump together when contaminated with fluid, fall to the base of the bed, and thereby the bed self sterilises. The beds are expensive, heavy and may cause practical difficulties. Air fluidised beds should be reserved for patients with specialised problems i.e. burns, exudating wounds or intractable pain. 5.5 Guidance for Practice Pressure relief or reduction can be achieved by a variety of means: use of a pressure reducing foam mattress with a vapour permeable two way stretch cover; use of a pressure reducing foam cushion; regular re-positioning of the patient using the 30 degree tilt; early rehabilitation of the patient; 15

18 use of an alternating/dynamic mattress/overlay; use of an alternating/dynamic cushion; seating appropriate to the individual patient s height/weight/mobility; patient and carer education. 5.6 Seating Patients at acute risk of pressure sore development, with or without pressure sore damage should not be nursed out of bed for long periods. A pressure relieving mattress or bed is superior to a pressure relieving cushion. When choosing chairs or cushions for at risk patients the advice of the occupational therapist or technical officer should be sought. Chairs must be carefully chosen and selection will depend upon how often the patient uses the chair. Consideration should be given to postural alignment, distribution of weight, balance, stability and pressure relief. Generally a chair should give support to thighs so that the patient s feet are flat on the floor, provide good lumbar support, maintain good head and neck posture and allow the arms to be in a comfortable and functional position. Patients should be referred to Occupational Therapy for a seating assessment and further advice, especially when they have special needs. Note: Do not use: ring cushions; additional covers to protect cushions, as these can become creased thus increasing shear forces. 5.7 Management of Mattresses Mattresses are subjected to an enormous amount of wear and tear. They should be: checked to see if they bottom out by a simple hand check; examined for splits and thinning in the covers; assessed to determine if the inner foam is wet, soiled or contaminated; date stamped on arrival; washed in between patient use; turned weekly or as per manufacture s guidelines; Note: a mattress replacement policy should be planned and on-going; an equipment inventory should be held in each department/locality. 16

19 6. MONITORING PRESSURE SORES The occurrence of pressure sores is typically measured as either prevalence or incidence within a population. The need to reduce the incidence and prevalence of pressure sores has been emphasised in the Department of Health document Pressure Sores: a key quality indicator (1993) which suggested an annual reduction of at least 5-10% in their incidence as a reasonable target. PREVALENCE is the number of people with ESTABLISHED pressure sores DIVIDED by the total population at a FIXED period of time. Prevalence can provide a useful snapshot of the distribution of pressure sores between different diagnostic groups covering a large population. However, it is strongly affected by factors such as admission of new patients, patients healing rates, effectiveness of pressure ulcer treatment, discharge policies etc. INCIDENCE is the number of people DEVELOPING pressure sores in a given population DIVIDED by the number of individuals in that population. Incidence, on the other hand is measuring how many patients develop pressure sores during their hospital stay/community care, possibly reflecting on the quality of preventive care and/or the case mix Data collection To set up a quality monitoring programme to measure incidence the following should be included: age; diagnosis; reason for admission; source of admission e.g. from home or another hospital; risk score e.g. Braden; state of skin on admission; presence of sores on admission; site of sore; grade of sore e.g. NPUAP tool; type of support surface. 17

20 7. DISCHARGE ARRANGEMENTS 7.1 Information Effective discharge/transfer of a patient from one care setting to another requires good quality written and verbal patient information, irrespective of the nature or type of health care problems. Further information for patients may be found in the Department of Health Guidance Your guide to pressure sores (1995). 7.2 Guidance for Practice Patients moving between care settings should have the following information provided: the risk score of the patient; details of pressure points and skin prior to discharge; type of bed/mattress the patient has required; type of seating the patient has required; details of any healed sores; site and size of existing sores; grade of sore/progress of sore; type of dressing currently used and frequency of change; any allergies to dressings; any on-going nutritional support. Advance notice should be given when transferring a patient from hospital to home/nursing home/hospice/residential care if pressure relieving equipment is required. 18

21 8. DEVELOPING A PRESSURE SORE PREVENTION AND TREATMENT POLICY Successful implementation of a pressure sore prevention and treatment policy requires the following: management support; education and training; the support and active involvement of key clinical staff. The Kings Fund (1993) paper The Prevention and Management of Pressure Sores within Hospital and Community Settings describes a strategy for individuals and groups seeking to introduce a properly organised and audited pressure sore prevention and treatment programme. The development of an effective strategy requires the following: 1. formation of a multidisciplinary pressure sore group; 2. collection of baseline information about patients, resources and existing knowledge; 3. interpretation of this data and identification of problems; 4. development of an implementation strategy; 5. monitoring the programme. Guidelines are more likely to be effective if they take into account local circumstances and are disseminated by an active educational and training programme. 19

22 9. AUDIT Audit of prevention of pressure sores could be divided into two aspects: patient audit; facility audit. 9.1 Patient Audit Has a risk assessment been carried out on this patient? Is this patient identified as being at risk of pressure sore development? If this patient is at risk of developing pressure sores, has a plan of care been instigated which highlights the following? the type of bed to use; the frequency of position changes; involvement of other disciplines. If the patient has a pressure sore has the following been noted: the site, size and grade of sore; the type and frequency of dressing to use; referral to the dietician; the effectiveness of the plan. 9.2 FACILITY AUDIT Has this unit got a prevention of pressure sore policy? Is there a mattress replacement policy in the unit? Is there guidance provided on allocation of pressure relieving equipment? Does the policy advocate the use of a single risk assessment tool? Is there guidance provided on the use of a grading tool? Do staff know of the existence of the policy? 20

23 Appendix 1 Braden Scale For Preventing Pressure Sore Risk HIGH RISK: Total score<12 MODERATE RISK: Total score LOW RISK: Total score if under 75 years old OR if over 75 years old DATE OF ASSESS. Risk factor Score/Description SENSORY PERCEPTION Ability to respond meaningfully to pressure related discomfort. 4. NO IMPAIRMENT: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. MOISTURE Degree to which skin is exposed to moisture. ACTIVITY Degree of physical activity. MOBILITY Ability to change and control body position. NUTRITION Usual food intake pattern. 1 NPO: Nothing by mouth 2 IV: Intravenously 3 TPN: Total parenteral FRICTION AND SHEAR TOTAL SCORE 1. COMPLETELY LIMITED: Unresponsive(does not moan, flinch or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body surface 1. CONSTANTLY MOIST: Skin is kept moist almost constantly by perspiration, urine etc. Dampness is detected every time patient is moved or turned. 1. BEDFAST: Confined to bed. 1. COMPLETELY IMMOBILE: Does not make even slight changes in body or extremity position without assistance. 1. VERY POOR: Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 serving or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR is NPO 1 and/or maintained on clear fluids or IV 2 for more than 5 days 1. PROBLEM: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. 2. VERY LIMITED: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over ½ the body. 2. VERY MOIST: Skin is often, but not always moist. Linen must be changed at least once a shift. 2. CHAIRFAST: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 2. VERY LIMITED: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 2. PROBABLY INADEQUATE: Rarely eats a complete meal and generally eats only about1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than the optimum amount of liquid diet or tube feeding. 2. POTENTIAL PROBLEM: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. Total score of 12 or less represents HIGH RISK 3. SLIGHTLY LIMITED: Responds to verbal commands, but cannot always communicate discomfort or need to be turned OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. 3. OCCASIONALLY MOIST: Skin is occasionally moist, requiring an extra linen change approximately once a day. 3. WALKS OCCASIONALLY: Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. 3. SLIGHTLY LIMITED: Makes frequent though slight changes in body or extremity position independently. 3. ADEQUATE: Eats over half of most meals. Eats a total of 4 servings of protein (meats, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered OR is on a tube feeding or TPN 3 regimen which probably meets most of nutritional needs. 3. NO APPARENT PROBLEM: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. 4.RARELY MOIST: Skin is usually dry, linen only requires changing at routine intervals. 4. WALKS FREQUENTLY: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours. 4.NO LIMITATIONS: Makes major and frequent changes in position without assistance. 4. EXCELLENT: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. ASSESS DATE EVALUATOR/SIGNATURE/TITLE ASSESS DATE EVALUATOR/SIGNATURE/TITLE 1 / / 3 / / 2 / / 4 / / NAME Last, First, Middle Attending Physician ID Number Source : Barbars Braden and Nancy Bergstrom Copyright, Reprinted with pernission. 21

24 Please Note: The Braden Scale has been reprinted with permission. Anyone wishing to use this scale in their own clinical setting should obtain permission by contacting Professor Nancy Bergstrom at: University of Nebraska Medical Centre College of Nursing 600 South 42nd Street Omaha, NE Fax: (402)

25 Appendix 2 Choosing Equipment for Patients at risk of Developing Pressure Sores NOTE: As the patient s condition changes - the surface they are nursed on should reflect the change. Your clinical judgement and patient wishes are an important part of your decision making process. Always read the manufacturers guidance on equipment use Trusts should refer to their own service level agreement with the CSA and hospital policy and select brand of mattress accordingly. 23

26 Appendix 3 Guideline Development Sub-Group Mrs Dianne Gill Dr James Kelly Ms Andrée McCollum Mrs Anne Witherow (Chairman) Pharmacy Services Manager United Hospitals Trust Consultant Physician Sperrin Lakeland Trust Director of Pharmaceutical Services Eastern Health and Social Services Board Tissue Viability Nurse Altnagelvin Hospital Trust These guidelines were circulated in draft form to a number of individuals with an interest in this clinical area both regionally and nationally. The group wish to thank everyone who read and commented on the draft guidelines. Special thanks are due to : Dr GCJ Bennett Dr A Beirne Dr M Bliss Mrs A Colgan Ms C Dealey Ms KS Gebhardt Mrs J Hutchinson Ms V Jones Ms C Leyden Ms A Nelson Consultant Geriatrician - Mile End Hospital, London Recorder European Pressure Ulcer Advisory Panel Consultant Geriatrician Altnagelvin Hospital Trust Consultant Geriatrician (Author) Homerton Hospital, London Inservice Education Consortium Western Health and Social Services Board Tissue Viability Nurse (Author & Clinician) Birmingham Tissue Viability Nurse St George s Hospital, London Editor of Journal of Tissue Viability Clinical Services Manager, Surgical Directorate Altnagelvin Hospital Trust Education Director Wound Healing Research Unit Cardiff Medicine, Wales Lecturer University of Ulster Lecturer and Research Fellow Cochrane Research Centre, York 24

27 Appendix 4 CREST WOUND MANAGEMENT GROUP Mrs Mary Waddell [Chairman] Dr John Andrews Mrs Lilian Bradley Miss Jackie Campbell Dr Vanessa Chambers Mrs Janette Collins Mrs Dawn Connolly Miss Jill Cundell Mrs Jeannie Donnelly Dr Brid Farrell Dr Colin Fitzpatrick Dr PJ Fox Mr Paul Gawley Mrs Dianne Gill Mr Stephen Guy Professor Randal Hayes Mrs Marilyn Higgin Dr Carmel Hughes Dr Hilary Jenkinson Mrs Kay Kane Dr James Kelly Director of Nursing Eastern Health & Social Services Board Consultant Physician United Hospitals Trust Leg Ulcer Advisor Ulster Community & Hospitals Trust Senior Podiatrist Newry & Mourne Trust Pharmacist DHSS Dermatology Ward Sister Craigavon Area Hospital Group Trust Research Project Nurse Craigavon Area Hospital Group Trust Chief Podiatrist Homefirst Community Trust Tissue Viability Nurse Royal Hospitals Consultant in Public Health Southern Health & Social Services Board Medical Advisor Eastern Health & Social Services Board General Practitioner Ballymena Health Centre Orthotist, Bullen Health Care Musgrave Park Hospital Pharmacy Services Manager United Hospitals Trust Pharmacist Royal Hospitals Consultant Physician Belfast City Hospital Trust Specialist Health Visitor Belfast City Hospital Trust/ South & East Belfast Community Trust Lecturer, School of Pharmacy Queens University, Belfast Consultant Dermatologist United Hospitals Trust Nurse Manager, Community Nursing South & East Belfast Community Trust Consultant Physician Sperrin Lakeland Trust 25

28 Mr Bernard Lee Dr Jill Mairs Dr Carolyn Mason Dr Barry Mitchell Ms Andrée McCollum Miss Alyson Moore Mrs Elizabeth Moore Dr Kenneth Moles Mrs Bronagh Monaghan Mrs Mary O Hare Mrs Heather Reid Dr Keith Steele Ms Kathryn Turner Dr Jane Whiteman Mrs Anne Witherow Miss Ruth Woodmartin Consultant Vascular Surgeon Belfast City Hospital Trust Regional Procurement Pharmacist Eastern Health & Social Services Board Assistant Director of Nursing Eastern Health & Social Services Board General Practitioner Lodge Health, Coleraine Director of Pharmaceutical Services Eastern Health & Social Services Board Chief Dietitian Royal Hospitals Senior Dietitian Royal Hospitals Consultant Physician Altnagelvin Hospital Trust Chief Podiatrist Belfast City Hospital Trust Research Pharmacist Royal Hospitals Project Manager Eastern Health & Social Services Board General Practitioner Dunluce Health Centre, Belfast Pharmaceutical Advisor Eastern Health & Social Services Board Senior Pharmacist Greenpark Health Care Trust Tissue Viability Nurse Altnagelvin Hospital Trust Chief Dietitian Greenpark Health Care Trust CREST REPRESENTATION Dr Philip McClements Deputy Chief Medical Officer, DHSS Convenor of CREST CREST SECRETARIAT Miss Angela Lowry Mrs Isobel Scott Mr Gary Hannan 26

29 GLOSSARY Bottoming out Debridement Erythema Blanchable erythema Non-blanchable erythema Eschar Exudate Fascia Friction Pressure Reduction Pressure relief Expression used to describe inadequate support from a mattress overlay or seat cushion as determined by a hand check. If, when a fist is pressed into the surface of a mattress or seat and the supporting base can be felt, the item has bottomed out and is no longer able to provide pressure relief. Removal of devitalized tissue and foreign matter from a wound by various means i.e. chemical, surgical or autolytic debridement. Redness of the skin. Reddened area that temporarily turns white or pale when pressure is applied with a fingertip. Blanchable erythema over a pressure site is usually due to a normal reactive hyperaemia response. Reddened area that remains red when pressure is applied. Thick, leathery, necrotic, devitalized tissue. Any fluid that has been leaked from a tissue or capillaries, more specifically because of injury or inflammation. A sheet or band of fibrous tissue that lies deep below the skin or encloses muscles and various organs of the body. Mechanical force exerted when skin is dragged across a coarse surface such as bed linens. Reduction of interface pressure, not necessarily below the level required to close capillaries. Reduction of interface pressure below capillary closing pressure. Support surfaces Air-fluidised bed Alternating mattress Rubber ring device Dynamic mattress Bed which uses a high rate of air flow to fluidize fine particulate material (such as sand) to produce a support surface that has characteristics similar to a liquid. Mattress or overlay with interconnecting air cells that cyclically inflate and deflate to produce alternating high and low pressure intervals. A rigid, ring shaped device created to relieve pressure on the sitting surface. Pressure-reducing device designed to change its support characteristics in a cyclical fashion. 27

30 Overlay Static mattress General term used to describe support surfaces placed on top of a standard hospital mattress Pressure reducing device designed to provide support characteristics that remain constant. 28