Policy Summary. Policy Title: Pressure Ulcer Prevention and Risk Assessment Policy. Reference and Version No: C13 Version 6

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1 Policy Title: Pressure Ulcer Prevention and Risk Assessment Policy Reference and Version No: C13 Version 6 Author and Job Title: Christine Russell Tissue Viability Coordinator Andy Brown Tissue Viability Specialist Nurse Executive Lead Director of Nursing and Patient Safety Validated By: Pressure Ulcer Operational Group Ratified By: Patient Safety Committee Policy Summary It is the overall aim of this policy to reduce the occurrence of pressure ulcers. It is recognised that risk assessment is a dynamic process and that all patients at the Trust, assessed to be at risk of developing a pressure ulcer, will have the correct evidence based preventative measures employed, according to the degree of risk and taking into account the wishes of the patient and their medical condition. Date Issued: 3 July 2015 Date for Review: 25 June 2018 Related Documents: NICE Guideline (2014) Prevention and management of pressure ulcers EPUAP (1999) European Pressure Ulcer Advisory Panel, Pressure Ulcer Prevention and Treatment Guidelines NPUAP (2010)National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Quick Reference Guide Braden Scale Pressure Ulcer Risk Assessment Parkhouse and Linet Resource Fileouse MUST (2003) Malnutrition Universal Screening Tool STAMP (2008) Screening Tool for the Assessment of Malnutrition in Paediatrics Tees-wide Multi-agency Safeguarding Adults Procedure Incident Reporting and investigation Policy; Inclusive of RM15 Never Event Reporting Requirements. C55 Wound management and dressing selection policy This Policy is Intended for: All clinical managers All clinical staff involved in the care of patients at risk of developing pressure ulcers. The Trust is committed to the fair treatment of all, regardless of age, colour, disability, ethnicity, gender, gender reassignment, nationality, race, religion or belief, responsibility for dependants, sexual orientation, trade union membership or non membership, working patterns or any other personal characteristic. This policy and procedure will be implemented consistently regardless of any such factors and all will be treated with dignity and respect. To this end, an equality impact assessment has been completed on this policy. 1 of 33 (Date for review 25 June 2018)

2 CONTENTS 1. Introduction 2. Purpose 3. Aims 4. Roles and Responsibilities 5. Identifying Individuals At Risk 6. Risk Factors 7. Skin Inspection 8. Pressure Ulcer and Grading 9. Pressure relieving devices and flow charts for Community and In Patient Episodes 10. Use of Aids 11. Positioning 12. Seating 13. Education and Training 14. Hospital Discharge Planning 15. Incident Reporting 16. Policy Monitoring 17. Safeguarding Adults and Pressure Ulcer Development 18. References List Appendices Appendix 1 SSKIN Bundle Appendix 2 Pressure Ulcer and Skin Integrity Aide Memoires Appendix 3 Patient re Positioning 30 Degree Tilt Method Appendix 4 Teeswide Safeguarding Adult Pressure Ulcer Screening Tool 2 of 33 (Date of review 25 June 2018)

3 1. Introduction From April 2010, the National Patient Safety Agency (NPSA) urged NHS organisations across England and Wales to adopt a zero tolerance approach to pressure ulcers and it became an NPSA requirement for providers to report all grade 3 and 4 pressure ulcers as Serious Untoward Incidents (SUIs). Pressure ulcers, also known as pressure sores, decubitus ulcers and bedsores, are areas of localised damage to the skin and underlying tissues. They are thought to be caused by a combination of pressure and shear combined with the effects of other variables including friction. acute illness, trauma and immobility are key factors but there appears to be many others. Pressure ulcers usually occur over bony prominences and should be graded or categorised to classify the degree of tissue damage observed (European Pressure Ulcer Advisory Panel (EPUAP), 2009). Protection of the individual patient from pressure damage is a fundamental aspect of nursing care (Wounds UK, 2013) and is the subject of national guidelines (NICE, 2014) which summarise current best evidence. It is also one of the High Impact Actions for nursing (NHS Institute for Innovation and Improvement, 2010). 2. Purpose This policy aims to provide staff with the current evidence base and guidance in order to reduce the occurrence of avoidable pressure ulcers. All patients assessed to be at risk of developing a pressure ulcer within the Trust will have appropriate, evidenced based preventative measures adopted, according to the degree of risk, and taking into consideration the patient s medical condition and their individual needs and wishes. 3. Aims The aims of this policy are: To provide a framework that supports professional practice at all levels in the prevention, early detection and treatment of pressure ulcers. To clarify roles and responsibilities. It is not the aim of this policy to be prescriptive but to guide evidence-based decision making. 4. Roles and Responsibilities 4.1 Trust Board will be responsible for accepting and supporting the Pressure Ulcer Prevention and Risk Assessment Policy (C13) 4.2 Assistant Directors and Senior Managers will ensure implementation of this policy within their areas of responsibility. 4.3 Senior Clinical Matrons and Clinical Leads have responsibility for ensuring staff have the opportunity to read the policy and promoting and monitoring adherence to this policy. 4.4 Matrons/Team Leads will ensure that this policy is implemented in their area/department. 4.5 All staff, including all members of the multidisciplinary team (doctors, occupational therapists, physiotherapists, podiatrists and dieticians), have a responsibility to adhere to this policy. They will ensure a wound care plan is implemented for all pressure ulcers, and the ulcers are 3 of 33 (Date of review 25 June 2018)

4 photographed (if appropriate), graded and measured as part of that plan. All staff must keep accurate contemporaneous healthcare records for all pressure ulcers and wound care. All staff will report the occurrence of all pressure ulcers, regardless of grade, via the Trust incident reporting system as soon as possible, within 12 hours of identification of the pressure ulcer (Incident Reporting and Investigation Policy, RM15). The Trust aims to learn from incidents in order to improve systems, processes and practices and identify areas of concern promptly so remedial plans can be developed and implemented e.g. training. Whenever a patient develops a grade 3 or 4 pressure ulcer there must be consideration as to whether there is a safeguarding concern (Appendix 4). This must be reported following the Protecting Vulnerable Adults Policy (C46) and recorded on the Trust incident reporting system. Staff must initiate the duty of candour policy (C40) for all patients who develop grade 3 or 4 pressure damage which is attributable whilst in the care of Trust staff. 4.6 The Tissue Viability Nurse (TVN) will provide specialist advice, support and training within the remit of this policy. The TVN will also attend the Trust weekly pressure ulcer meetings to assist in the validation of reported pressure damage, review the root cause analysis reports and determine avoidable / unavoidable, and attributable/ not attributable whether in a hospital or community setting. 4.7 Tissue Viability Champions will attend meetings relating to tissue viability and cascade to staff members, within their teams, information from these meetings. Champions will promote this policy and liaise with the Tissue Viability Nurses to ensure best practice in their clinical areas. 4.8 Senior Health Professionals involved in care of a patient who has developed a grade 3 or 4 pressure ulcer will be required to complete a 24 hour over view document and attach to the incident reporting system. 4.9 Pressure Ulcer Operational Group is responsible for validating this policy as updates are required. All issues to which this policy pertains should at first be brought to the attention of this group for address. 5. Identifying Individuals At Risk Risk assessments should be carried out by personnel who have undergone appropriate training to recognise the risk factors that contribute to the development of pressure ulcers and know how to initiate and maintain correct and suitable preventative measures. Risk assessment training should include skin assessment, the importance of repositioning schedules and who to refer to if further help or resources are needed. 5.1 Assessing an individual s risk of developing pressure ulcers should involve both informal and formal assessment All patients referred to Trust services will have an assessment of their risk performed by a registered nurse, associate practitioner or registered health professional. Risk assessment asks the question Do I think my patient is at risk of developing a pressure ulcer? This assessment is a fundamental part of preventing pressure ulcers and prescribing care. This involves the combination of clinical judgement and experience, and can be undertaken by anyone who is competent in recognising the signs of potential or actual pressure damage. All risk assessments need to be accessible by all members of the interdisciplinary team. 4 of 33 (Date of review 25 June 2018)

5 5.1.1 Initial risk assessment Assessment of risk will commence in the Accident and Emergency Department, Emergency Assessment Unit, Urgent Care Services (if applicable), pre-assessment clinics, access lounge or upon admission to caseload (community) Upon admission into care patients should be checked for pressure damage; with the patient s consent this should be a visual check although it is acknowledged that some patients may not consent to this. If a patient refuses consent to staff visually checking for pressure damage then questioning a patient with capacity should be done. Particular attention should be paid to those areas most at risk of developing pressure damage (i.e., sacrum, buttocks, heels, elbows etc.). Where wounds are identified they must be recorded on the Trust body mapping documentation. Any pressure ulcer present on admission to the episode of care must be fully documented and assessed (as outlined in the Wound Management and Dressing Selection Policy C55). Any pressure ulcer present on admission to the episode of care should be reported on the Trust incident reporting system Braden risk assessment Risk assessment tools should be used as an aide memoire and should not replace clinical judgement. A formal risk assessment will be undertaken using the Braden risk assessment tool (Braden Scale, (HCR084)) within six hours of admission to hospital or on initial assessment in the community setting. This must take into account individual areas of risk specific to that patient. A level of risk can then be ascertained and care planned accordingly. The Braden Risk Scale (Bergstrom and Braden, 1987) should be used to support a health professional s clinical judgement and as documented evidence that a formal assessment of risk has taken place. As all patients are different, any individual or specific areas of risk not included within the Braden Scale should be recorded. Although this scale gives an indication of the levels of risk it must also incorporate the professional judgement to decide the final holistically assessed level of risk. Formal risk assessment, using The Braden Risk Scale, should be re-assessed as appropriate depending on the individual s care needs. As a minimum this should be when the patient s clinical condition changes, either deteriorates or improves SSKIN Bundle Where patients are deemed to be at any risk of developing pressure ulcers the Trust SSKIN bundle should be implemented (Appendix 1). The SSKIN bundle is a 5 point pressure ulcer prevention strategy developed for the purpose of cementing all fundamental preventative components into a single unit of care (NHS Scotland 2011, NHS Midlands and East 2012). Trusts throughout the UK have had significant success in the reduction of avoidable pressure ulcers through implementation of the SSKIN bundle. Where hospital inpatients are assessed as requiring a dynamic air flow pressure relieving mattress they should have an SSKIN assessment completed and recorded every 2 hours during daytime hours and every 4 hours during the night. On occasion it may not be appropriate to disturb the patient or the patient may not consent to being disturbed. These occasions should be documented as a variance in the patient s contemporaneous record. Where patients are receiving care in their own homes, the frequency of completion of the SSKIN bundle should be individually assessed and documented on the SSKIN bundle. Patients at 5 of 33 (Date of review 25 June 2018)

6 greatest risk of skin deterioration should have an SSKIN bundle completed and documented once daily where the patient is receiving daily care, or at every community nurse visit where care is less frequent than once daily. Where patients are in receipt of 24 hour care, or frequent care interventions from nursing homes, care homes or care agencies, Trust staff will encourage and promote use of the principals of the SSKIN bundle. Where staff have promoted the SSKIN bundle this should be documented in the patient s contemporaneous record. 5.2 If considered not at risk on initial assessment, reassessment should occur if there is a change in an individual s condition which increases risk. Pressure ulcer risk assessment is a dynamic process and informal assessments will take place throughout a patient s care episode. Any change in condition which results in a change in risk status will trigger a more formal assessment by a competent health care professional. Risk status can increase or decrease; both may require changes in care. 6. Risk Factors Individual risk of developing a pressure ulcer can change over a short or long period of time. It is linked with the general health and wellbeing of the person in the majority of cases (intrinsic); however small changes in care or routine can dramatically increase risk (extrinsic). 6.1 An individual s potential to develop pressure ulcers may be influenced by the following intrinsic factors which therefore should be considered when performing a risk assessment: reduced mobility or immobility; sensory impairment; acute illness; level of consciousness; extremes of age; vascular disease; severe chronic or terminal illness; previous history of pressure damage; malnutrition and dehydration certain medication incontinence / moisture (wet skin is more prone to damage and requires extra care for example use of soap substitutes and barrier preparations). proximity to end of life. This is not an exhaustive list. Where patients are found to have specific areas of risk these should be documented as part of the assessment process Nutritional status Poor nutritional intake should be recorded as a compounding factor in the prevention and management of pressure ulcers. There is a clear link between an individual having poor nutritional status and the development of a pressure ulcer (Donini et al, 2005). Emaciated and obese people have also been associated with being at a higher risk (Finucane, 1995). EPUAP guidelines (2009) recommend the screening and assessment of the nutritional status for each individual with a pressure ulcer. This should occur on admission and with each condition change, and/or when the pressure ulcer does not progress to healing. 6 of 33 (Date of review 25 June 2018)

7 The Trust uses the Malnutrition Universal Screening Tool (MUST; National Collaborating Centre for Acute Care, 2006). The completion of the MUST score guides staff as to what interventions need to be put in place for the patient. This may range from simply making food and fluids available, encouraging people to eat well and drink regularly, assisting patients where necessary, or referral to a dietician. Where patients have developed a grade 2 or above pressure ulcer, referral to dietician should be considered. The at-risk patient should be observed for signs of dehydration, and if these are noted, appropriate action taken Incontinence and moisture The impact of incontinence, or any form of extrinsic moisture, can lead to the breakdown of vulnerable skin (Beeckman et al, 2009), and can put the patient at greater risk of skin maceration, friction and shearing forces. Effective management of incontinence is an essential part of skin care and fundamental to maintaining a person s dignity and comfort. Therefore the key practice issue is the presence or absence of wet skin (Defloor, 1999). To address this, the patient s elimination needs must be assessed, with the following taken into consideration, and managed as appropriate: To consider and address the cause of incontinence Appropriate use of moisture absorbing or continence aids To manage sweat or any exudate to the skin Establish a skin care routine with timely cleansing of soiled and wet skin. All of these elements must be re-assessed regularly and adapted as necessary. In addition, there may be a need to refer or seek advice from the local continence advisor. Appendix 2 shows the Trust Skin Integrity Aide Memoire to be used as a guide for the identification and treatment of moisture related skin changes The use of continence aids should not interfere with any pressure redistributing surface an individual may be placed upon Skin Hygiene An individual s skin may be exposed to a variety of moist substances - urine, faeces, perspiration and wound drainage - which may make it more susceptible to injury. Adequate skin care therefore is critical to the prevention of skin breakdown. The skin should be inspected and cleansed regularly, and if the skin is soiled the skin should be cleansed immediately. The optimal ph of the human skin is 5.5 which is fairly acidic, and this acts as a bacterial barrier. Together, sweat and sebum combine to create an acid mantle of between and if detergent products are used the acid mantle is broken leaving the skin vulnerable to irritation and excoriation. The skin produces sebum that enables it to maintain a naturally acidic ph, usually between 4.0 and 5.5 (Bianchi, 2012). The mixing of urine and faeces creates an alkaline skin ph in incontinent patients (Rees and Pagnamenta, 2009). This is responsible for the dermatitis excoriation seen in individuals with incontinence (Gray et al. 2007). When cleansing the skin a ph neutral agent should be used. Aqueous cream or emulsifying ointment should be used with warm (rather than hot) water to minimise irritation and drying then a barrier film spray or cream should be applied (Benbow, 2012). Barrier films should be reapplied as indicated by the manufacturers instructions 7 of 33 (Date of review 25 June 2018)

8 Moisturisers should be applied to areas of dry skin. Skin rubbing and massage, particularly over bony prominences should be avoided (Britton, 2003).- The use of detergent products (including detergent wipes, foamy cleansers and shower gel) or talcum powder should be avoided. The use of Sudocrem, Drapolene, Metanium, Unguentum Merk and zinc and castor oil ointment is deemed unnecessary if the above procedure is followed. These should also not be used in conjunction with continence aids. 6.2 The following extrinsic factors are involved in tissue damage and should be removed or diminished to prevent injury: pressure, shearing and friction. Pressure is the exertion of continuous force on an area. Pressure damage occurs when the skin and other tissues are directly compressed between bone and another surface. The relationship between pressure and tissue damage is dependent on two characteristics: the intensity of the pressure and the duration of the pressure. Shear occurs when tissues are wrenched in opposite directions, resulting in disruption or angulations of capillary blood vessels. Tissue damage caused by shear is usually a result of poor posture and/or long periods of time spent in a semi-recumbent position. Tissue damage caused by friction occurs when the skin has rubbed against another surface. Typically it is the result of poor moving and handling. 7. Skin Inspection 7.1 Skin inspection should occur regularly and the frequency determined in response to changes in the individual s condition in relation to either deterioration or recovery. If a patient is considered to be at risk of developing pressure damage then skin should be inspected for signs of pressure damage during every episode of care and this evaluation documented using the SSKIN bundle (Appendix 1). Exceptions to this are patient refusal or where it is inappropriate due to proximity to end of life (exceptions to care should always be documented in the contemporaneous healthcare record). Carers/family members should be encouraged to participate where necessary, when safe and able to do so, following appropriate provision of information and training. The Trust patient information leaflet on Pressure Ulcer Prevention is available and should be provided to patients/carers/family members with an explanation of the contents where appropriate. Health professionals should be aware of how changes in a patient s condition can affect tissue viability and therefore the frequency of skin inspection. Early warning indicators can include redness of the skin and/or the patient complaining of sore skin over bony prominences without any skin changes. 7.2 Skin inspection should be based on an assessment of the most vulnerable areas of risk for each patient. These are typically heels, sacrum, buttocks, parts of the body affected by anti-embolic stockings, hips, elbows, temporal region of the skull, shoulders and back of the head and toes. In addition the following may be applicable, parts of the body where pressure, friction and shear is exerted in the course of an individual s daily living activities; parts of the body where there are external forces exerted by equipment and clothing. Other areas should be inspected as necessitated by the patient s condition. Skin inspection can take place during routine care taking into account patient consent, preferences, privacy and dignity. 8 of 33 (Date of review 25 June 2018)

9 7.3 Individuals who are willing and able should be encouraged, following education, to inspect their own skin. Where practicable the patient and/or their carers/family members should be involved in the inspection process. The importance of reporting to the health professional any areas of concern should be stressed. 7.4 Individuals who are wheelchair users should use a mirror to inspect the areas that they cannot see easily or get others to inspect/assist them. 7.5 Health care professionals should be aware of the following signs which may indicate pressure ulcer development: persistent erythema pain non-blanching hyperaemia previously identified as non-blanching erythema blisters discolouration localised heat localised oedema localised induration In those with darkly pigmented skin: purplish/bluish localised areas of skin localised heat which, if tissue becomes damaged, is replaced by coolness localised oedema localised induration. Full assessment of skin areas can often involve removal of clothing, surgical appliances and mobility aids. Pressure ulcers can often be felt as hot hard areas of skin. Skin damage and redness may also be caused by incontinence associated dermatitis or other moisture related skin conditions. Skin changes should be documented / recorded immediately in the contemporaneous healthcare record. 8. Pressure Ulcers and Grading When assessing a patient s skin integrity, consideration must be given to the mechanism of injury/damage, where patient s skin is compromised. Where the initial injury/damage to the skin is caused primarily by factors other than pressure, the injury may not be considered to be a pressure ulcer. These factors include:- incontinence associated dermatitis moisture related damage trauma vascular insufficiency (including leg ulcers) complications arising from diabetes (for example neuro-ischaemic foot ulcers) skin changes at life s end (SCALE) (see 8.1) Where an injury is determined to be a pressure ulcer it should be graded/categorised using the European Pressure Ulcer Advisory Panel classification system. Wounds that are not pressure ulcers should not be catagorised by this system. 9 of 33 (Date of review 25 June 2018)

10 Grade/Category 1: Intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Grade/Category 2: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or signs of deep tissue injury. Grade/Category 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present. May include undermining and tunneling. The depth of a grade/category 3 pressure ulcer may vary by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and grade/category 3 ulcers can be shallow. In contrast, areas of significant. adiposity can develop extremely deep grade/category 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Grade/Category 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.the depth of a grade/category 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Grade/category 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis more likely to occur. Exposed bone/muscle is visible or directly palpable. Documentation and management of any pressure ulceration should follow the recommendations as outlined in the Trust s Wound Management and Dressing Selection Policy (C55). This is in addition to following the guidance in this policy to prevent deterioration of the ulcer. 8.1 Skin Changes at Life s End (SCALE) Palliation/End of life is defined as a phase of life when a person living with an illness will experience deterioration due to that illness, which will eventually cause death. This time period is not restricted to that short time period when the person becomes moribund, when death is imminent, but may begin some weeks beforehand (Qaseem et al, 2008). The SCALE (2009) document proposes that the skin, the largest organ of the body, is not impervious to dysfunction at the end of life and that this may result in varying degrees of skin/tissue damage (Beldon 2010). Healthcare professionals caring for those patients who suffer extremely debilitating effects during the final months of their lives have noted that despite providing good skin care, repositioning, appropriate pressure-relieving equipment and optimising nutrition where possible, some patients will still develop skin damage (Beldon 2010). 9. Pressure Relieving Devices and Flowcharts for Community and in-patient episodes (Pressure Relieving and Pressure Redistributing Devices) 9.1 Decisions determining which pressure relieving or pressure redistributing device to use should be based on an overall assessment of the individual and not solely on the basis of scores from risk assessment scales. Pressure relieving and pressure redistributing equipment does not replace the need for repositioning and should be used as an adjunct, with a repositioning and skin inspection regime that suits the patient and circumstances. 10 of 33 (Date of review 25 June 2018)

11 Decisions about support surfaces should be influenced by holistic assessment of an individuals risk, comfort and general health state. Assessment should be on-going throughout an individual s episode of care and the type of pressure relief support changed to suit any alteration in risk. Where patients refuse use of recommended equipment this needs to be documented in the contemporaneous record. Patients must be informed of the risks of not using recommended equipment. Where there is doubt of a patient s capacity to make decisions follow the Trust policy C53. For suggested equipment use please see the Pressure Relieving Devices Selection Flowcharts below. 9.2 Equipment choice NICE (2014) acknowledge limited evidence on the effectiveness of pressure relieving devices and if sophisticated pressure relieving devices are more effective than more basic pressure redistributing devices, such as high specification foam mattresses. NICE (2014) also recognise that pressure redistributing mattresses are widely accepted methods of trying to prevent the development of pressure areas for people assessed as being at risk. Patients within this Trust at very high risk of developing pressure ulcers should be placed on an alternating pressure mattress replacement or have a sophisticated continuous low pressure system for example low air loss, air floatation redistributing systems. The availability and choice of support surface can be found in the ward based or community nursing team base resources files. This file also contains relevant contact telephone numbers and ordering details Patients own mattress The quality of the patients own mattress will vary considerably. Where patients are at risk of developing pressure damage the appropriateness of them continuing to use their own mattress needs to be discussed with them. Where patients are offered a pressure relieving mattress and they subsequently refuse this should be documented in the healthcare record. Patients should be informed of the risks of them not using equipment that is recommended High Specification foam mattress - these consist of several layers of different foams and have a pressure redistributing/reducing action. They can be used for patients at low to high risk of developing pressure ulcers. They should be cared for and cleaned according to the manufacturer s instructions. They should be tested monthly for bottoming out (if you can feel the bed base through the mattress when applying your full weight then this has occurred) and for signs of leakage (strikethrough) into the foam interior. This will usually involve unzipping the mattress cover and checking the inside for leakage and damage. If strikethrough is found, the mattress must be condemned and removed. All ward matrons/managers should be aware of the protocol for replacement of mattresses Alternating pressure mattress replacements - these replace the foam mattress and attach to the base of the bed. They use cyclic inflation and deflation of air cells over a short period of time. They often, but not always, contain a sensor pad which controls the pressure within the mattress. They are used for very high risk patients and those patients with existing pressure ulcers. They can also be used on patients with a lower clinical risk of pressure damage when other measures are not adequately preventing pressure damage. 11 of 33 (Date of review 25 June 2018)

12 9.2.4 Low air loss mattress replacement - these also replace the foam mattress and attach to the base of the bed. They use a continuous flow of air from the surface of the mattress by using material which is micro-porous. They can be used on individuals who are very high risk or those at lower risk who are showing signs that, despite the use of pressure reducing surface, they are developing pressure damage. 9.3 Patients undergoing clinical procedures Pressure redistributing mattresses should be used on the operating table of individuals assessed to be at high risk of pressure ulcer development Patients who are undergoing surgery are considered at risk (Scott, 2000) by virtue that the patient is nil by mouth and unconscious, therefore individual clinical judgement should take into account factors such as: length and severity of operation general health of the patient as indicated by the ASA grading whether the patient was classed as at risk prior to surgery and whether they will be classed as at risk after the surgery. the patients Body Mass Index Where epidural anaesthesia/pain relief is used there will be an increase in risk for the patient and this should be communicated to the ward staff on transfer of the patient back to the ward area. Patients undergoing lengthy or prolonged procedures in any department should have their risk assessed prior to attending the department. If found to be at an increased risk then the department should be notified prior to the procedure, where applicable and practicable, a preventive strategy must be employed to minimise the risk To ensure continuity of preventive care, post-procedure management of at risk individuals should include the use of pressure redistributing mattresses. When any patient is identified as at risk before or after any clinical procedure, the appropriate equipment should be transferred to the recovery area and the patient nursed on this surface immediately after surgery. 12 of 33 (Date of review 25 June 2018)

13 Pressure Redistributing/Relieving Equipment Selection Flow Chart (community setting). Clinical assessment of the patient and Braden Score No Risk Low Risk Medium Risk High Risk Re-assess level of risk if and when the clinical condition changes Patient able to relieve own pressure areas Patient s ability to relieve own pressure areas independently is reduced Patient is unable to relieve own pressure areas Reinforce need to relieve pressure areas independently. Consider pressure redistributing/reducing support surface linked with clinical assessment Consider equipment choice: Consider alternating pressure or low air-loss replacement mattress +/- cushion if required, with patient consent, using clinical judgment. At least 2-4 hourly position changes to be performed/encouraged when practicable Equipment choice mattress replacement: either alternating or constant low pressure mattress replacement, with a chair cushion as necessary. A minimum of 2-4 hourly positional changes to be performed/encouraged when practicable. Assess manual handling risk and risk from shearing forces- consider use of electric profiling bed. NOTE: DYNAMIC SYSTEMS NEVER REPLACE THE NEED FOR REGULAR REPOSITIONING 13 of 33 (Date of review 25 June 2018)

14 Pressure Redistributing/Relieving Equipment Selection Flow Chart (Hospital setting) Clinical assessment of the patient and Braden Score No Risk Low Risk Medium Risk High Risk Re-assess level of risk if and when the clinical condition changes Patient able to relieve own pressure areas Patient s ability to relieve own pressure areas independently is reduced Patient is unable to relieve own pressure areas Reinforce need to relieve pressure areas independently. Provide pressure redistributing/reducing support surface (high specification foam) as a minimum. Consider equipment choice: High specification foam or consider alternating pressure or low air-loss replacement mattress +/- chair cushion if required, with patient consent, using clinical judgment. At least 2-4 hourly position change. Equipment choice mattress replacement: either alternating or constant low pressure mattress replacement, with a chair cushion as necessary. A minimum of 2-4 hourly positional changes. Assess manual handling risk and risk from shearing forces- consider use of electric profiling bed. NOTE: DYNAMIC SYSTEMS NEVER REPLACE THE NEED FOR REGULAR REPOSITIONING 14 of 33 (Date of review 25 June 2018)

15 10. Use of Aids The following previously used items should now never be used as pressure relieving aids: water filled gloves; synthetic sheepskins; genuine sheepskins and doughnut-type devices. Doughnut type devices impair lymphatic drainage and therefore are likely to cause rather than prevent pressure ulcers. Water filled gloves have been found to be ineffective because their small surface area does not redistribute the pressure. Sheepskins and fibre filled overlays can be used to provide comfort at the patient s request but neither provides relief from pressure. With both, care should be taken with regard to cross infection and correct laundering. 11. Positioning 11.1 Individuals who are at risk of pressure ulcer development should be repositioned and the frequency of repositioning determined by the results of skin inspection and individual needs not by a ritualistic schedule. When repositioning a patient staff should note any area of redness. Continuous redness does not always lead to ulceration but should be documented and closely monitored. The following procedure can be used to determine whether this redness is normal or not: Area of redness identified after patient turned Lightly press area of redness with a finger Area where pressure is applied should turn white (blanch) then return to its normal colour when pressure is lifted Return to normal colour should take no longer than twice the length of time the finger pressure was applied If blanching does not occur or return of colour is slow, capillary damage has occurred Frequency of position changes should be increased (Simpson et al. 1996) Repositioning should take into consideration other relevant matters, including the patient s medical condition, their comfort, the overall plan of care and the support surface. When a patient declines an intervention which aims to prevent pressure damage this should be documented in their healthcare record along with their reason for declining the care. If the patient s medical condition prevents repositioning this should also be documented in the patients healthcare record. 15 of 33 (Date of review 25 June 2018)

16 11.3 Positioning of patients should ensure that prolonged pressure on bony prominences is minimised, that bony prominences are kept from direct contact with one another and friction and shear damage is minimised. The use of the 30 degree tilt (see Appendix 3) has been found to be beneficial (Preston 1998). It involves the patient being positioned at a 30 degree angle using pillows and other simple devices. This will reduce the risk of pressure damage to hips and is sometime preferable to placing the patient at a ninety degree angle, which would place them directly onto their hip and therefore at increased risk. Pillows can be used to intermittently elevate areas to relieve pressure (e.g. elevation of lower legs to suspend heels) for limited periods of time. Such elevation is used to offload pressure from an area in order to promote healing or prevent deterioration. If this technique is used particular attention should then be given to the skin supported by the pillows. Elevating body parts in this way may subject the tissue to increased risk of pressure damage. In addition this method negates the effect of a pressure relieving mattress for the duration that the area is elevated from the mattress A repositioning schedule, agreed with the individual, should be recorded and established for each person at risk. NICE (2014) recommends that patients at risk of developing a pressure ulcer are encouraged to change their position frequently and at least every 6 hours. Patients at high risk of developing pressure ulcers should change their position at least every 4 hours. Within an acute setting patients who require repositioning will have a prescribed repositioning schedule which staff are required to sign when they move the patient. This will be recorded on the Trust SSKIN bundle (see Appendix 1). Within a community setting patient repositioning schedule should be discussed with the patient and/or those responsible for the patient s care. The SSKIN bundle will be used to document repositioning performed by Trust staff. Care providers other than Trust staff should be encouraged to reposition patients at time intervals as prescribed on the SSKIN bundle Individuals and/or carers, who are willing and able, should be taught how to redistribute weight Manual handling devices should be used correctly in order to minimise shear and friction damage. After manoeuvring, sling, sleeves or other parts of the handling equipment should not be left underneath individuals. 12. Seating When sat in a chair 70% of the body weight is spread over 8% of the surface area. This means that sitting in a chair increases the risk of pressure damage. Poor seating increases the risk even more Individuals who are considered to be at high risk of developing pressure ulcers should restrict chair sitting to less than two hours until their general condition improves. Repositioning and pressure relief must continue even when patients are sat in a chair. This may involve standing the patient every 30 minutes if they are at high risk The benefits of a pressure redistributing device should not be undermined by prolonged chair sitting. Patients considered at high risk should not be sat out of bed for longer then two hours at a time. 16 of 33 (Date of review 25 June 2018)

17 When assessing the need for specialist equipment the health care professional should take into account the need for appropriate seating provision Seating assessments for specialised aids and equipment should be carried out by trained assessors who have the acquired specific knowledge and expertise (for example, physiotherapists/occupational therapists). Assessment and provision of seating (e.g. moulded wheelchairs or patient specific chairs and seats) for high risk individuals, such as those with paraplegia or sensory problems, should be completed by specialist health care professionals. Consideration should be taken into account of postural alignment, distribution of weight and support of feet Advice from trained assessors with acquired specific knowledge and expertise should be sought about correct seating positions. Any patient admitted to the hospital who normally uses specialist seating and/or equipment at home should have the same levels of equipment provided. Relatives should be encouraged to bring the equipment into hospital for the use of their relative. Advice should be sought from all members of the multi-disciplinary team about the care of these patients No seat cushion has been shown to perform better than another, so this policy makes no recommendation about which type to use for pressure redistributing purposes. 13. Education and Training 13.1 Health care professionals should receive relevant training or education in pressure ulcer risk assessment and prevention. A mandatory training programme is available for all newly registered nurses and midwives as a component of the preceptorship program via the training department. Additional/refresher training will be facilitated by the Tissue Viability Nurses where required or requested. The Trust has also developed a training booklet focussing on pressure ulcer prevention and management. Staff member s individual training needs analyses (TNA) indicates who should complete this training Health care professionals with recognised training in pressure ulcer management should cascade their knowledge and skills to their local health care teams Each area should appoint a registered nurse to be a champion for tissue viability. In addition the area may also appoint a healthcare assistant or associate practitioner to act as a second link worker. The Tissue Viability Nurses will facilitate training via the Tissue Viability Champions Group and these nurses will be expected to cascade their knowledge to their peers An inter-disciplinary approach to the training and education of health care professionals should be adopted Patients who are able and willing should be informed and educated about risk assessment and resulting prevention strategies. This should, where appropriate, include carers. 14. Hospital Discharge Planning 14.1 This section of the policy should be used in conjunction with the interagency admission transfer and discharge policy (C1) 17 of 33 (Date of review 25 June 2018)

18 When transferring an at risk patient between care settings and/or to their home, the following factors need to be addressed, documented and communicated: Onward referral to an appropriate professional where there are any concerns or conditions relating to the patient s skin integrity assessment and indication of level of risk, including date of last assessment a description of the condition of the person s pressure areas details of any tissue damage including size, Grade/Category, position and treatment preventive measures the person has required, including the type of pressure redistributing device(s) used ensuring appropriate measures and equipment are in place prior to transfer or discharge written and verbal information for users/carers about assessment and prevention should be provided. Any patient requiring specialist equipment such as a pressure relieving mattress should have their discharge planned: referral to the Discharge Liaison Team may be required. Liaison with District Nurse colleagues may also be required particularly if the patient has an existing pressure ulcer. Photographs should be taken of any areas of pressure damage and wounds prior to discharge from hospital Discharge to Primary care Where hospital inpatients are assessed as being at high risk of pressure damage, or have an actual pressure ulcer, consideration should be made for provision of a pressure redistributing or pressure relieving mattress and chair cushion upon their discharge. It is expected that an appropriate period of notice is given for planned discharge in order that equipment can be in place in a timely manner. Where patients are being discharged into the areas of Stockton and Hartlepool, provision of pressure relieving equipment in community settings should follow the protocols for the current equipment provision supplier. Where patients are discharged to areas outside of those covered by this Trust the Trust Discharge Liaison Team will help to ensure adequate provision is in place for pressure relieving devices prior to the patient discharge. 15. Incident Reporting 15.1 As a Trust we are aiming to eliminate all avoidable pressure ulcers as defined by EPUAP and NPUAP (2009) 15.2 All grades of pressure ulcers must be reported via the Trust incident reporting system (Datix) Any pressure ulcer that deteriorates to a higher grade must be reported as a new incident Where patients develop pressure ulcers consideration will be given as to whether that change is attributable to the care provided by the Trust. Pressure ulcers will be considered to be serious incidents (reportable through the Strategic Executive Information System (STEIS)) where :- an act or omission of care results in unexpected or avoidable death, 18 of 33 (Date of review 25 June 2018)

19 an act or omission of care results in unexpected or avoidable injury causing serious harm, all avoidable grade 4 pressure ulcers will be STEIS reported, all avoidable grade 3 pressure ulcers that require extensive or prolonged treatment where the tissue damage is extensive. In addition:- Trends of pressure ulcer reporting will be identified via incident reports presented to the pressure ulcer operational group. After analysis, consideration will be given to reporting trends via STEIS. To aid reporting via STEIS all reportable incidents require an interim report to be completed within 24 hours. The Trust governance team can give further advice and information on incident reporting and the subsequent root cause analysis process Pressure ulcer incidents which are deemed to be attributable to the Trust are listed below:- Hospital inpatients who develop pressure damage, or who have existing pressure damage which deteriorates to a higher grade, during their stay within this Trust (where the pressure ulcer developed or deteriorated after 72 hours of admission into the care of the Trust). Patients who are on a district nursing caseload, who receive a visit more frequently than twice weekly. This may include visits for frequent dressing changes, daily tinzaparin administration, diabetic monitoring Details of which incidents the Trust considers to be not attributable are listed below:- Where the pressure ulcer developed or became evident within 72 hours of admission into the care of the Trust. Patients who are on a community nursing caseload, who receive a visit twice weekly or less frequently. Patients where damage developed whilst they are in a care home or nursing home care who receive community nurse visits less than three times weekly. Patients who are in a nursing home Patients who have been discharged from a caseload no longer requiring intervention from a community nursing team. Patients who develop pressure ulcers where the patient has not taken advice of Trust Staff. This includes patients who refuse the appropriate pressure relieving devices including mattresses and cushions. This also includes patients who refuse to take advice on body repositioning. All refusals to use recommended equipment must be documented in the patient s healthcare record. Patients who develop pressure ulcers where patients are in the receipt of paid care, if there is evidence that care staff have not followed advice and recommendations of Trust staff and this contributed towards development of a pressure ulcer. 19 of 33 (Date of review 25 June 2018)

20 15.5 Avoidable and unavoidable pressure ulcers The definitions of avoidable and unavoidable pressure ulcers were initially developed by the Department of Health from a position paper by the Wound, Ostomy and Continence Nurses Society (2009), and have been adapted by the Trust Definition of avoidable pressure ulcer Trust staff evaluated the individual s clinical condition and pressure ulcer risk factors: but failed to define and or implement interventions that are consistent with individual needs, goals and recognised standards of practice. Or completed risk assessments and implemented interventions but failed to monitor and evaluate the impact of the interventions; and revise the approaches as appropriate. The Trust will also consider the following factors when considering provision of care Incomplete Health Care Record including care plan, body mapping and evidence of assessment, planning, implementation and evaluation (including use of SSKIN). Pressure relieving equipment not ordered when indicated by assessment Prescription for dressings not ordered in a timely manner If determined to be avoidable then statements will be required from identified staff. Evidence of a delay in reporting or non reporting of a pressure ulcer on the Trust reporting system (Datix) Appropriate Photography of the wound, and regularity of recording of progression of the wound Definition of unavoidable pressure ulcer This is categorised as when the patient develops a pressure ulcer even though staff evaluated the patient s clinical condition and pressure ulcer risk factors, using the Trust Braden tool and SSKIN bundle, then defined and implemented interventions that are consistent with individual needs goal and recognised standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Consideration also needs to be given to the following factors. Health Care Record completed including care plan, body mapping and evidence of assessment, planning, implementation and evaluation (including use of SSKIN). Appropriate pressure relieving equipment ordered and received in a timely manner Patient concordance with advice and equipment provided to them Prescription for dressings ordered in a timely manner Evidence the pressure ulcer has been reported on the trust reporting system Appropriate Photography of the wound, and regularity of recording of progression of the wound In patients with chronic health conditions e.g. Multiple Sclerosis/Spinal Injury, healing or prevention may not be their goal or choice. Although the individual should be assessed and offered all preventative therapies as appropriate including education. The individual s choices will be respected and recorded. It is important to note that every effort will be made to prevent pressure ulceration in patients with the aforementioned conditions. They will also have access to essential services, pressure redistributing or pressure relieving equipment and will have a plan of care instigated that will be subject to regular review. 20 of 33 (Date of review 25 June 2018)

21 16. Policy Monitoring As a minimum an annual audit will be completed in both the inpatient and community settings which will audit pressure ulcers prevalence. This audit will include within it Information relating to patient age, gender, care setting Origin of pressure ulceration Ensuring there is a wound care plan in place Appropriate use of equipment Use of risk assessment tools The results of this audit will be fed back to the Pressure Ulcer Operational Group, which in turn feeds into the Integrated Nursing and midwifery Professional Board. Any noted deficiencies in policy application arising from this audit will be addressed via an action plan presented to the Pressure Ulcer Operational Group. 17. Safeguarding Adults and Pressure Ulcer Development Where there is reason to believe that the patient has developed a pressure ulcer as a result of neglect and/or poor care from a healthcare professional(s) or carers (whether formal or informal), information should be gathered about the patient and the history of the pressure damage. A screening tool (see Appendix 4) has been developed with the involvement of a multi-disciplinary team across the Tees area and this should be followed to gather further information about the patient. The Trust Tissue Viability Nurses should be informed that there are concerns about a patient and they can help, if appropriate, with the assessment process. If following the screening procedure it is felt that the patient s pressure ulcer is as a result of neglect and/or poor care then a referral must be made to the local safeguarding adults team. The following should be considered when assessing the patient: The patient s history whether there was rapid onset or deterioration of a severe ulcer, issues of patient compliance or behaviour, or whether the damage appears disproportionate to a low risk patient. Co-morbidity medical history, chronic or terminal disease, mental health issues. Care regime poor quality of care, appropriate equipment in place, evidence of appropriate care regime and ongoing evaluation, continence management, deterioration of personal appearance (consider nails and/or oral care), recurrence of pressure damage and evidence of ongoing risk assessment. Hydration and nutrition evidence of ongoing monitoring of oral intake, fluid balance (if appropriate) and regular weighing, when practicable Under/over use of medication use of sedation if the patient is immobile for extended periods, is pain assessed and managed appropriately Contributory circumstances of ulcers detailed history of the patient journey, changes in care setting, history of falls, previous pressure ulcers, carer involvement and health/social care involvement. This is not an exhaustive list but can be used as a guideline along with the flow chart and screening tool (Appendix 4). 21 of 33 (Date of review 25 June 2018)

22 18. Reference List Beeckman. D., Schoonhoven, L., Verhaeghe, S., Heyneman, A. and Defloor, T. (2009) Prevention and treatment of incontinence-associated dermatitis: literature review. Journal Advanced Nursing, 65 (6): Beldon, P. (2010). Skin changes at life s end (SCALE): a consensus document. Wounds UK, 6(1), Benbow, M. (2012) Skin care of the incontinent patient. Journal of Community Nursing, 26 (2): Bergstrom, N., Braden, B. J., Laguzza, A. and Holman, V. The Braden Scale for Predicting Pressure Sore Risk. Nursing Research. 1987, 36: Bianchi, J. (2012) Causes and strategies for moisture lesions. Nursing Times, 108 (5): Britton, J. (2003) The use of emollients and their correct application. Journal of Community Nursing, 17 (9): Defloor, T (1999) The risk of pressure sores: a conceptual scheme. Journal of Clinical Nursing, 8: Donini, L. M., De Felice, M. R., Tagliaccica, A., De Bernardini, L. and Cannella, C. (2005) Nutritional status and evolution of pressure sores in geriatric patients. Journal of Nutritional Health and Aging, 9 (6): European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel, Finucane, T. E. (1995) Malnutrition, tube feeding and pressure sores: data are incomplete. Journal of American Geriatrics Society, 43: Gray, M., Bliss, D. Z., Doughty, D. B., Ermer-Seltun, J., Kennedy-Evans, K. L. and Palmer, M. H. Incontinence-associated dermatitis: a consensus. Journal of Wound Ostomy and Continence Nursing Jan-Feb, 34 (1): 45-54; National Collaborating Centre for Acute Care (2006) Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. NICE Clinical Guideline 32. National Collaborating Centre for Acute Care, London. Available at (accessed 10/06/2014). NHS institute for innovation and improvement (2010) High impact actions for nursing and midwifery, NHS institute for innovation and improvement, Warwick. National Institute for Clinical Excellence (2003) The use of pressure-relieving devices (beds, mattresses and overlays for the prevention of pressure ulcers in primary and secondary care, RCN, London. National Institute for Health and Clinical Excellence (2014) Pressure ulcers: Prevention and Management of pressure ulcers: April 2014 NICE clinical guideline 179. NHS Midlands and East (2012) Pressure Ulcer Pathway. (accessed 10/06/2014)). NHS Scotland (2011) SSKIN care bundle. Available at: (accessed 10/06/2014). 22 of 33 (Date of review 25 June 2018)

23 Preston, K. W. (1988) Positioning for comfort and pressure relief; the 30 degree alternative, Care, Science and Practice 6(4): Qaseem A, Snow V, Shekelle P (2008) Evidence-based interventions to improve the palliative care of pain, dyspnoea and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med 148(2): Rees, J. and Pagnamenta, F. (2009) Best practice guidelines for the prevention and management of incontinence dermatitis. Nursing Times, 105 (36): Royal College of Nursing (2001) Pressure ulcer risk assessment and prevention: Clinical Practice Guideline, RCN, London. Sibbald, R. G., Krasner, D. L., Lutz, J. B., et al. (2009) The SCALE Expert Panel: Skin Changes At Life s End. Final Consensus Document. October 1, accessed at (July 2013) Scott, E. M. (2000) The prevention of pressure ulcers in the operating department, Journal of Wound Care 8 (1): Simpson, A.. (1996) Pressure Sore Prevention, Whurr Publishers, London. Wound, Ostomy and Continence Nurses Society (2009) Position Paper: Avoidable and Unavoidable Pressure Ulcers, March Wounds UK (2013). Best Practice Statement. Eliminating pressure ulcers. London: Wounds UK of 33 (Date of review 25 June 2018)

24 Using the SSKIN Bundle Appendix 1 Is the patient at ANY risk of developing or has existing pressure damage? Yes, Use SSKIN Bundle, timing assessed to the individual patient s need, discuss with patient and/or carers. No, Reassess as appropriate Step 1 - Surface Is the mattress and/or cushion the patient is being nursed on appropriate to their clinical need? Has the mattress and/or cushion been checked to ensure it is working properly and/or intact Any variances and/or patient refusals should be documented in the healthcare record. Step 2 Skin Have all areas prone to pressure damage been checked? Are any of these areas showing signs of pressure damage? Any variances and/or patient refusals should be documented in the healthcare record. Step 3 Keep moving Document repositioning of the patient, whether they are in the bed or chair, regardless of their mobility status. Any variances and/or patient refusals should be documented in the healthcare record. Step 4 Incontinence Is the patient incontinent of urine and/or faeces? Any variances and/or patient refusals should be documented in the healthcare record. Step 5 Nutrition Has the patient had food, fluids or nutritional supplements since the last intervention? Any variances and/or patient refusals should be documented in the healthcare record. Reassess and evaluate care as dictated by individual patient need. 24 of 33 (Date for review 25 June 2018)

25 Appendix 1 SSKIN Bundle for Pressure Damage Prevention Name: Address: DOB: CRN/ Hospital No: NHS Number: Frequency of care delivery: i.e. 1hrly, 2hrly, 3hrly, 4hrly, 5hrly, 6hrly, 8hrly, 12hrly Date Time record using 24 hour clock 1. Surface tick when checked Mattress appropriate (please tick) Cushion appropriate (please tick if used) Functional/integrity check of equipment performed Any variance or evaluation must be recorded in the Contemporaneous record 2. Skin inspection All pressure areas checked (please tick) Redness/discolouration present ( N if no damage present. Y if damage present. Grade in evaluation. Any variance or evaluation must be recorded in the Contemporaneous record 3. Keep moving tick which position patient is in when encouraged/assisted to move Right side 30 tilt Bed Left side 30 tilt Chair Back Any variance or evaluation must be recorded in the Contemporaneous record 25 of 33 (Date of review 25 June 2018)

26 Appendix 1 SSKIN Bundle for Pressure Damage Prevention Name: Address: DOB: CRN/ Hospital No: NHS Number: Frequency of care delivery: i.e. 1hrly, 2hrly, 3hrly, 4hrly, 5hrly, 6hrly, 8hrly, 12hrly Date Time record using 24 hour clock 4. Incontinence Urine Record Y if patient incontinence of urine / faeces or both. Record N if patient dry. Bowels Any variance or evaluation must be recorded in the Contemporaneous record 5. Nutrition tick when checked (Food and/or Fluid Balance Charts must be used if appropriate) Diet Fluids Supplement(s) Initials Any variance or evaluation must be recorded in the Contemporaneous record Use following codes as applicable: O = Off Ward R = Refused (Record comments in the Contemporaneous record) V = Variance (Record comments in the Contemporaneous record) 26 of 33 (Date of review 25 June 2018)

27 Pressure Ulcer Prevention and Risk Assessment C13 v6 Appendix 2 27 of 33 (Date for review 25 June 2018)

28 Pressure Ulcer Prevention and Risk Assessment C13 v6 28 of 33 (Date for review 25 June 2018)

29 Pressure Ulcer Prevention and Risk Assessment C13 v6 Patient re-positioning 30 degree Tilt Method Appendix 3 There are more than the three positions (above) into which patients can be repositioned. 30 tilt describes the use of pillows to position a patient off their bony prominences (hips & sacrum) so that weight is redistributed over the larger surface area of the buttocks The tilt positions should not be used exclusively but offer alternatives positions to traditional side to side turns. By having 5 alternative positions the time period any part of the body is exposed to pressure is reduced It may be possible to extend the time period between 30 tilt positions as the pressure is spread over a greater surface area. Also because the patient does not need to be physically rolled it is often possible to reposition the patient without assistance. 29 of 33 (Date for review 25 June 2018)

30 Pressure Ulcer Prevention and Risk Assessment C13 v6 Having placed the patient in the 30 tilt position, you should be able to place a hand beneath the patient and touch the sacrum ensuring that it is free of pressure. Limb elevation is integral to 30 tilt. 1 or 2 pillows should be used (depending on limb size) to elevate the lower limbs leaving the heels extended over the end completely free of pressure. This position should be adopted routinely for all at risk patients even if they are on a pressure relieving mattress Tilting the foot end of the bed by will prevent the patient slipping down the bed. This has the dual effect of reducing exposure of the skin to shear and friction and limiting the need for moving and handling by nursing staff. However, staff should be aware that this can increase pressure over the sacrum / buttocks which may require more frequent observation. 30 of 33 (Date for review 25 June 2018)

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