Pressure ulcers are a major Wound Care People Ltd. Pressure ulcer identification and management WOUND CARE

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1 Pressure ulcer identification and management Pressure ulcers are a major burden to healthcare systems, patients and carers, affecting 0.77 per 1,000 of the UK adult population (Stevenson et al, 2013; Cross et al, 2017), with 4% ( billion) of the annual NHS healthcare budget being spent on their treatment and management ment (Posnett et al, 2009; Stevenson et al, 2013). In the community, pressure ulcers are thought to affect approximately 30% of the general population and 20% of those living in residential or nursing ng homes (NHS institute for Innovation and Improvement, 2013). Prevalence e is defined as the number of people within a population with a pressure ulcer divided by the number of people in the total population at a given point in time (Agency for Healthcare Research and Quality, 2014). Reported incidence of pressure ulcers in adults varies from 0 12% in acute care settings, % in critical care settings, and % in elderly care settings (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance [NPUAP/ EPUAP/PPPIA], 2014; Blenman and Marks-Maran, 2017). ASSESSING THE RISK Identifying patients at risk of developing pressure ulcers is the a JCN learning zone feature most important factor in prevention, for which assessment ssment is key (Glasper et al, 2009; National Institute for Health and Care Excellence [NICE], 2014; McCoulough, 2016). Indeed, NICE (2014) recommends that every patient should have a risk assessment undertaken by an appropriately trained healthcare professional within six hours of admission, or at first assessment in the community. Determining if a patient is at risk requires a number of skills, such as: Gathering information by talking to the patient, carers and family Careful history-taking Examining the skin Observing mobility Assessing a patient s nutritional status Gaining insight into the patient s/carer s understanding of pressure ulcers. Before assessment is carried out, it is vital that healthcare professionals are aware of the known intrinsic and extrinsic factors that increase the risk of skin breakdown (NICE, 2014; NPUAP/EPUAP/PPPIA, 2014; McCoulough, 2016; ). In addition, some people are more susceptible, for example, patients: Who are frail and elderly Who are terminally ill Who are malnourished Passess THE SCIENCE A pressure ulcer is defined as localised injury to the skin and underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers, although the significance of these is yet to be elucidated (EPUAP/NPUAP/PPPIA, 2014). 32 JCN

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3 Table 1: Risk factors for pressure ulcer development Intrinsic Extremes of age Acute illness Sensory impairment Altered level of consciousness Vascular disease Patient receiving palliative care Cognitive impairment Previous history of pressure damage Dehydration Malnutrition Who are sedated and/ or anaesthetised With spinal cord injuries With a fractured neck of femur With neurological disorders Who are unable to reposition themselves. As patients may be visited at home by healthcare professionals from various health and social care disciplines, assessment needs to take a multidisciplinary approach. Skin assessment Once a patient has been identified as being at high risk of pressure ulcer development, it is important that a visual inspection of the skin is carried out by anyone suitably trained to recognise early signs of skin damage, taking into consideration: Pain Discolouration Skin integrity Variations in heat Firmness and moisture due to oedema or incontinence. It is also important to observe if the skin appears pears dry or inflamed, particularly over bony prominences (NICE, 2014; NPUAP/EPUAP/ PPPIA, 2014). Healthcare assistants, relatives or carers who provide personal care, and therefore see the skin, play an important role in identifying changes in the skin. Understanding what these changes mean and acting on them can be the difference between skin damage improving or deteriorating. For example, requesting and using appropriate equipment, using turning charts, or upgrading mattresses can all be put in place Extrinsic Pressure Shear Moisture as preventive measures (NPUAP/ EPUAP/PPPIA, 2014; NICE, 2014). The following definitions are a useful guide to aid skin inspection: Reactive hyperaemia: this is a normal response to pressure, which we all experience. It can be seen as a bright flush (erythema) associated with the release of an obstruction to the circulation and resultant increase in blood flow Blanching erythema: this is a normal response e and indicates that the circulation is intact. It can be seen as a reddened area that temporarily turns white or pale when pressure is applied with a finger tip. In highly pigmented skin, this may appear as a purplish/blue discoloration. Blanching erythema over a pressure site is usually due to normal reactive hyperaemic response Non-blanching erythema: this is indicative of damage to the microcirculation and is classed as a stage 1 pressure ulcer. There is observable alteration to intact skin when compared to adjacent or opposite areas of the body. STAGING PRESSURE ULCERS Staging pressure ulcers correctly can be a challenge for many community staff. The literature suggests that clinicians are often unable to stage pressure ulcers reliably (Defloor et al, 2006; Fletcher et al, 2011), with the All Wales Tissue Viability Nurse Forum and Welsh Wound Innovation Centre identifying that staging may be inaccurate in up to 18% of patients (AWTVN and WWIC, 2016). Furthermore, it can be subjective (Wounds UK, 2013). A number of tools exist to assess and stage pressure ulcers. However, the NPUAP/EPUAP/PPPIA (2014) staging system has been accepted by NICE (2014) this has since been updated by NPUAP in 2016 (see below). Pressure ulcers range in severity from stage 1, intact skin with non-blanching erythema, to stage 4, where there is full-thickness tissue loss and exposed bone, tendon or muscle. Stages 2 and 3 range from partial- to full-thickness skin loss, and staging depends on the depth of dermis and the anatomical location involved, for example nose, buttock or heel. Two further stages, unstageable and suspected deep tissue pressure injury (DTPI; depth unknown), were adopted by the USA in 2009 and integrated into the latest guidelines (NPUAP, 2016). Healthcare professionals need to have a good understanding of the skin, as this will enable them to identify what is missing and help to establish the stage of pressure damage (Table 2). TREATMENT Management of pressure ulcers involves wound care, adjunctive therapies and support surfaces (NICE, 2014). Patients and their carers should have the opportunity to make informed decisions about their care and treatment in partnership with healthcare professionals. If the patient is under 16, their family or carers should also be given information and support to help the child or young person make decisions about their treatment (NICE, 2014; NPUAP/EPUAP/PPPIA, 2014). Treatment falls into the following key areas: Nutrition Support surfaces Repositioning Wound care. Practice point Identification and prevention of pressure ulcers is seen as an indication of the quality of care given (Vowden and Vowden, 2015). 34 JCN 2017, Vol 31, No 6

4 Table 2: Staging (adapted from NPUAP/EPUAP/PPPIA, Figures used with permission of the National Pressure Ulcer Advisory Panel, October 2017) 201 Intact skin with a localised area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Colour changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunnelling may occur. Fascia, muscle, tendon, ligament, cartilage age and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury d Full-thickness skin and tissue loss s with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/ or tunnelling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury W 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 or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischaemic limb should not be softened or removed Intact or non-intact skin with localised area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin colour changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (Unstageable, stage 3 or stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions are The skin is intact, no visible tissue loss and stays red when pressed with finger tip The epidermis and dermis are exposed People Ltd The epidermis, dermis, subcutaneous fat, may be missing or visible Epidermis, dermis, subcutaneous fat, muscle with tendon and bone exposed The epidermis and dermis but the depth of tissue loss is obscured by sloughy tissue, dry black eschar. Appropriate dressings need to be applied and careful observations before full classification can be defined There is no breakage in the skin, on examination it may be firm, mushy or boggy and warmer or cooler to touch when compared to other parts of the skin JCN 35

5 Nutrition Nutritional screening is used to identify individuals who need comprehensive nutritional assessment due to characteristics that put them at potential risk. This can be undertaken by any member of the healthcare team, and should be conducted on admission to the healthcare facility, or at first visit in community settings (NPUAP/ EPUAP/PPPIA, 2014). While poor nutrition may not be the direct cause of pressure damage, it is possible that it may increase tissue vulnerability (Mathus-Vliegan, 2001), and can affect the healing process (Stacey, 2016). If malnutrition is indicated, nutritional intervention will be required, and involve carers improving the patient s protein intake. In some cases, proteinrich energy supplements may be prescribed. It is also important to ensure that patients do not become dehydrated, as this can result in dry flaky skin, which is vulnerable to trauma and injury. Support surfaces Woodhouse and Graham (2014) discussed the importance of working in collaboration with community services to provide appropriate training and equipment by developing a mattress/equipment selection tool utilising the Braden risk assessment score with NPUAP/ EPUAP/PPPIA (2014) stages to ensure that patients have the specific pressure-relieving device to suit their needs (NHS Quality Improvement Scotland, 2009). Several factors need to be taken into account when placing equipment in the community setting. For example, it is important to ensure that patients have the appropriate priate room to accommodate bedframes, heights and mattress specifications, ions, as well as considering the patient s upper body strength and ability to self-move. Requesting Practice point Always follow local policy and guidelines and ensure that dressing selection is only made after a thorough wound assessment. and using appropriate equipment, using turning charts or upgrading mattresses, can all be put in place as preventive measures (NPUAP/ EPUAP/PPPIA, 2014). Repositioning Regular repositioning is necessary to reduce the duration and magnitude of pressure over vulnerable areas of the body. Thus, patients should be made aware of this and encouraged to change position (Glasper et al, 2009; NPUAP/EPUAP/PPPIA, 2014). The more movement a patient makes, the more they can relieve pressure from areas on their skin. When thinking about how a patient can change position to redistribute pressure, consider if a patient who is confined to bed can lie on their side? For wheelchair users, suggest returning to bed for an hour or two in the afternoon (Payne, 2016). Wound care Thorough wound assessment should be undertaken for any pressure ulcers where the skin is broken (Coleman et al, 2017). This should include size, depth, description of tissue present, slough, necrosis or exudate. Photographs and/or wound tracings should be taken and documented. It is important to be aware of patient confidentiality and where possible gain written consent (Royal College of Nursing [RCN], 2005). All pressure ulcers should have appropriate dressings applied as soon as possible (Gray and Hampton, 2015). Pressure ulcers often occur over the sacrum and heels, making them difficult to dress. Adhesive dressings can be cut to shape, which may make this easier (Gunnewicht and Dunford, 2004). The optimum wound healing environment should be created by using modern wound dressings such as hydrocolloids, hydrofibers, foams (including silicone foams, where pain may be an issue), films or alginates. NICE (2014) suggests that negative pressure wound therapy (NPWT) should only be applied under specialist supervision. Larval therapy should only be considered when autolytic debridement or surgical debridement has been excluded. NICE (2014) also advises that no adult patient should be offered gauze dressings to treat pressure ulcers. Many trusts will have formularies that support the healthcare professional in using modern dressings. Silicone foam dressings The NPUAP/EPUAP/PPPIA (2014) guidelines support the use of silicone foam dressing sing for the treatment of pressure sure ulcers, particularly when used as a contact layer to promote ote atraumatic dressing changes, and to protect periwound injury when the skin is fragile or friable. Silicone dressings have also demonstrated positive outcomes when used for managing various volumes of exudate, while remaining comfortable and conformable for patients (Bateman, 2015; Stephen-Haynes et al, 2015). The volume of exudate produced in stages 3 or 4 pressure ulcers can be a challenge, particularly if the fluid is sloughy and viscous, and, as said, wounds in the sacral or heel areas can be difficult to dress (Kalowes et al, 2016; Mahoney, 2016; Bajjada, 2017). Silicone dressings are also easy to apply for both healthcare professionals and carers (Black et al, 2013; Hampton, 2016; Mahoney, 2016; Walker et al, 2017). An example of one silicone foam dressing, which has been recently redesigned and is suitable for treating pressure ulcers, is Cutimed Siltec (BSN medical, an Essity company). CUTIMED SILTEC Cutimed Siltec consists of a perforated silicone wound contact layer with an option of tack (from gentle to tacky) to help secure adherence, while also allowing the dressing to be removed and reapplied easily and atraumatically when needed (Figure 1). The different strengths of adherence, include: Low tack Cutimed Siltec, Cutimed Siltec L Soft tack Cutimed Siltec Plus Soft tack in a border dressing Cutimed Siltec B). These tack options help to balance the need to protect frail and 36 JCN 2017, Vol 31, No 6

6 Highly breathable coloured polyurethane film (with printed branding) giving a dynamic moisture vapour transfer rate (MVTR) Superabsorbent hotmelt stripes for additional absorption and retention capacity Figure 1. delicate skin, while also securing the dressings in place, particularly in difficult-to-dress anatomical areas, such as the sacrum or heels. The perforations in the silicone, combined with the large pores of the soft, polyurethane foam core, ensure even the most viscous exudate is managed well, by wicking fluid vertically away from the wound and thereby protecting the periwound skin. Fluid is then absorbed into the superabsorbent adhesive strips on the top of the foam layer for additional absorption and retention capacity and to help prevent maceration. The smooth, polyurethane top film is breathable, adapting and supporting moisture vapour transmission to saturation level. The transparency of the top film also allows visible inspection to help determine the ideal time for dressing change without unnecessarily disturbing the wound ( ). Cutimed Siltec comes in a variety of shapes (oval, sacrum, heel), with rounded corners to ensure perfect fit wherever applied. The products are designed for atraumatic dressing change to promote patient comfort. Furthermore, the bordered versions are water-resistant, so patients can shower between dressing changes. Perforated silicone layer, with either low tack (Cutimed Siltec, Cutimed Siltec L), or soft tack (Cutimed Siltec Plus ), or soft tack in a border dressing (Cutimed Siltec B) CONCLUSION There are few areas of health care where patients will not be at risk of developing pressure ulcers. It should be remembered ered that pressure ulcers are not bound to happen, even if the patient is considered to be at high risk, and so their prevention should be a priority for healthcare professionals (National Patient Safety Agency [NPSA], 2010). It is essential to undertake great care in assessment and management by using the multidisciplinary team and applying an appropriate care plan that colleagues can follow. Skin inspection and good skin care is an integral part of pressure ulcer care, and should be undertaken to identify any existing skin or pressure damage, assess the patient s overall skin condition, and to inform a plan of care (Lloyd-Jones, 2014). With many national and local guidelines available, healthcare professionals need to ensure that both their knowledge and practice is competent and up to date, and that they are familiar with products available, such as the versatile Cutimed Siltec range, to provide their patients with the most suitable treatment options that promote optimal outcomes and patientcentred care. JCN 2017 Wound Care re Peo eop Highly absorbent open-porous polyurethane foam for fluid absorbency Ltd INSIGHT... for individual e-learning and CPD time Having read this article, why not go online and take your individual learning further by testing your knowledge of this topic in the INSIGHT section of the FREE JCN e-learning zone ( learning-zone)? If you answer the accompanying online questions correctly, you can download a certificate to show that you have completed this JCN e-learning unit on pressure ulcer identifcation and management and the role that Cutimed Siltec can play in treatment. Then, add the article and certificate to your free JCN revalidation e-portfolio, as evidence of your continued learning safely, securely and all in one place: JCN 37

7 REFERENCES Agency for Healthcare Research and Quality (2014) Preventing Pressure Ulcers in Hospitals. How do we measure our pressure ulcer rates and practices? Available online: www. ahrq.gov/professionals/systems/hospital/ pressureulcertoolkit/putool5.html (accessed 18 September, 2017) AWTVN Forum, WWIC (2016) National Pressure Ulcer Audit Unpublished data presented at the Tissue Viability Society conference, Cardiff Bajjada T (2017) Using a step-up, step-down approach to exudate management. J Community Nurs 31(2): 32 8 Bateman SD (2015) 150 patient experiences with a soft silicone foam dressing. Br J Nur 24(Suppl 12): S16 S23 Bethell E (2003) Controversies in classifying and assessing grade I pressure ulcers. J Wound Care 12(1): 33 6 Black J, Alves P, Brindle CT, Dealey C, Santamaria N, Call E, Clark M (2013) Use of wound dressings to enhance prevention of pressure ulcers caused by medical devices. Int Wound J 12(3): Blenman J, Marks-Maran D (2017) Pressure ulcer prevention is everyone s business: the PUPS project. Br J Nurs 26(6): Tissue Viability Supplement Charlton S (2014) Pressure ulcer grading and appropriate equipment selection. Br J Nurs 23(Suppl 15): S4 S13 Coleman S, Nelson EA, Vowden P, et al (2017) Development of a generic wound care assessment minimum data set. J Tissue Viability. Available online: org/ /j.jtv Cross C, Hindley J, Carey N (2017) Evaluation of a formal care worker educational intervention n on pressure ulceration in the community. J Clin Nurs 26: Browning P (2016) Wound care today: costs and treatments. Br J Health Management 22(12): Defloor T, Schoonhoven L, Wee K, Weststrate, JA, Myny D (2006) Reliability of the European Pressure Ulcer Advisory Panel classification system. J Adv Nurs 54(2): Department of Health (DH 2015) Review of Operational Productivity in NHS Providers Interim Report. DH, London Fletcher J, Ousey K, Clark M, James C (2011) Why do we bother grading pressure ulcers? Wounds UK 7(2): Glasper A, McEwing G, Richardson J (2009) Cambridge Media: Osborne Park, Australia Foundation skills for caring: using studentcentred learning. Palgrave Macmillan, NHS England (2014) NHS Five Year Forward View. NHS England, London. Available Basingstoke: Chap 10: online: Gray S, Hampton S (2015) A united approach futurenhs/ (accessed 10 September, 2017) to the prevention of pressure ulcers. Nurs NHS Quality Improvement Scotland (2009) Residential Care 17(3): Best Practice Statement: prevention and Gunnewicht B, Dunford C (2004) Fundamental management of pressure ulcers. Aspects of Tissue Viability Nursing. Quay Edinburgh, Scotland. Available online: Books, London our_work/patient_safety/tissue_viability_ sue_v Hampton S (2016) Dressing selection for older resources/pressure_ulcer_best_practice.aspxr_best_practi people with open wounds. Nurs Residential Care 18(10): Payne D (2016) Strategies to support prevention, identification and management Kalowes P, Messina V, Li M (2016) Five-layered of pressure ulcers in the community. Br J soft silicone foam dressing to prevent Community Nurs 21(Suppl 6): S10 S18 pressure ulcers in the intensive care unit. Am J Crit Care 25(6): e108 e119 Posnett t J, Gottrup F, Lundgren H, Saal G (2009) The resource impact of wounds on Lloyd-Jones M (2014) Pressure ulcer health-care providers in Europe. J Wound prevention: a priority. Wound Care Today Care 18: (1): 14 8 Royal College of Nursing (2005) The Mahoney K (2016) Finding a cost-effective e management of pressure ulcers in primary and dressing solution with multiple applications. plications. secondary care: A clinical practice guideline. J Community Nurs 30(5): 36 RCN, London Mathus-Vliegan E (2001) Nutritional status, Stacey M (2016) Why don t wounds heal? nutrition and pressure ulcers. Nutr Clin Wounds Int 7(1): Practice 16: Stephen-Haynes J, Callaghan R, Bethell E, et al McCoulough S (2016) Adapting a SSKIN (2015) Assessing an adherent silicone foam bundle for carers to aid identification of dressing: a clinical evaluation across five pressure e damage and ulcer risks in the NHS trusts. Br J Community Nurs 20(Sup12): community. munity. Br J Community Nurs 21(Suppl S32 S38 6): S19 S25 Stevenson R, Collinson M, Henderson V, et al NHS Commissioning Board (2013) (2013) The prevalence of pressure ulcers in Commissioning for quality and innovation community settings: an observational study. (CQUIN): 2013/14 guidance. DH, London. Int J Nurs Studies 50: Available online: www. england.nhs.uk/wpcontent/uploads/2013/02/cquin-guidance. Vowden K, Vowden P (2015) Documentation in pressure ulcer prevention and management. pdf (accessed 10 September, 2017) Wounds UK 11(3 suppl 2): 6 9 NHS Institute for Innovation and Improvement Walker R, Huxley L, Juttner M, et al (2017) (2013) High Impact Action: Your Skin Matters. A pilot randomized controlled trial using Available online: prophylactic dressings to minimize sacral (accessed 10 September, 2017) pressure injuries in high-risk hospitalized National Institute for Health and Care patients. Clin Nurs Res 26(4): Excellence (2014) NICE quality standard White R, Cutting K, Jeffrey S (2016) Efficiency Pressure ulcers: prevention and management savings in wound care must not compromise (CG179). NICE, London. Available online: patient care. BMJ. Available online: blogs.bmj.com (accessed 17 September, (accessed 12 September, 2017) 2017) National Patient Safety Agency (2010) Woodhouse L, Graham K (2014) Meeting NHS to adopt zero tolerance to pressure targets in pressure ulcer prevention in the ulcers. Available online: community by collaborating with industry.br uk/corporate/news/nhs-to-adopt-zerotolerance-approach-to-pressure-ulcers J Community Nurs 19(Suppl 12): S14 S20 Wounds UK (2013) Best Practice Statement: National Pressure Ulcer Advisory Panel, Eliminating Pressure Ulcers. Available online: European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2014) statements/best-practice-statement- eliminating-pressure-ulcers Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed). (accessed 16 September, 2017)?? 38 JCN 2015, 2017, Vol 29, 31, No 56