Maintaining Skin Integrity and Preventing Pressure Ulcers

Transcription

1 Maintaining Skin Integrity and Preventing Pressure Ulcers Information for Nursing Care Homes Version January2018 (Review date 2020)

2 Introduction to using this resource folder This folder contains comprehensive information about the assessment, monitoring and maintenance of skin integrity for care home residents. The focus is on prevention of skin damage but also includes what to consider if the skin is broken. Where available, it includes National evidence-based guidelines. This folder contains information for registered nurses including top tips to ensure your residents are protected from skin breakdown. All care home staff should have training on how to prevent pressure ulcers and this guide contains information that can support staff training. Registered nurses should have training in wound management and work within their sphere of competence (NMC 2015). This resource folder has been developed by the Sutton Homes of Care Vanguard. The contents of this folder represent best practice in this area of care; however, the safe and effective management of residents needs remains the legal responsibility of the care home. Contents Page 1.0 The Skin Why is the skin important? 3 What happens to the skin as we get older? 3 What causes damage to the skin? Pressure ulcers What is a pressure ulcer? 4 How do I know if my resident is at risk of pressure ulcers? 5 Interpreting the Waterlow score- what to do next Minimising risk using SSKIN prevention guidance 3.1 Surface: Support surfaces including mattresses and cushions 3.2 Skin: How to keep the skin healthy, how to inspect the skin and what to look for 3.3 Keep moving: Supporting your residents to change position 3.4 Incontinence: Supporting your residents with incontinence 3.5 Nutrition: Supporting your residents to eat and drink well 3.6 How to write a care plan for residents at risk/with pressure ulcers Other types of skin damage 4.1 Moisture lesions 4.2 Trauma (Skin tears) 4.3 Skin changes at end of life Safeguarding your residents Residents transferring between care settings References, acknowledgements and further information 17 Appendices Page A Stages of pressure ulcers (3 pages) 19 B Waterlow risk assessment tool 22 C Guidance on checking mattresses 23 D Example repositioning/turning chart (double-sided) 24 E Resident and family information leaflet 26 F Example wound assessment chart 27 G Pictures of moisture lesions 29 2

3 1.0 The Skin Why is the skin important? The skin is the largest organ in the human body and is a protective barrier. It shields the body against heat, light, injury, and infection. The skin also helps regulate body temperature and gathers sensory information from the environment e.g. touch, pain, pressure, vibration and temperature. The skin stores water, fat and vitamin D, and plays a role in the immune system protecting us from disease. The skin is naturally acidic with a ph of which inhibits the growth of bacteria and fungi. The skin is made up of three layers which are outlined in table 1 below. Table 1: Layers and function of the skin Layer Thickness Components Function Epidermis 0.1mm Skin cells Protective shield Dermis 2 mm Connective tissue, blood vessels, lymph vessels, nerve fibres, sweat glands, hair follicles, sebaceous (oil) glands Hypodermis variable Fat cells Connective tissue Structure and support Temperature regulation Sensation e.g. touch, pain Skin hydration and nourishment Insulation from cold Shock absorption Storage of nutrients and energy What happens to the skin as we get older? As the skin ages it becomes thinner and loses elasticity so it becomes more wrinkled and saggy. The amount of fat under the skin tends to decrease, making the skin more prone to bruising, more fragile and easily damaged. There is often a reduced blood supply which means any injuries to the skin may be slow to heal and regulation of body temperature is not as effective. The loss of natural moisturising factors in the older person s skin also reduces skin hydration and causes it to become dry and flaky. Dry skin is itchy and this can lead to scratching and skin breakdown. 3

4 What causes damage to the skin? The skin can be damaged by cuts, bruises, scrapes, tearing, constant moisture, friction, unrelieved pressure and shearing forces (the skin moving in one direction and the body moving in the opposite direction) as outlined in Table 2 below. In older people, the skin is more fragile and less resilient and therefore is at high risk of damage from any of the above. This resource folder contains information regarding pressure ulcers, moisture lesions and skin tears. Table 2: Causes of skin damage *Definition from Oxford English dictionary (online) Pressure* Continuous physical force exerted on or against an object by something in contact with it Shear* A strain produced by pressure in the structure of a substance, when its layers are shifted laterally (sideways) in relation to each other (the skin and underlying body are pulled in different directions, e.g. when a person slips down the bed) Friction* The action of one surface or object rubbing against another, e.g. heels rubbing against a sheet Moisture Water or other liquid, e.g. urine, faeces and sweat in contact with the skin Trauma Physical injury for example due to cutting, tearing or burning 2.0 Pressure Ulcers What is a pressure ulcer? A pressure ulcer occurs when the skin and underlying tissue gets damaged by unrelieved pressure. Essentially the skin, its blood supply and underlying tissue are squashed between the hard surface (the cause of pressure) and the underlying bone. The extent of the damage is dependent on which of the skin layers (see section 1 above) are affected and in serious cases; the underlying muscle and bone can also be damaged. What you see at the skin s surface is often the smallest part of the ulcer, and the tissues under the skin near the bone suffer the greatest damage. Every pressure ulcer seen on the skin, no matter how small, should be regarded as serious because of the probable damage below the skin surface. Damage can result from high pressure for a short period of time or low pressure for a longer period of time. In 95% of cases, pressure ulcers are completely preventable with good care and therefore they are classified as an avoidable harm. This is why skin damage and pressure ulcers have to be reported- see section 5. The areas that are most at risk of developing pressure ulcers are the parts of the body that are not covered by a high level of body fat (bony prominences) and are in direct contact with a supporting surface, such as a bed or chair. Common areas are the heels, toes, sacrum, hips, elbows, shoulders and back of the head as shown in picture 1 below. Pressure damage can be caused by items other than hard surfaces, for example tight clothes and buttons, support stockings, wrinkles in the bed sheets, medical devices such as urinary catheters and oxygen tubing, or body parts laying on each other such as knees/ankles when in bed. Being observant whilst caring for your residents will help you identify other potential risks to their skin. 4

5 Picture 1: Common areas at risk of developing pressure ulcers Pressure ulcers can have a significant impact on the wellbeing of your residents, including long-term pain and distress, embarrassment (some pressure ulcers smell), restricted lifestyle whilst the ulcer is healing and an increased risk of life-threatening infection, such as sepsis. Pressure ulcers are categorised into different stages depending on the extent of damage to the skin and underlying tissues. Appendix A illustrates the different stages of pressure ulcers. How do I know if my resident is at risk? There are many factors that increase the risk of developing a pressure ulcer and these are outlined in table 3 below. Generally anyone living in a care home will be at risk due to a combination of factors such as their age, reduced independence and levels of mobility and long term health conditions. Early recognition of individuals at risk of pressure damage is an essential part of prevention and formal assessment enables the correct interventions to be started and maintained. Table 3: Risk factors for developing pressure ulcers Risk factor Rationale Age The older you are the more fragile and thin your skin is. Sex Women are at higher risk due to distribution of body fat compared to men. Reduced/restricted The less able a person is to move independently, the less able they are to mobility relieve pressure. Poor moving and handling techniques can increase a person s risk, particularly moving someone up in the bed/chair as there is an increased Condition of the skin including previous pressure ulcers Body shape Reduced sensory function Incontinence Appetite and diet Medicines risk of both shear and friction forces on the skin. Skin that is already compromised or damaged is at greater risk of further breakdown. A history of previous pressure ulcers constitutes high risk Being underweight means the skin has less fat to provide protection whereas being overweight means the additional body weight adds extra pressure. Reduced sensitivity to feeling pain and pressure (due to a medical condition or nerve damage) makes it harder to recognise that something is wrong. Exposure to constant moisture damages the skin, urine and faeces are particularly irritating. Good nutrition and hydration are important to keep the skin healthy and to promote healing in any damaged areas. Some medicines affect the thickness of the skin e.g. steroids and antiinflammatories or make the skin more prone to bruising e.g. anticoagulants. 5

6 Other health conditions Some medical conditions affect the blood supply to the skin and therefore it receives less oxygen and nutrients to keep it healthy. Examples include diabetes, organ failure, peripheral vascular disease and anaemia. Neurological conditions (affecting the brain and/or spine) such as stroke and multiple sclerosis impact on the skin due to a combination of reduced mobility, changes to sensation, blood circulation and medicines. Being completely immobile for a period of time (usually 2 days or longer) increases the risk. Examples for care home residents include a period of illness requiring bed rest, a visit to A+E where they will be lying or sitting on a trolley, waiting in transport lounge. Every resident should have their risk of developing pressure ulcers assessed using a validated tool such as the Waterlow risk assessment scale. This should be completed within 6 hours of admission to the care home (NICE 2014). The risk should also be reassessed as frequently as required and when there is a clinical concern or change in the person s mental or physical status, for example in the following situations: weight loss or change to appetite changes to the skin e.g. bruises, cuts changes to continence e.g. diarrhoea or increasing episodes of incontinence prolonged or recurrent illness or infection changes to mobility levels If your resident has been in hospital (or another care setting), it is good practice to reassess their risk of pressure ulcers (and other risk assessments) when they return to the care home, in case they have changed whilst in hospital. A copy of the Waterlow tool can be found in Appendix B. Interpreting the Waterlow score -What to do next? The action required will be slightly different depending on whether your resident has scored between (at risk), (high risk) or more than 20 (very high risk). The main differences will be what type of pressure ulcer prevention strategies will be required. For every resident, it is important to initiate prevention measures which can be remembered by the abbreviation SSKIN: Surface, Skin, Keep moving, Incontinence, Nutrition (see The SSKIN preventative measures relate to the risk factors that can be addressed and modified and they are discussed further below. Health conditions that affect the risk of developing pressure ulcers should be reviewed and their treatment and management optimised in liaison with the GP (e.g. good control of diabetes and blood glucose levels). A medication review can identify medicines that are affecting the risk score and consider whether this risk can be reduced. Registered nurses need to initiate preventative measures (using SSKIN principles outlined below), including the provision of suitable pressure relieving equipment and minimising known risk factors. Any wounds or pressure ulcers identified during the risk assessment require a management plan. 6

7 3.0 Minimising risk using SSKIN prevention guidance 3.1 Surface This refers to the surface that residents are sitting or lying on, in other words, the chair cushion and bed mattress. The surface underneath the resident needs to provide the right amount of support and comfort and no resident at risk of pressure ulcers should be nursed on anything less than a high-specification foam mattress (NICE 2014). Residents are at greater risk of pressure damage when seated than they are when lying in a bed due to the distribution of their body weight. Continue to move residents frequently whatever the type of support surface is used and make sure bedclothes and clothing are smooth under the resident when repositioning. Don t use too many Inco sheets or plastic-backed Inco sheets as this may make the skin sweat more and add risk of moisture on the skin (see section 4.1). It is important to use the correct moving and handling techniques as tissue damage may also occur when a resident slumps in a chair or slips down the bed during repositioning. Support surfaces may also be described as pressure relieving equipment that work by either spreading out the pressure (redistribution) or removing pressure regularly from different parts of the body (alternating). These are expensive sophisticated products which, in the case of residents at high and very high risk, can make all the difference to their susceptibility to pressure ulcer damage. It is important that you know how to check and document that the support surface being used is in good working order so that it provides the support your resident requires. How to check a foam mattress The amount of support a mattress/cushion will provide is dependent on it being fit for purpose. After a period of use, mattresses/cushions can bottom out. This can be tested for by spreading the hands and pushing down on the middle third of the mattress. It should not be possible to feel the base of the bed. Though a very simple test, it is one that is easily carried out, and gives you a very good idea of the state of the mattress. Mattresses and mattress covers should be examined for damage or staining, which will create a risk of cross infection. Further information for care home managers regarding checking mattresses can be found in Appendix C. How to check a pressure-relieving mattress There are several things that need checking to ensure the mattress will provide the support that is required. These are outlined in the table below and should be explained in the manufacturer s instruction booklet. Table 4: Things to consider when checking a mattress Power supply Check it is plugged in and switched on Weight-setting Is it set correctly for the weight of your resident? Is there a static button Is the static button switched to Off? (not all mattresses have this) Settings/buttons What are the other settings- should they be on/off? Alarms What do the different alarms mean? What do you need to do to correct the problem? Cover Is it damaged or stained? 7

8 To select the right mattress, the following need to be considered: the level of risk, weight and size of the resident, ease of use, moving and handling requirements and any safety issues. Consult the manufacturer s instructions to ensure you know how to check the settings, alarms and that it is working. The mattress settings should be clearly documented on a pressure ulcer prevention care plan (see section 3.6). To check that the air mattress is working effectively: With the resident on the mattress, place a hand underneath the residents heaviest part (i.e. their pelvis/buttocks) Press to see if you can feel air supporting the resident. You should not be able to feel the hard bed-base If you can feel the hard bed-base, your resident will also feel the bed-base and the mattress is not providing adequate support. Pressure relieving equipment should be checked every time the resident is assisted to change their position and this can be easily documented on a repositioning/turning chart, see Appendix D. If the equipment is not working as expected, urgent action is required to rectify the problem to ensure your resident still receives pressure-relief. 3.2 Skin How to inspect the skin Routine skin inspection plays a role in decreasing the incidence of pressure ulcers. All residents should have their skin assessed on admission as part of a holistic assessment and then checked at least every day. Inspect all areas of the skin regularly, with particular attention paid to bony prominences (see picture 1) and areas of skin that come into contact with devices such as catheters, compression stockings etc. A compact mirror is helpful to visualise difficult to see areas such as the heels when the resident is in a chair. Encourage and educate residents who are willing and able to inspect their own skin and ensure relatives know how they can help. A resident and carer information leaflet can be found in Appendix E. When inspecting the skin, look for any of the following (early signs of pressure damage): Reddened areas of skin on light skinned people Blue/purple patches on dark skinned people Blisters Hot or cool areas Swelling Signs of irritation, or scratches Patches of hard skin Where an area of redness or skin discolouration is noted, it is important to check the integrity of the skin using the finger test below: Apply light finger pressure to the area for approximately 3 seconds and then release 8

9 If the area you pressed is white and then returns to its original colour, there is probably an adequate blood supply If the area remains red it indicates pressure damage For individuals with dark skin pigmentation, it may be more difficult to identify changes in skin colour. Alternative signs such as localised heat (inflammation) or coolness may indicate pressure damage. The presence of skin blisters over bony prominences is another marker of early pressure damage. Do not ignore any signs of early skin damage or assume an area of discolouration is simply superficial damage; deep tissue damage may present as an area of purple discolouration. Where skin is intact; Keep the skin healthy and well hydrated Continue to inspect the skin daily Continue to use SSKIN prevention measures For areas at risk of breakdown, consider using appropriate skin protection products to maintain skin integrity Initiate a pressure ulcer prevention care plan Where an area of redness, discolouration or breakdown is noted: If non-blanching erythema is noted, the skin should be reassessed every 2 hours until resolved (NICE 2014). Document what you see on a wound chart, including the location, size, depth, stage and the state of the wound bed. An example wound chart can be found in Appendix F. If your resident consents, take a photograph for your records, ideally using a camera with integral grid to enable accurate measurement. Initiate a treatment plan, utilising the latest guidance in the Sutton Community Health Services Wound care Formulary to identify the correct dressing to use. Document areas of pressure damage in the health records and implement a pressure ulcer management care plan (see section 3.6). The time to heal and frequency of re-dressing the wound will be variable depending on the extent of the wound and the dressings used. If the wound does not appear to be healing, refer to the Tissue Viability Nurse specialist (TVN) for further advice and assessment. It is good practice to seek advice from the TVN for all stage 3 and 4 or multiple stage 2 pressure ulcers. Increase the frequency of skin inspection, initiate a repositioning/turning chart and initiate other preventative strategies immediately to reduce pressure to affected areas. Complete a pain assessment and liaise with the GP to ensure adequate pain relief. Any damage to resident s skin, including pressure ulcers are notifiable to the CQC and local safeguarding team- see section 5. How to keep the skin healthy Dry, fragile skin should be rehydrated using a simple, unperfumed moisturiser. Application of the moisturiser should follow the direction of the body hair and be gently smoothed onto the skin. Skin cleansers can be used to clean the skin without rinsing (traditional soaps should be avoided as they can irritate the skin) and be dried gently. Eating well and drinking enough 9

10 water can also keep skin healthy and is vital for wound healing. Fragile skin is at high risk of tearing and therefore if dressings or tapes are needed, these should be non-adherent (nonsticky) dressings. Residents should be encouraged to keep their nails clean and short to reduce the risk of accidental skin tears and infection. If skin becomes too wet, it can become soggy and more easily damaged. It is important to protect the skin from contact with urine and faeces and the harmful irritants in them. Where skin changes are due to excessive moisture, barrier films or creams may also be used to create a protective layer (see section 4.1). Particular care should be taken to ensure that areas of skin folds e.g. buttocks, under breasts and in tummy folds are thoroughly dried. For residents who have contractures (a disorder in which there is abnormal shortening of a muscle so it becomes permanently tightened (contracted), there is a higher risk of skin breakdown due to it being more difficult to keep the area clean and dry. Seek advice for residents who have contractures of the hands due to the risk of their fingernails digging into the palm of the hand and causing pressure ulcers. 3.3 Keep moving To prevent skin damage and pressure ulcers it is important that your resident keeps moving as much as possible and residents who are immobile are at highest risk of developing pressure ulcers. Regular movement or repositioning will redistribute pressure and help prevent pressure damage. Residents who are being cared for on a support surface still need to be repositioned. Residents who are able to get out of bed or their chair should be encouraged to do so whenever possible. Teach residents to change position (offload) every 15 minutes. These movements need only be small but may give a significant difference in pressure. Changing position can be incorporated into everyday activities, e.g. standing up to get a drink, walking/transferring to the toilet. For residents who need help, reposition at least every 1-2 hours when sitting in a chair or in bed e.g. on their left side, then on their back, then on their right side. Residents who have actual damage to their sacral area should only sit out for 45mins-1 hour at a time (depending on severity). When deciding how frequently repositioning is required, consider the wishes of the resident and what they are able to tolerate. Changes to position should be recorded on a repositioning/turning chart, see example in Appendix D. It is important that manual handling aids are used when moving residents e.g. sliding sheets, to avoid dragging the resident along the mattress. To help residents maintain their position when in bed, use a wedge/pillow to maintain a 30-degree side-lying position. Raise the head of the bed to less than 30 degrees to prevent them slipping down the bed. A 30-degree tilt can also be achieved in a reclining chair using a wedge/pillow. This will reduce the risk of placing additional pressure on the hip area. Ensure the resident knows why they are being repositioned and encourage those who can do it for themselves. Ensure relatives know how they can help to reduce the risk. Sometimes 10

11 residents refuse to move or have their position changed for them and further advice on how to manage this situation is outlined in section Incontinence Both urine and faeces are highly irritating to the skin, making it more susceptible to pressure damage and therefore it is important to maintain continence and actively manage incontinence. Incontinence is not a normal or inevitable part of ageing and has many different causes. Always check whether your resident has a urinary tract infection (UTI) as this can be a cause of incontinence in the elderly or make incontinence worse. Where continence problems are identified, the resident should have a full continence assessment to identify the cause and develop a management plan. Some residents will benefit from a referral to the continence service to ensure their continence is being optimally managed. There are a few easy ways to promote continence and reduce the risk of moisture sitting on the skin: Take the Toilet First approach, ensuring residents can access toilet facilities, wear clothing that is easy to remove and are regularly offered support to visit the toilet (every two to four hours). For residents who are regularly incontinent, it may be helpful to develop a timetable that offers a reminder for going to the toilet. Gently clean and dry the skin when continence pads are changed or incontinence occurs. Wash gently, do not rub. Avoid using traditional soaps as they can irritate the skin. Skin cleansing products can be used to clean the skin without rinsing or use a low ph soap which is less irritating. Apply a barrier cream or spray, following manufacturers instructions on how to apply. Prevent the resident becoming too hot and sweaty. Ensure your resident is not constipated as this may have an impact on continence; monitor their bowel activity using the Bristol stool chart. Ensure residents drink enough fluids to prevent them becoming dehydrated. Consider asking the care home pharmacist for a medication review as some medicines can affect continence. If using pads, use 1 pad only, folding length-ways to form a channel. Continence pads should be changed as often as is necessary. Do not use thick creams, ointments or talcum powder as these can reduce the absorbency of the continence pad. If the resident has a catheter, ensure the bag is emptied regularly to prevent it becoming too heavy. Catheter tubing should be secured safely and any problems with the catheter addressed quickly. Continence aids: Using continence aids can help to keep the resident comfortable and protect skin when used appropriately. Incontinence pads and pull-up pants can be worn day and night, or during the night only, to draw fluids away from the skin. It is important to find the right type and absorbency for the individual. They should be comfortable without chafing the skin or 11

12 leaking. They should be changed as often as necessary. Male residents may benefit from using a male continence sheath and these may be particularly helpful when worn at night. 3.5 Nutrition Adequate nutrition and hydration is important for preventing as well as healing pressure ulcers. A nutritional assessment, for example using MUST, will identify residents who are not receiving enough nutrition. Encourage residents to eat a healthy balanced diet and have regular drinks, ensuring residents have a choice and variety available. Encouraging participation in the activities surrounding preparing and serving meals will also keep your residents moving. Assist residents who find eating meals difficult and ensure those at risk of malnutrition are referred to a dietician. If a resident develops a pressure ulcer, it is good practice to refer them to the dietician to ensure their diet is sufficient to enable the ulcer to heal. More information about nutritional assessment and helping residents to eat and drink enough can be found in Nutrition and Hydration- Guidance for nursing and residential care homes. 3.6 How to write a care plan for residents at risk of/ with pressure ulcers Residents who are at risk of developing pressure ulcers need to have a care plan that concisely outlines what specific support is required to enable that person to prevent pressure damage and reduce their risk score. Those who have skin damage or a pressure ulcer will also need a care plan that outlines how the pressure ulcer is being managed and how to promote healing and prevent further damage. Care plans should be written in discussion with the resident and their family and should be specific, measurable, achievable, realistic and time-framed (SMART). The care plan for prevention should outline the following: 1. How often you will reassess their risk of developing pressure ulcers 2. What support surface the resident should be using in the bed/chair, how often this will be checked that it is working properly and how you will know if it is not working or intact. If they are using a pressure-relieving mattress, the correct settings should be documented 3. How often you will inspect their skin and what you are looking for that indicates potential skin damage. If they have specific items that pose a pressure risk, such as support stockings or a catheter, how will these areas be checked 4. How will you encourage the resident to change position (or support those who are unable to move themselves), how often this needs to happen and where will this be documented e.g. turning chart. For those who are unable, include the moving and handling equipment required to change their position and refer to their moving and handling care plan 12

13 5. If there are continence issues, how are these being managed to reduce the impact of urine/faeces on the skin and refer to their continence care plan. If barrier creams/sprays are being used, where and how often should these be applied 6. If nutrition and hydration are contributing to the risk level, what steps are you taking to address this, e.g. fluid chart or additional protein snacks. Refer to their nutrition/hydration care plan 7. If they are using any other pressure relieving equipment e.g. heel protectors, when should it be used and for how long 8. How you will monitor whether the care plan interventions are successful 9. What to do if interventions are not having the impact expected i.e. when and how to refer to the TVN for further advice The care plan for those with a pressure ulcer should outline the following: Elements 1-9 above What treatment/dressing is being used (or refer to the wound chart if this includes this information) and what to do if the dressing comes off How often the pressure ulcer requires reassessment 4.0 Other types of skin damage 4.1 Moisture lesions What is a moisture lesion? A moisture lesion is defined as erosion of the skin due to excessive moisture. The moisture is usually caused by urine, faeces or perspiration. The skin is naturally acidic and both urine and faeces are alkaline, thus changing the acidity of the skin and causing it to breakdown. Exposure to excessive moisture causes the skin to become damp, soggy and clammy and increases the risk of infection and damage due to other reasons e.g. pressure, shearing and friction. The skin affected by a moisture lesion can be described as excoriated (red and dry) or macerated (red and white, soggy and shiny). Moisture lesions are most likely to develop in skin folds e.g. between the buttocks and groin area (particularly with urine and faeces) or underneath the breasts or folds of tummy (particularly with perspiration). Moisture lesions can be extremely painful. Moisture lesions are sometimes confused with pressure ulcers however there must be moisture present before you develop a moisture lesion. Moisture lesions also look different to pressure ulcers; they are superficial, with irregular edges, look red or pink and are blotchy. Appendix G shows what a moisture lesion might look like and Table 5 below outlines the difference between a moisture lesion and a pressure ulcer. Be aware that residents can have both a moisture lesion and a pressure ulcer. Table 5: Differentiating between a moisture lesion and a pressure ulcer Characteristic Moisture lesion Pressure ulcer Cause Moisture must be present e.g. shiny wet skin caused by urinary incontinence or diarrhoea Pressure and/or shear must be present 13

14 Location Shape Skin folds, particularly buttocks, inner thigh and groin area Less likely over bony prominences Irregular shape May be linear or mirror image Diffuse, in several superficial spots Most common over bony prominences (unless the pressure has been caused by a piece of equipment e.g. urinary catheter) Usually circular Regular shape Depth Superficial skin loss Superficial or deep, dependent on stage of ulcer Colour Non-uniform redness Blanchable or non-blanchable erythema Pink/white surrounding skin Uniform redness Edges Diffuse or irregular edges Distinct edges, may be raised Necrosis No necrosis A black necrotic scab may be present, dependent on stage of ulcer How to prevent and manage a moisture lesion The best way to prevent and manage a moisture lesion is to ensure that all skin areas are kept clean and dry. For residents with continence problems, ensure they are offered regular toileting and that the skin is gently cleaned and dried when continence pads are changed or accidents happen. Wash gently, do not rub and use a cleansing wash rather than soap and water (unless low ph soap). Residents whose skin is a risk from exposure to moisture (e.g. those with episodes of urinary or faecal incontinence) may benefit from using a barrier cream or spray (e.g. Conotrane) on certain areas such as the buttocks. These provide a waterproof protective layer to prevent moisture coming into contact with the skin. Ensure you read the instructions for any barrier cream or spray as different brands require a different frequency of application to the skin. Some residents will benefit from a referral to the continence service to ensure their continence is being optimally managed. For severe moisture lesions, a referral to the TVN may be required. 4.2 Trauma- skin tears What is a skin tear? The skin of older people is thin and fragile and is therefore at high risk of cuts and tears. The skin is easily torn when in contact with sharp edges and objects such as jewellery, wheelchair levers and footplates and watches. The risk factors for developing skin tears are: Previous history Shearing, friction and pressure Older age Bruising Impaired mobility Dry or fragile skin Impaired vision Medications Cognitive impairment, e.g. dementia Health conditions affecting the kidneys, heart or lungs Impaired sensation Poor nutrition and hydration 14

15 How to prevent a skin tear Skin tears are painful and if not managed properly could develop into a nasty wound with a high risk of infection. There are many things you can do to prevent your residents tearing their skin. These include: Keep fingernails short (residents and staff) Beware of jewellery (residents and staff) Use the correct moving and handling techniques Beware of wheelchairs, particularly foot plates and levers Use padding to protect vulnerable areas e.g. bed rails and wheelchair arms Ensure good lighting Keep residents skin moisturised Ensure good nutrition and hydration Encourage long-sleeved clothing Be vigilant How to manage a skin tear Rinse with sterile normal saline (0.9%NaCl) Pat dry (clean gauze), applying gentle pressure if bleeding Ensure the flap of skin is returned to its normal position Cover with a soft silicone-coated atraumatic net dressing (e.g. Atrauman; Silfix etc.) Indicate the direction of the skin fold Leave dressing intact, keep dry Review after hours, depending on size Monitor for indicators of non-healing e.g. signs of infection, hot, redness, behaviour change 4.3 Skin changes at end of life As a person reaches end of life, all the organs of the body start to shut down and slowly stop functioning. This includes the skin. Changes at the end of life may affect the skin and soft tissues and changes in skin colour, texture or integrity can be seen. These changes may also cause pain and may be unavoidable despite appropriate interventions. Signs and symptoms associated with Skin Changes At Life s End (SCALE) may include: Muscle weakness and loss of mobility/unable to move independently Loss of appetite, weight loss, not eating or drinking. Reduced supply of blood and oxygen to the skin The management of skin changes at end of life are exactly the same and the prevention of skin damage and management of pressure ulcers should follow the SSKIN principles discussed above. The goals of care are prevention of skin breakdown, promoting healing of existing wounds, providing palliation and comfort (managing pain, minimising odour and risk of infection) and responding to residents preferences and wishes. The supportive care home team can provide further advice and guidance around individualised care planning to support residents at end of life. 15

16 5.0 Safeguarding your residents Reporting incidents and safeguarding The majority of pressure ulcers can be prevented and therefore when they happen, they need to be reported, either as an incident or as a safeguarding. Care Quality Commission (CQC) Regulation 18 outlines that all incidents that affect the health, safety and welfare of people who use services are reportable to the CQC and should also be reported to the commissioner for that bed (e.g. local authority or continuing healthcare). Regulation 18 states: Any injury to a service user which, in the reasonable opinion of a health care professional, has resulted in o changes to the structure of a service user's body, o the service user experiencing prolonged pain or prolonged psychological harm Injuries include those that lead to damage to o any major organ of the body (including the brain and skin) o bones o muscles, tendons, joints or vessels o the development after admission of a pressure ulcer of stage 3 or above (or multiple stage 2) that develops after the person has started to use the service It is good practice to report all incidents of resident harm, including all stages of pressure ulcers to the local authority and CQC. The Safeguarding Vulnerable Adults team at the local authority will determine whether incidents relating to the development of skin damage and pressure ulcers require a safeguarding investigation. Stage 3 or 4 pressure ulcers, unstageable pressure ulcers and multiple stage 2 ulcers must be reported as a safeguarding alert. Care providers also have a Duty of Candour (honesty) to inform the resident and their family members or appropriate others who are involved regarding any pressure damage acquired at the home. Managing residents choice and capacity It is not unusual for residents to refuse to change position or allow care staff to help them turn in bed. For residents with the capacity to make decisions, it is important that you help them to understand what pressure ulcers are, why they are at risk and what they can do to prevent skin damage occurring. You may find the resident information leaflet in Appendix E helpful. If the person has capacity and refuses care, their reasons for refusal should be addressed and clearly documented in their notes. They should continue to be offered the care daily (or again later the same day as appropriate) as people do change their mind. For residents who lack the capacity to make decisions regarding their pressure area care, a best interests meeting must be arranged by the care home to discuss this element of their care requirements. The best interest meeting should involve the family members or advocate, the GP and any other people involved in the care of that resident (e.g. allocated social worker, continuing healthcare if they are funding the placement, TVN). The outcome 16

17 must be clearly documented in their care notes. If additional restrictions are subsequently put in place in order to deliver care in the persons best interests, and they are subject to a DoLS (deprivation of liberty safeguard) the relevant Best Interest Assessor should be informed. Clear documentation of discussions about pressure area care with residents and their family members or appropriate others who are involved will reduce the chances of the home being accused of poor care in the event of a resident developing pressure ulcers. 6.0 Residents transferring between care settings For residents who are at risk or have identified damage to their skin for example a pressure ulcer, moisture lesion or bruising, it is important that this information is communicated if the resident has to go to another care setting e.g. hospital, outpatient appointment, day centre, hospice or other. Staff in these settings will be responsible for ensuring your residents skin integrity is maintained whilst they are there, however they will not know the specific care requirements for your resident. In these situations, it is important to send with them the Waterlow score, a body map and/or wound chart and copies of their skin integrity/pressure ulcer care plans. This will ensure your resident is supported to keep their skin healthy (or have their pressure ulcers/ wounds appropriately managed) whilst they are out of your care. Good documentation and communication with other care settings also helps to prevent the potential for a safeguarding alert for residents attending hospital with skin damage. 7.0 References Alzheimer s Society Continence and using the toilet. Available at: g_the_toilet.pdf 2016 Beldon, P Skin changes at life s end (SCALE): a consensus document. Wounds UK 6(1). Care Quality Commission Regulation 18: Notification of other incidents. Available at: European Pressure Ulcer Advisory Panel SCALE: Skin changes at life s end, final consensus statement. Available at: Guy, H The difference between moisture lesions and pressure ulcers. Wounds Essentials, Volume 1. Available at: NHS Midlands and East. (Date unknown). How to: keep residents skin healthy. Available at: NHS Midlands and East. (Date unknown). How to: Use support surfaces appropriately. Available at: 17

18 NHS Midlands and East. (Date unknown). How to: maintain high quality nutritional care. Available at: NHS Midlands and East. (Date unknown). How to: manage incontinence/moisture. Available at: NHS Midlands and East. (Date unknown). How to: Keep patients moving. Available at: Nursing and Midwifery Council The code for nurses and midwives. Available at: Waterlow, J Pressure ulcer prevention aids. Available at: Wounds UK Moisture Lesions Supplement. Wounds UK, London. Available at: pdf Sources of further information (all of these include resources specifically for carers and care homes) The following factsheets for carers may be useful: 1. Support me, 2. Keep me moving, 3. Feed me well, 4. How to manage Incontinence, ToGuides/howtogreatskinincontinencefinal.pdf Acknowledgements: This guidance document was supported by information provided by The Royal Marsden Hospital Community Services. 18

19 Appendix A: Different stages of pressure ulcers Stage 1 Skin is not broken but is red or discoloured or may show changes in hardness or temperature compared to surrounding areas. When you press on it, it stays red and does not lighten or turn white (blanch). The redness or change in colour does not fade within 30 minutes after pressure is removed. On dark skin tones, the redness may not be easily seen however skin may instead look purple or blue-ish. Healing time: approximately 3-7 days Stage 2 The topmost layer of skin (epidermis) is broken, creating a shallow open ulcer. The second layer of skin (dermis) may also be broken. Drainage (pus) or fluid leakage may or may not be present. Healing time: approximately 3 days- 3 weeks 19

20 Stage 3 The wound extends through the dermis (second layer of skin) into the fatty subcutaneous (below the skin) tissue. Bone, tendon and muscle are not visible. Look for signs of infection (redness around the edge of the ulcer, pus, odour, fever, or greenish drainage from the ulcer) and possible necrosis (black, dead tissue). Healing time: approximately 4 weeks-6 months Stage 4 The wound extends into the muscle and can extend as far down as the bone. Usually lots of dead tissue and drainage are present. There is a high possibility of infection. Healing time: approximately 3 months- 2 years 20

21 Unstageable Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (top picture) or eschar (bottom picture). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Slough = dead tissue separated from living tissue, usually yellow, tan, grey, green or brown colour Eschar = a scab, usually tan, brown or black colour in the wound bed Suspected Deep Tissue Injury Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This type of pressure ulcer cannot easily be categorised as the extent of damage to underlying tissues cannot be determined Adapted from The National Pressure Ulcer Advisory Panel. 21

22 Appendix B: Waterlow risk assessment WATERLOW RISK ASSESSMENT Residents Name: Date (Day/Month/Year) Time Gender Male 1 Female Age Average BMI Build Above average BMI Obese BMI > 30 2 Below average BMI < 20 3 VISUAL ASSESSMENT OF AT RISK SKIN AREA (select one or more options) MOBILITY (Select one option ONLY) CONTINENCE (select one option ONLY) Tissue Malnutrition (select one or more options) Appetite (select one option) Neurological Deficit (score depends on severity) Major Surgery Trauma (up to 48 hours post-surgery) MEDICATION TOTAL SCORE Healthy 0 Thin and fragile 1 Dry 1 Oedematous 1 Clammy (Temp ) 1 Previous pressure ulcer or scarring 2 Discoloured Stage 1 2 Broken Stage Fully 0 Restless/fidgety 1 Apathetic 2 Restricted/Bed bound 3 Inert (due to consciousness) 4 Chair bound/wheelchair 5 Continent/catheterised 0 Occasional incontinence 1 Incontinent of Urine 2 Incontinent of Faeces 2 Doubly incontinent 3 Terminal Cachexia 8 Multi Organ Failure 8 Single Organ Failure (Respiratory/Renal/Cardiac) 5 Peripheral Vascular Disease 5 Anaemia HB < 8 2 Smoking 1 Average 0 Poor 1 N.G Tube/ Fluids only 2 NBM/anorexic 3 Diabetes, CVA, MS, Motor/Sensory Paraplegia, epidural 4-6 Above waist 2 Orthopaedic, below waist, spinal > 5 2 hours on theatre table 6 hours on theatre table 8 Cytotoxics, high dose/long term 4 Steroids, Anti-inflammatory INITIALS Risk Score: 10+ AT RISK 15+ HIGH RISK 20+ VERY HIGH RISK 22

23 Appendix C: Mattress checking- guidance for care home managers The support surface underneath the resident is an important factor in preventing skin damage due to pressure. Support surface applies to chair cushions and bed mattresses and includes regular cushions/mattresses as well as those specifically designed to be pressure-relieving. There are many different products available, each of which will have specific characteristics and instructions for appropriate use and care. There are a couple of principles that apply, regardless of the product selected for purchase. All covers should be made of 2-way stretch material, to reduce the risk of adding to the shearing forces on a resident s skin. Every care environment needs a mattress monitoring plan which identifies the time intervals for testing and replacement. All mattresses should be dated at the time of first use. The ends of the bed should be identified from 1-4 to give an easy reference to systematic turning, end to end, and top to bottom. Some companies supply pressure mattresses already marked with this information. Further information on selecting a suitable support surface can be found at the Disabled Living Foundation or Wounds-UK 23

24 Appendix D: Example Repositioning / Turning Chart Repositioning chart Residents name: Week beginning: Sunday Monday Tuesday Time Side Pressure areas checked? Mattress working? Sig. Side Pressure areas checked? Mattress working? Sig. Side Pressure areas checked? Mattress working? Sig. Key: L= left side, R= right side, B= on back Pressure areas to check: head, shoulders, elbows, buttocks/sacrum, hips, knees, ankles, heels and other (please specify) Equipment checks: Is it plugged in and switched on? Are all settings correct? Is it working? 24

25 Repositioning chart Residents name: Week beginning: Wednesday Thursday Friday Saturday Time Side Pressure areas checked? Equipment working? Sig. Side Pressure areas checked? Equipment working? Sig. Side Pressure areas checked? Equipment working? Sig. Side Pressure areas checked? Equipment working? Sig. Key: L= left side, R= right side, B= on back Pressure areas to check: head, shoulders, elbows, buttocks/sacrum, hips, knees, ankles, heels and other (please specify) Equipment checks: Is it plugged in and switched on? Are all settings correct? Is it working? 25

26 Appendix E: Information for residents and family 26

27 Appendix F: Example wound assessment chart Residents Name: Date of first assessment: Background information Duration of wound (PleaseTick) Acute (<6 weeks) Chronic (>6 weeks) Type of wound (Please Tick) Pressure ulcer Burn/scald Skin tear/ laceration Moisture lesion Leg ulcer Diabetic foot ulcer Sinus/fistula Traumatic wound Surgical wound Other If pressure ulcer, what category? Factors affecting wound healing: Comments Diabetes Nutritional Status Medications Other Allergies including dressings and tapes: Actions Location of wound: Date: Wound size: Max. length (cm) Max. width (cm) Max. depth (cm) Undermining/tracking? Wound bed: Necrotic (black) Slough (yellow/brown) Granulating (red) Epithelialising (pink) Overgranulating Bone/ligament/tendon visible? Infected/critically colonised? Surrounding skin: Healthy/intact Fragile Initial assessment Review Review Review 27

28 Dry/cracked Scaly Erythema Macerated Oedematous Excoriated Skin nodules Skin stripping Other (state) Exudate level: None Low Moderate High Increasing? Decreasing? Odour: None Slight Moderate Strong Bleeding: None Slight Moderate Heavy At dressing change Infection suspected? Swab taken? (Y/N) Signature/designation of assessor Other actions required (insert date completed) Photograph taken Pressure relieving equipment in place MUST reviewed Waterlow reviewed Pain assessment completed Wound management care plan completed Family and care staff informed Reported to CQC Reported to safeguarding Duty of candour required? Referrals required? E.g. TVN, podiatry, dietician, other Reason for referral Signature/designation 28

29 Appendix G: Pictures of moisture lesions 29