Major Change. Outline of the information that has been added to this document especially where it may change what staff need to do

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1 Policy Number LCH-75 This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form. Part A Information about this Document Policy Name Pressure Ulcer Guideline Policy Type Board Approved (Trust-wide) Trust-wide Divisional / Team / Locality Action No Change Minor Change Major Change New Policy No Longer Needed Approval As Mersey Care s Executive Director / Lead for this document, I confirm that this document: a) complies with the latest statutory / regulatory requirements, b) complies with the latest national guidance, c) has been updated to reflect the requirements of clinicians and officers, and d) has been updated to reflect any local contractual requirements Signature: Date: Part B Changes in Terminology (used with Minor Change, Major Changes & New Policy only) Terminology used in this Document New terminology when reading this Document Part C Additional Information Added (to be used with Major Changes only) Section / Paragraph No Outline of the information that has been added to this document especially where it may change what staff need to do Part D Rationale (to be used with New Policy & Policy No Longer Required only) Please explain why this new document needs to be adopted or why this document is no longer required Part E Oversight Arrangements (to be used with New Policy only)

2 Accountable Director Recommending Committee Approving Committee Next Review Date LCH Policy Alignment Process Form 1 Page 2 of 42

3 SUPPORTING STATEMENTS This document should be read in conjunction with the following statements: SAFEGUARDING IS EVERYBODY S BUSINESS All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult; knowing how to deal with a disclosure or allegation of child / adult abuse; undertaking training as appropriate for their role and keeping themselves updated; being aware of and following the local policies and procedures they need to follow if they have a child / adult concern; ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust s safeguarding team; participating in multi-agency working to safeguard the child or adult (if appropriate to your role); ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation; ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session EQUALITY AND HUMAN RIGHTS Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership. The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices. Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act. Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy Page 3 of 42

4 Prevention and Management of Pressure Ulcers Page 4 of 42

5 Title Guideline reference number Aim and purpose of guideline Author Type Prevention and Management of Pressure Ulcers 75 To assist in the prevention, assessment and management of pressure ulcers Is this a new guideline? Or a review of an existing guideline? Review date June 2018 Person/group accountable for review Type of evidence base used Issue date Authorised by Clinical Standards Group A: Evidence obtained from systematic reviews and/or randomised controlled trials B: Evidence from multiple unacceptable studies or a single acceptable study (weak or inconsistent evidence) C: Evidence which includes published and /or unpublished studies and expert opinion (limited scientific evidence) January 2018 slight amendment noted at Clinical Standards Group meeting on st June 2016 Equality Analysis Undertaken Yes No June 2016 Evidence collated Evidence collated Page 5 of 42

6 Version Control Sheet Version: 7 Ratified by: Name of originator/author Approving body/committee: review Clinical Standards Group Clinical Standards Group Date issued: January 2018 Review date: June 2018 Target audience: Name of lead Director/ Managing Director Changes / Alterations made to previous version: Healthcare professionals within Liverpool Community Health involved in caring for patients at risk of or with existing pressure damage. Director of Nursing The word friction has been removed from page 11 of these guidelines Page 6 of 42

7 Contents Introduction... 8 Purpose... 8 Scope of the Guideline... 8 Definitions... 8 References Monitoring Tool Development of the Guideline Contributors and Peer Review Impact Assessment Distribution List/Dissemination Method Risk Assessment Pressure Ulcer Assessment Skin Assessment Pressure Ulcer Management Repositioning Pressure Redistribution Devices Pressure Ulcers to the Foot Seating Miscellaneous aids used in the prevention and treatment of pressure ulcers Education and Training APPENDIX A Waterlow Tool updated APPENDIX B - Pathway for Patient at Risk of Developing / With Pressure Ulcers APPENDIX C - EPUAP Pressure Ulcer Classification System (2014) APPENDIX D MIOSTURE LESIONS APPENDIX E - 30º tilt APPENDIX F - Repositioning Chart APPENDIX G - Foot Wound / Ulcer Reporting Guideline APPENDIX H - SSKIN BUNDLE Check List APPENDIX I - SKIN CARE BUNDLE / INTENTIONAL ROUND APPENDIX J - Pressure Ulcers Referral to APPENDIX K - Audit Tool for Patients at Risk or with Pressure Ulcers Page 7 of 42

8 Introduction A pressure ulcer is localized injury to the skin and/or 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; the significance of these factors is yet to be elucidated. (NPUAP/EPUAP 2014) UK pressure ulcer prevalence estimates specifically for community settings have reported rates of 0.77 per 1000 adults in a UK urban area (Stevenson 2013). Pressure ulcers represent a major burden of sickness and reduced quality of life for patients and create significant difficulties for patients, their carers and families. The impact of pressure ulcers is psychologically, physically and clinically challenging for both patients and NHS staff. In an economically constrained health service, revenue spent on pressure ulcers is a concern, as it is suggested that many pressure ulcers can be avoided with appropriate risk assessment and use of interventions targeted at combating this risk (Moore 2014). However, despite this premise, the estimated treatment costs of pressure ulcers in the UK is as much as million per year and these costs are primarily accrued through community nursing services. Approximately 90% of overall costs account for Nurse and Healthcare Assistants time. Purpose These guidelines principles are based on clinical guidelines recommended by the National Institute of Clinical Evidence (NICE 2015). It aims to minimise the risk of patients developing pressure ulcers and ensure effective management, improve clinical practice and reduce variations in standards of care; and to disseminate best practice across Liverpool Community Health. Scope of the Guideline This Clinical Guideline applies to any registered health professional employed by the Liverpool Community Health who is involved in the management of patients at risk of developing or with existing pressure ulcers. To be used in conjunction with LCH Wound Assessment Clinical Guideline and LCH Leg Ulcer Management Clinical Guideline Definitions Dynamic / Alternating-pressure mattresses: the patient lies on air-filled sacs, which sequentially inflate and deflate and relieve pressure at different anatomical sites for short periods; these devices may incorporate a pressure sensor. Page 8 of 42

9 Blanching erythema: Reddened area that temporarily turns white or pale when pressure is applied with a fingertip. Blanchable erythema over a pressure site is usually due to a normal reactive hyperaemia response. Debridement: Removal of devitalized (dead) tissue and foreign matter from a wound by various means. Erythema: non-specific redness of the skin which can be localized or general in nature and which may be associated with cellulitis, infection, prolonged pressure or reactive hyperaemia. Gel (viscoelastic) filled pads: frequently used on operating theatre tables to protect head, heels and ankles. High-specification foam pressure-relieving devices ('foam alternatives'): for example, high-specification foam, convoluted foam, cubed foam; these are conformable and aim to redistribute pressure over a large contact area. High-tech devices: Alternating support surface where inflatable cells alternately inflate and deflate. Hyperemia: Reactive hyperemia: the characteristic bright flush of the skin associated with an increased volume of the pulse on the release of an obstruction to the circulation, or a vascular flush following the release of an occlusion of the circulation which is a direct response to incoming arterial blood. Hyperemia: Blanching hyperemia: the distinct erythema caused by reactive hyperaemia, when the skin blanches or whitens if light finger pressure is applied, indicating that the patient s microcirculation is intact. Non-Blanching Hyperemia (previously identified as Non Blanching Erythema): indicated when there is no skin colour change of the erythema when light finger pressure is applied, indicating a degree of microcirculatory disruption. Pressure Reduction: Reduction of interface pressure, not necessarily below the level required to close capillaries. Pressure relief: Reduction of interface pressure below capillary closing pressure. Overlay: General term used to describe support surfaces placed on top of a standard mattress Static mattress: Pressure reducing device designed to provide support characteristics that remain constant. Turning beds/frames (kinetic beds): beds that either aid manual repositioning of the patient or reposition the patient by motor driven turning and tilting. Page 9 of 42

10 References Bailey F, MD Harman S, MD, FACP (2016) Pallative care; the last hours and days of life. Wolter s Kluwer health version 31 Bennett G Dealey C, Posnett J (2004) Age and Ageing 2004; 33: Colin, D., Abraham, P., Preault, L., Bregeon, C. and Suamet, J.L. (1996) Comparison of 90 degree and 30 degree laterally inclined position in the prevention of pressure ulcer using transcutaneous oxygen and carbon dioxide pressures. Advances in Wound Care 9 (3) p Collins, F. (2004) Seating: assessment and selection. Journal of wound Care/Therapy Weekly. May p9 12. Cullum, N., Nelson, E.A. and Sheldon, T. (2001). Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy. Health Technology Assessment: 5 p European Pressure Ulcer Advisory Panel (2014) Prevention and Treatment of Pressure Ulcers: Guidelines. EPUAP and NPUAP. Fletcher, J. (2008) Understanding the difference between Moisture lesions and Pressure ulcers. Nursing Times / Gray, D, Cooper, P.J, Stringfellowe, S. (2001) Evaluating pressure reducing foam mattresses and electric bed frames. British Journal of Nursing 10 (22) S23-24, S26, S28. Medical Devices Agency (1997) Evaluation PS4. Wheelchair cushions static and dynamic. HMSO, Norwich. Moore, Z. et al (2014) Pressure ulcer Risk Assessment and Prevention: What difference does a risk scale make? A comparison between Norway and Ireland. Journal of wound Care. 23 (7) NICE (2004) Type 2 Diabetes. The prevention and management of foot problems. CG10. NICE London. NICE (2014) Pressure ulcers: The management of pressure ulcers. Clinical Guideline April NICE, London. NICE (2014) Pressure ulcers: The management of pressure ulcers. Clinical Guideline April NICE, London. Information for the public NICE (2015) Pressure ulcers: Quality Standard. June NICE, London. Page 10 of 42

11 NMC (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London. National Pressure Ulcer Advisory Panel. The facts about reverse staging in 2000: The NPUAP Position Statement. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel (2009) Prevention and treatment of pressure ulcers: clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel (2010) Pressure Ulcers in Individuals receiving palliative Care; A national Pressure Ulcer Advisory Panel White Paper. Advances in Skin and Wound Care Journal. 23 (2) Stevenson, R. et al (2013) The Prevalence of pressure ulcer in the community setting: An observational study. International Journal of Nursing Studies 50 (11) Tissue Viability Society (2009) Seating and pressure Ulcers: Clinical Practice Guideline. Tissue Viability Society (2012) Achieving Consensus in Pressure Ulcer Reporting. Page 11 of 42

12 Monitoring Tool The implementation of this guideline will be facilitated by Pressure Ulcer Prevention and Management Training provided by the. These will be made available through the Learning and Development Bureau. The clinical content of this guideline has been incorporated in a Pressure Ulcer Competency Framework. This consists of e-learning and practical / theoretical training, supported practice-based learning in the clinician s place of work and completion of the competency framework document. This will ensure that the knowledge learned in the classroom is translated into clinical practice and demonstrated through competent performance. The audit of this guideline will be undertaken as per Provider Services Local Forward Audit Plan. An audit tool is provided in Appendix K. Development of the Guideline This guideline incorporates evidence which is included in national guidance on the prevention and management of pressure ulcers, made available by the National Institute for Clinical Excellence. In addition key recommendations to be included in, or omitted from, this guideline followed discussions held locally within the Trust. Contributors and Peer Review The guideline has been developed and peer reviewed by: The Clinical Lead Podiatry Service CEDAS Equipment Specialist Nurses Wheelchair Service Dieticians Manual Handling Team Safeguarding Adults Team Equality Analysis Assessment This guideline is believed to have no differential impact for any group or groups. A full Impact Assessment is not required however a Screening Process Recording Proforma has been completed and accepted by The Equality and Diversity Team and a copy held by the. Distribution List/Dissemination Method Once approved, this guideline will be added to the Clinical Policies Database and communicated to Liverpool Community Health Employees via the Communication Bulletin. Page 12 of 42

13 Risk Assessment (NICE 2014 and NPUAP /EPUAP 2014) The pathway for the prevention and management of patients with / at risk of pressure ulcers in Liverpool Community Health is summarised in Appendix B. Risk assessment 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 should take place at the first face-to-face visit (NICE 2015), or within 6 hours of admission on all individual s. All patients are potentially at risk of developing a pressure ulcer (NICE, 2015). A Waterlow is the risk assessment tool of use within Liverpool Community Health (Appendix A). Reassessment should occur on planned review dates that are set out in the care plan, or sooner if there is a change in an individual s condition, which increases risk (NICE 2015). Any patient assessed as being vulnerable to pressure ulcer development should be nursed on an appropriate pressure-relieving mattress. Formal risk scales should be used in conjunction with clinical judgement. This enables staff to formulate an individualised care plan identifying pressure-reducing measures which should take into consideration the care setting that the patient is being cared for in. The following Intrinsic factors contribute to tissue damage and should be considered during the assessment: Increasing age Body weight (under / overweight) Reduced mobility / the inability to reposition themselves Sensory perception Acute / Chronic illness Nutritional status Factors affecting perfusion and oxygenation e.g. cardiovascular disease Medication Terminal illness Alteration in levels of consciousness Significant cognitive impairment The Extrinsic factors involved in the development of pressure ulcers are: Pressure Shearing Moisture Other Risk Factors: Previous pressure damage Page 13 of 42

14 Pressure Ulcer Assessment (NICE 2014 & EPUAP / NPUAP 2014, Fletcher 2008) Assess the pressure ulcer as part of the holistic assessment identify and address the patient s holistic needs. Assess the pressure ulcer following LCH wound assessment guidelines and wound documentation Record the pressure ulcer category using the European Pressure Ulcer Advisory Panel Classification System (2014) (Appendix C) This should be supported by photography (refer to LCH Digital Photography Policy available on the intranet) or tracings. The dimensions of the pressure ulcer should be measured recording the longest length/longest width as an estimate of surface area (use of tracings); the deepest part of the wound should also be measured using a sterile probe. Pressure ulcers should not be reverse graded to ensure that the original degree of tissue damage is taken into consideration. Pressure ulcers heal to progressively more shallow depth; they do not replace lost muscle, subcutaneous fat, or dermis before they reepithelialise. Instead, the ulcer is filled with granulation (scar) tissue composed primarily of endothelial cells, fibroblasts, collagen and extracellular matrix. A Category/stage 4 pressure ulcer therefore cannot become a Category/stage 3. When a Category/stage 4 pressure ulcer has healed it should be classified as a healed category/stage 4 and not a Category/stage 0 pressure ulcer. If a pressure ulcer re-opens in the same anatomical site, the ulcer resumes the previous staging diagnosis (i.e. once a healing category/grade 4 always a category/grade 4). Moisture lesions - are skin lesions and are not caused by pressure and/or shear, a continence assessment should be completed and the use of a barrier preparation to prevent skin damage. Descriptors to support differentiating include: Location not necessarily over bony areas; e.g. the anal cleft and have a linear shape Colour more purple colours Oedematous/swollen wet skin. Patient history of incontinent/diarrhoea Shape - Diffuse edges, superficial lesion, irregular shape; Kissing ulcer Combination of Moisture V Pressure: A very common presentation is a combined ulcer, where the patient has one or more wounds with elements of both pressure and moisture damage, for example in a patient who is immobile and has continence problems or who has pressure damage and a heavily exuding wound. It is important to be aware of all the causes of skin damage, assess the patient s risk and plan management accordingly. If the moisture lesion does not improve despite the use of skin barrier products and incontinence/moisture management, and pressure and/or shear is present, consider Page 14 of 42

15 the possibility that the ulcer is a pressure ulcer and grade accordingly (Fletcher 2008). Reassessment of the ulcer should be performed at least weekly or what has been specified on the care plan but may be required more frequently, depending on the condition of the wound and the result of holistic assessment of the patient. If the condition of the patient or the wound deteriorates, re-evaluate the treatment plan as soon as any evidence of deterioration is noted and consider a /referral to the for further support. Clinical Incident Reporting - All pressure ulcers graded 2 and above should be documented as a Clinical Incident via Datix. Moisture lesions should not be reported as pressure ulcer incidents, however where the cause is a combination of moisture and pressure, these should be reported as pressure ulcers. (TVS 2012) Nutrition Ensure adequate dietary intake to the extent that it is compatible with the individual s wishes or condition by following the appropriate Malnutrition Screening tool - MUST Consider the patient s protein, energy, hydration, Vitamin and mineral intake. Check weight / BMI / relevant blood profiles and discuss with dietician / General Practitioner if appropriate. Nutritional status screening for the treatment of patients at risk / with pressure ulcers should be made using the MUST Tool and: o Patient preference; o Dietetic input to support decision-making if appropriate o The appropriate care pathway should be followed for each MUST score and referred into to the dietetics team as stated on the flow chart which can be found on LCH Intranet. o Pain Pain assessment and management should include: whether the individual is experiencing pain; causes of pain; level of pain; location and management interventions. A number of studies have identified pain as a major factor for individuals with pressure ulcers. Several studies also offer some indication that pain over the site was a precursor to tissue breakdown. Psychosocial assessment Assess resources (e.g. availability and skill of caregivers, home conditions, equipment, and patient s preference) for individuals being treated with pressure ulcers in the home. In any situation were staff consider an Adult to be at Risk of Abuse staff should refer to guidance within the Safeguarding Adults Policy available on the Intranet and liaise with LCH Safeguarding Adult s Team. Page 15 of 42

16 Skin Assessment (NICE 2014 and NPUAP /EPUAP 2014) A complete skin inspection is part of the risk assessment that should be performed on the first face-face visit and on an ongoing basis. Skin inspection should be based on an assessment of heels, sacrum, ischial tuberosities, spine, parts of the body affected by anti-embolic stockings, femoral trochanters, and parts of the body where pressure, friction and shear are 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, elbows, temporal region of skull, shoulders, back of head and toes. Other areas should be inspected as necessitated by the patient s condition. Individuals who are willing and able should be encouraged, following education to inspect their own skin; or alternatively, family or carers. Informed decision making should be supported by the provision with the patient information leaflet Pressure Ulcer Prevention and Management. (Available from skin service intranet page). Any changes should be reported to a health care professional as soon as possible. Individuals who are wheelchair users should use a mirror to inspect the areas that they cannot see easily or get others to inspect them. On-going assessment of the skin is necessary to detect early signs of pressure damage and prompt intervention to prevent further skin deterioration. Health care professionals should be aware of the following signs of potential tissue damage: * Persistent erythema * Non-blanching hyperaemia (previously identified as non blanching erythema) * Blisters * Discoloration * Localised heat * Localised oedema * Localised induration. As it is not always possible to see signs of redness on darkly pigmented skin, these additional signs should be considered in the assessment: * Purplish/bluish localised areas of skin * Localised heat which, if tissue becomes damaged is replaced by coolness * Localised oedema * Localised induration. Skin changes should be documented/ recorded immediately, with the appropriate action taken. The SSKIN bundle should be completed at identified frequency to support on-going monitoring of skin integrity.(see Appendix H / I) Page 16 of 42

17 Pressure Ulcer Management (NICE 2014, NPUAP /EPUAP 2014, NMC 2015) Use in conjunction with LCH Wound Assessment and Debridement Guidelines and wound documentation. Pressure ulcer treatment strategies comprise a combination of pressure relief (in the form of support surfaces), positioning and repositioning, and wound management strategies. The selection of the wound dressing should be based on the tissue in the ulcer bed, the condition of the skin around the ulcer bed, and the goals of the person with the ulcer. Generally maintaining a moist ulcer bed is the ideal when the ulcer bed is clean and granulating to promote healing or closure. Several moisture-retentive dressings are available. However, the type of dressing may change over time as the ulcer heals or deteriorates. Wounds should not be routinely irrigated or cleansed unless pus, dressing debris or foreign bodies is present. Many pressure ulcers are colonised with bacteria, therefore a clean technique using a non-sterile cleansing solution i.e. tap water can be used in most cases. Pressure ulcer debridement may be required when appropriate for a patient s condition and consistent with the patient s goals. Further advice can be obtained from the. With the terminally ill patient their overall quality of life should be taken into account when deciding whether to debride the wound and which method should be used. The dressing should be documented in the plan of care with rationale for its use. Choice of dressings should be based on the ulcer/skin assessment, treatment objective, risk of adverse events (sensitivities / allergies), patient preference, dressing characteristics, and indications for use. Refer to Liverpool Community Health Wound Formulary. The use of advanced technologies such as topical negative pressure may be considered as part of wound management for non-healing pressure ulcers. The approach to care should be interdisciplinary, involving all those needed in the management of pressure ulcers. Patients with non-healing/deteriorating pressure ulcers should be referred to the as per referral process to the (APPENDIX J) Patients who fail to respond to conservative measures may need referral to a plastic surgeon for possible surgery (NICE 2014) Skin Care Massage cannot be recommended as a strategy for pressure ulcer prevention where there is the possibility of damaged blood vessels or fragile skin. As well as Page 17 of 42

18 being painful, rubbing the skin can also cause mild tissue destruction or provoke an inflammatory reaction, particularly in the frail elderly. Skin emollients may be used to hydrate dry skin in order to reduce risk of skin damage. Protect the skin from exposure to excessive moisture with a barrier product (refer to wound formulary) in order to reduce the risk of tissue damage. Delegated / Shared Care The delegation of nursing care must be appropriate, safe and in the best interests of the patient at all times and the decision to delegate must always be based on an assessment of their individual needs When pressure ulcer management is shared with other disciplines or providers of care e.g. care home staff / social care agencies, community nurses must document the agreed level of shared care required for the patient. This may include advice on frequency of repositioning, manual handling, manual handling aids and skin inspection. Any variations from the plan may warrant reporting as a clinical incident and the safeguarding team informed. NMC (2015) advocate working in partnership with people to ensure care is delivered effectively. Self - caring Individuals who are self caring, should be informed, educated and a plan of care agreed on the prevention and management of pressure ulcers (NICE, 2014) (Refer to education and training section). Shared Decision Making This is a joint process between patient and clinician about their treatment which takes into account the patient s wishes, needs and preferences and the clinician s expert knowledge. It involves patients who have full mental capacity in important decisions about their care and acts as a record of what has been discussed risks, benefits and other options. This is useful if patients are declining treatment i.e. dressing choice, frequency of visits, positional changes and equipment such as cushions, mattresses etc. as there may need to be a compromised plan of care in line with what the patient agrees/consents to or a review date agreed to discuss the treatment options again. If this tool is utilised it can be reviewed periodically and updated to reflect any behavioural or physical changes to the patient s condition. Consent / Mental Capacity If an individual is unable to consent at the time the treatment decision is made due to lacking mental capacity as per the Mental Capacity Act 2005 this must be documented and a best interest decision will be required in order to undertake the most appropriate action for the patient at that time. This must incorporate consideration of the known wishes, feelings, beliefs and values of the patient and anyone close to them if appropriate. For further information please refer to the LCH Mental Capacity Act policy which contains the mental capacity and best interest assessments. Page 18 of 42

19 Repositioning (NICE 2014 & 2015 and NPUAP / EPUAP 2014, NPUAP 2010, Bailey F, MD Harman S, MD, FACP 2016) ALL patients with pressure ulcers should actively mobilize to change their position or be repositioned frequently. High pressures over bony prominences, for a short period of time, and low pressures over bony prominences, for a long period of time, are equally damaging. In order to lessen the individual s risk of pressure ulcer development, it is important to reduce the time and the amount of pressure she/he is exposed to. Individuals who are at risk of pressure ulcer development should be repositioned if it is medically safe to do so, and that when repositioning patients to do so in such a way as to minimise the impact on bony prominences and individual vulnerable areas and ensure that bony prominences are kept from direct contact with one another. Do not position an individual directly onto a non-blachable area and or existing pressure ulcer. Individuals who are acutely at risk of developing pressure ulcers should restrict chair sitting to less than 2 hours until their general condition improves. 1 Consider use of 30º tilt when repositioning patients. So far not supported by systematic evaluation (refer to Appendix E - 30º tilt) Encourage individuals to reposition at least every 6 hours for patients at risk, and every 4 hours for patients at high risk (NICE 2014). If individuals are unable to reposition themselves, health and social care professionals should offer help to do so, using appropriate equipment if needed. Although, repositioning frequency will be determined by the individual s tissue tolerance, his/her level of activity and mobility, his/her general medical condition, the overall treatment objectives, and assessments of the individual s skin condition. The 24 hour frequency of repositioning must be recorded on the care plan. A repositioning schedule, agreed with the patient, should be recorded and established for each vulnerable person as part of a pressure ulcer prevention programme. Frequency of re-positioning should be determined by the patient s individual needs and recorded. See Appendix F for Trust Repositioning Chart. For those patients who are actively dying, prevention and treatment of a Pressure Ulcer may be superseded by the need to promote comfort by minimising turning and repositioning (NPUAP 2010). Recognising that a person is entering the imminently dying or terminal phase of their illness is critical to appropriate care planning, with a shift to comfort care and the patient s overall condition may even be exacerbated by the continuation of standard 1 Clinical judgement must be used to determine if a patient with existing tissue damage should not sit out. Page 19 of 42

20 care (Bailey F, MD Harman S, MD, FACP 2016). Individuals or carers, who are willing and able, should be taught how to re-distribute their weight. No pressure-relieving device should be relied upon as a substitute for regular change of a patient s position. Manual handling Manual handling issues relating to the repositioning or transfer of patient s needs to be assessed involving informal and formal carers. Manual handling risk assessment must be completed if required and the details and technique recorded on the care plan. Lifting and handling techniques need to be adapted to reduce the risk of shearing and friction. Specific equipment to aid repositioning should be considered e.g. slide sheets, hoists. Further advice and demonstrations can be sought from the manual handling team. Page 20 of 42

21 Pressure Redistribution Devices (Gray 2001, NPUAP / EPUAP 2014, NICE 2015) Decisions about which pressure relieving 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. Decisions about whether to obtain pressure relieving devices again should be based on clinical judgement i.e. individuals can have high risk validated score however remain mobile and self-caring (if the decision is not to obtain pressure relieving devices a rationale for decisions should be clearly documented). Refer to Community Equipment Resource Guide and On Line Ordering available via the Intranet for full listing of all available stock items. Community Equipment Services can provide static high specification foam replacement mattress and dynamic/alternating pressure replacement mattress. High specification foam- and dynamic/alternating pressure cushions, heel protectors and electronic profiling beds can also be requested. Initial choice and subsequent decisions, following re-assessments, related to the provision of pressure-relieving support surfaces for patients with pressure ulcers should be based on: ulcer assessment (severity) level of risk - from holistic assessment location and cause of the pressure ulcer general skin assessment general health status mobility patient s weight (NICE 2015) DELIVERY OF EQUIPMENT Clinicians should contact Community Equipment Service if delivery is required other than the standards as identified below. EOL End of Life (RED) same day delivery. Priority 1 aim to deliver the equipment within 48 hours of receipt of the referral. This will only include; Hospital discharges where equipment is essential for discharge home and non-delivery would result in delayed discharge. E.g. bed, mattress, suction machine, hoist Pressure area care where ulcers are categorised 3 and 4 Prevention of an immediate hospital admission An immediate risk of accident or injury and unable to put any safety measures in place. If individuals are in significant pain, require toileting aids / equipment. Equipment that is broken and poses an imminent risk of injury to the individual if not replaced/repaired. Page 21 of 42

22 Priority 2 aim to deliver equipment with 7 days of receipt of the referral. This will include; Hospital discharges where equipment is non-essential for discharge home e.g. perching stool, trolley Pressure area care for patients identified as at risk or with category 1 or 2 pressure ulcers All other referrals where equipment is required to reduce long term risk or support independent living. Priority 3 Special equipment where the appropriate documentation has been completed and the request has been agreed by the Special Equipment Panel. Orders are completed within 72 hours, and delivered within 48hours (of the item being received at stores). Mattress Criteria Within LCH provision of a static high-specification foam mattress with pressure reducing properties will be given for patient identified as being at risk of developing pressure ulcers, unless clinical information states otherwise. Provision of a dynamic mattress will be given for patients identified as being at a high risk of developing pressure ulcers. Consideration will be given outside of these parameters if the patient s clinical condition / clinical assessment indicates a different mattress is required e.g. limited carer input for repositioning or mattress provided is not being effective. Referral to the Skin Service or Community Equipment Nurse Specialist (CENS) team can advise on more specialist equipment. Ensure that the individual is within the recommended weight range for the mattress. Page 22 of 42

23 Pressure Ulcers to the Heels / Foot (NPUAP / EPUAP 2014, NICE 2014, NICE 2004) Heel Pressure Ulcers: Heels should be inspected regularly. If additional equipment is required, heelprotection devices are available from Equipment Services. Use of a pillow under the calves so that heels are elevated (i.e. floating ) may be considered. Any equipment should support the whole lower leg along the calf without putting pressure on the Achilles tendon. The knee should be in slight flexion. Hyperextension of the knee may cause obstruction of the popliteal vein, and this could predispose an individual to deep vein thrombosis. Use a slide sheet placed under heels when repositioning will aid with the reduction of shear or friction. Patients with heel pressure ulcers category 2-4 and Deep Tissue Injury (DTI) pressure ulcer and should be referred to the Podiatry Service for assessment, and if appropriate, provide debridement and off-loading (e.g. soft casting). Podiatry will only assess foot wounds below the ankle N.B. Not all foot ulcers are pressure ulcers. Refer to Appendix G - foot wound / ulcer reporting guideline to support appropriate reporting. Where possible, a vascular assessment should be completed for extremity pressure ulcers. This may include physical examination, palpation of foot pulses, listening of pulses, history of claudication, rest pain and APBI if no contraindications to establish vascular supply and determine healing potential. Prior to considering debridement of heel pressure ulcers it is important to exclude arterial insufficiency. Stable dry eschar should not be debrided on ischaemic limbs. Patient with diabetes who develop new foot ulcers should be referred to the Multidisciplinary diabetic foot ulcer team based at Aintree or the Royal Liverpool and Broadgreen University Hospital as per NICE guidelines (NICE 2004). Page 23 of 42

24 Seating (Collins 2004, TVS 2009 & 2012 NPUAP / EPUAP 2014, (AHCPR 1992; Department of Health 1994) Priorities of care The provision of pressure reducing cushions should not be based solely upon the outcomes of a risk assessment but take into account the patients individual needs as well as the properties of the cushion. While restriction of chair use may be the apparent solution to promote healing of severe pressure ulcers (category/grade 3 and 4) this may restrict an individual s life style and ability to work. The risks of continued chair use should be explained and an informed decision reached and documented. Key outcomes for the long term seated individual should include whether the equipment has: Maintained their occupational performance Provided satisfaction Maintained their health-related quality of life. Seating for the Assessment for the acutely ill individual s vulnerability to pressure ulcer development should be based on consideration of risk factors. If an acutely ill individual is established to be at risk of pressure ulcer development they should sit for no longer than 2 hours at a time then be returned to bed (ideally with a pressure redistributing mattress), with assisted repositioning if required or where appropriate the individual should be encouraged to walk and then lie down and rest, and to avoid sitting down again within an hour (TVS 2009) Limit the time at risk individual spends seated in a chair without pressure relief. When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities. As the loaded area in such cases is relatively small, the pressure will be high; therefore, without pressure relief, a pressure ulcer will occur very quickly. LCH CENS team can undertake seating assessments for clients who are placed with residential or nursing homes identified at risk of developing pressure ulcers due to poor posture and sitting balance, to access this service CENS@liverpoolch.nhs.uk. Seating assessments for clients within their own home have to be referred to Liverpool Social Services Occupational Therapy department via Careline Pressure mapping is available via CENS and Liverpool Wheelchair Service liverpoolwheelchairservice@liverpoolch.nhs.uk. Wheelchair users should receive a specialist seating assessment/referral (including an appropriate cushion) to Wheelchair Services. Positioning of individuals who spend substantial periods of time in a chair or wheelchair should take into account: distribution of weight; postural alignment and support of the feet / heels. Adapt a seated posture that is acceptable for the individual and minimises the pressures and shear exerted on the skin and soft Page 24 of 42

25 tissues. Consideration should be taken of the position of the feet when seating this should include the use of foot stools / leg rests / recliner chairs as this can increase the risk of pressure damage. Minimise seating time and consider periods of bed rest to promote healing in individuals with existing pressure ulcers. If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischial, limit sitting to three times a day in periods of 60 minutes or less. Every effort should be made to avoid or minimise pressure on the ulcer ensuring appropriate seating / support surfaces and/or positioning techniques are in place. Re-evaluate seating surfaces / time schedules and the individual s posture if the ulcer deteriorates (NPUAP / EPUAP 2014). Avoid seating an individual with an ischial ulcer in a fully erect posture (chair or bed). If sitting in bed is necessary, avoid head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx (NPUAP / EPUAP 2014). Seat dimensions and the prevention of pressure ulcers The variables to consider when preventing pressure ulcers while seated in wheelchairs or armchairs should include the adjustment of the chair with consideration given to the: Height of the seat Depth of the seat Width of the seat Backrest height The angle between the seat and the back of the chair Design of the armrests If prescribing pressure cushions and chair raisers are already in situ this will need reviewing to ensure height remains appropriate and prevent pressure areas developing at back of thighs. Self Repositioning Seated individuals where appropriate should be advised to perform pressure relief movement. This intentional movement can be undertaken in three main ways: A - Roll when the individual raises one buttock at a time by leaning or rolling sideways, and this movement usually relies upon the use of armrests for support. B - Forward lean when the individual leans forwards with their chest moving towards their thighs whilst their buttocks remain in contact with the seat. Although this movement does not take the buttocks away from the seat it can alleviate pressure underneath the ischial tuberosities. C - Lift-off when the individual pushes down onto the chair armrests taking their weight through their arms to lift the buttocks away from the seat. It is generally recommended that purposeful, planned pressure relief movement is undertaken every minutes (AHCPR 1992; Department of Health 1994; TVS 2009) to encourage tissue reperfusion. However the practicality, the effect on pressure ulcer Page 25 of 42

26 formation and acceptance of this practice is unclear. Clinical judgement must be used to determine if a patient with existing tissue damage should not sit out. Page 26 of 42

27 Miscellaneous aids used in the prevention and treatment of pressure ulcers (NPUAP / EPUAP 2014) Care should be taken to ensure that these aids do not interfere with the action of any other pressure relieving support surfaces Inflatable heel protector: Effective in the prevention of heel pressure ulcers. Can be placed under heels of patients when seated in chair with feet elevated on stool or can be used as additional support when patient is in bed. These can be used in conjunction with a pressure relieving mattress, where the mattress doesn t relieve the high peak pressures to the heels. Pillows: Useful for supporting patients in bed when using a 30-degree tilt regime to alter weight-bearing areas. To keep bony prominences from direct contact with one another. Foam Wedges: To keep bony prominences free from excess pressure. Electric Profiling Bed Frame: Aid repositioning and contribute to pressure relief (redistribution of pressure). Bed extension: This will prevent feet pressing against the footplate and increasing risk of pressure damage. Knee Brake (Profiling bed): This will prevent shear and friction forces from sliding down the bed. Aids NOT recommended for use: Avoid use of synthetic sheepskin pads; cut-out, ring, or donut-type devices; and water-filled gloves, all which may be detrimental to skin integrity. Prevention and Management of Pressure Ulcers Revised June

28 Education and Training (NICE 2014) Health care professionals should receive relevant training or education in pressure ulcer risk assessment and prevention that are identified within LCH training needs and requirements. Patients, who are able and willing, should be informed and educated about risk assessment / causes of a pressure ulcer / early signs of a pressure / ways to prevent a pressure ulcer / implications of having a pressure ulcer / risk of pressure ulcers in the future / treatment options / repositioning and prevention strategies i.e. demonstrate techniques and equipment used to prevent a pressure ulcer. This strategy should, where appropriate, include carers. Shared decision making should be promoted in care planning. In those instances where risks are identified with patients choice, the processes of informed decision making should be clearly documented. Further information can be obtained from: LCH Consent to Treatment Policy Risk Assessment Policy Guidelines for Shared Decision Making and/or Treatment Plans ADULTS For further advice regarding Non Adherence to care / equipment consider liaising with CENS or the Skin Service on CENS: or Skin Service: Prevention and Management of Pressure Ulcers Revised June

29 APPENDIX A Patient Details Surname... Forename... DoB... NHS No... WATERLOW PRESSURE ULCER RISK ASSESSMENT TOOL (ADAPTED) incorporating MUST Frequency to be completed Complete within 6 hours of admission or on first home visit. Reassess as specified on care plan /change in the patients condition DATE OF ASSESSMENT TIME OF ASSESSMENT NAME DESIGNATION Sex SCORE Male 1 Female 2 Age Build/Weight for Height (BMI=weight in Kg/height in m 2 ) Average BMI Above average BMI Obese BMI > 30 2 Below average BMI < 20 3 Continence Complete/catheterised 0 Incontinent urine 1 Incontinent faeces 2 Doubly incontinent (urine & faeces) 3 Skin Type visual inspection of at risk areas Healthy 0 Tissue paper (thin/fragile) 1 Dry (appears flaky) 1 Oedematous (puffy) 1 Clammy (moist to touch) /pyrexia 1 Discoloured - category 1 pressure ulcer 2 Broken - category 2-4 pressure ulcer 3 Mobility Fully mobile 0 Restless/fidgety 1 Apathetic (sedated/depressed/reluctant to move) 2 Restricted (due to chronic disease /splints, casts etc) 3 Bedbound (unconscious/unable to change position) 4 Chair bound (wheelchair /unable to move independently) 5 Nutritional Element MUST score Unplanned weight loss in past 3-6 months: < 5% Score 0, 5-10% Score 1, >10% Score BMI >20 Score 0, BMI Score 1, BMI < 18.5 Score Patient/ client acutely ill or no nutritional intake > 5 days 2 Special Risks Tissue Malnutrition Multiple organ failure/terminal cachexia 8 Single organ failure e.g. cardiac, renal, respiratory 5 Peripheral vascular disease 5 Anaemia Hb < 8 2 Smoking 1 Special Risks Neurological Deficit Diabetes/ MS/ CVA/ motor/ sensory/ paraplegia Max Special Risks Surgery/Trauma Orthopaedic/ below waist/spinal 5 On table > 2 hours (discount 48 hours post op if recovering ) 5 On table > 6 hours (discount 48 hours post op if recovering) 8 Special Risks Medication Cytotoxic, anti-inflammatory, long term/high dose steroid Max 4 4 TOTAL WATERLOW SCORE Score Indicates - At Risk: 10+ High Risk: 15+ Very High Risk: 20+ Adapted Waterlow pressure ulcer risk assessment reproduced with kind permission from: Judy Waterlow and NATVNS Scotland 2011 PS Rev Oct 13

30 APPENDIX B - Pathway for Patient at Risk of Developing / With Pressure Ulcers RISK ASSESSMENT Waterlow Risk Assessment Tool To be completed on first face-to-face visit or within 6 hours of admission and on-going. Patient assessed as NOT at risk of developing pressure ulcers No further action risk assessment to be reviewed minimum of 3 monthly or on change in the patient s condition ASSESSMENT and PREVENTION Patients assessed AT RISK of / WITH pressure ulcers should have an individual management/ care plan based upon outcomes of holistic assessment MANAGEMENT Provide patient Information leaflet Complete SSKIN bundle at identified frequency Develop individualised care plans that address any underlying risk factors e.g. continence, nutrition and significant cognitive impairment complete capacity assessment if required. Involve multi-disciplinary team as appropriate Develop individualised care plan that identifies equipment, 24 hour repositioning, manual handling techniques and frequency of skin inspection. Category/Stage 2 4 pressure ulcers - Complete wound assessment documentation and tracing / photography. Pressure Ulcers Grade / Category 2 and above should be reported as a Clinical Incident ALL non-community and LCH acquired pressure ulcers category 2 should be reassessed by Senior Nurse within 2 subsequent visits or within 7 days of occurrence ALL non-community and LCH acquired pressure ulcers category 3 & 4 should be reassessed by Senior Nurse on following visit or within 48 hours of occurrence. Consider Referral to LCH Safeguarding Adults Team for Grade 3 and above pressure ulcers and contact the Safeguarding Adult Duty Line for further advice and support regarding referral to the Local Authorities. LCH acquired pressure ulcer incidents category 2 should be investigated by Senior Nurse / or equivalent and Pressure Ulcer checklist completed. LCH acquired pressure ulcer incidents category 3 & 4 should have a Pressure Ulcer checklist completed Prevention and Management of Pressure Ulcers Revised June

31 APPENDIX C - EPUAP Pressure Ulcer Classification System (2014) Category/Grade I: Non-blanchable redness of intact skin Intact skin with non-blanchable redness of a localized 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. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Category/Grade 2: Partial thickness skin loss or blister Partial thickness loss of dermis 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 serosanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.*bruising indicates deep tissue injury. Category/Grade 3: Full thickness skin loss (fat visible) Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling. The depth of a Category 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Grade 4: Full thickness tissue loss (muscle/bone visible) 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 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. Category 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional descriptors where the true extent of the pressure ulcer cannot be established: Unstageable/ Unclassified: Full thickness skin or tissue loss depth unknown Prevention and Management of Pressure Ulcers Revised June

32 Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category 3 or 4. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body s natural (biological) cover and should not be removed. May develop into a category 3 or 4 but cannot be confirmed until extent of damage is evident, should be documented as a minimum of a grade 3. Suspected Deep Tissue Injury-depth unknown Purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Classification may not be possible until the ulcer is debrided. Damage may be recoverable with effective off-loading of affected area Prevention and Management of Pressure Ulcers Revised June

33 APPENDIX D MIOSTURE LESIONS Moisture lesions are skin lesions and are not caused by pressure and/or shear. Descriptors to support differentiating include: Location not necessarily over bony areas; e.g. the anal cleft and have a linear shape Colour more purple colours Oedematous/swollen wet skin. Patient history of incontinent/diarrhoea Shape - Diffuse edges, superficial lesion, irregular shape; Kissing ulcer Prevention and Management of Pressure Ulcers Revised June

34 APPENDIX E - 30º tilt Illustrations courtesy of MSS (Medical Support Systems) Prevention and Management of Pressure Ulcers Revised June

35 Patient Details Surname... Forename... DoB... NHS No... APPENDIX F - Repositioning Chart REPOSITIONING CHART Manual Handling Requirements (circle as appropriate) Hoist Slide Sheet Other (please state) Repositioning Regime (as agreed with patient if possible) Date and Time Position of Patient Manual Handling Aids Used Results of Skin Inspection and Action Taken Problems Relating to Repositioning and Action Taken Signature / Print Name All Individuals who are at risk of pressure ulcer development and unable to move themselves should be repositioned - See reverse of the form to guide completion and for important considerations when repositioning patients. NOTE: Use in conjunction with local and/or national guidance on pressure ulcer prevention and management. Prevention and Management of Pressure Ulcers Revised June

36 Completing the Repositioning Chart: Position of patient and ensure new position of patient is documented. Manual handling aids used record all equipment used in repositioning. Results of skin inspection record any new early signs of pressure damage and review repositioning regime accordingly. Problems relating to repositioning record any problems encountered during repositioning (e.g. patient refused, equipment not available) and also any action taken in order to address the problems identified. Additional considerations: Skin inspection should be based on assessment of the most vulnerable areas of risk i.e. the bony prominences. Ideally this should take place at each position change but at least daily. Any skin changes should be documented immediately and interventions and care plans altered accordingly. Frequency of repositioning should be determined by skin inspection and individual needs not by a ritualistic schedule. If there are signs of persistent erythema, then the interval for repositioning should be reduced. If the patient is marking after 2 hours or category 1 pressure damage occurs then the pressure relieving surface may require upgrading. Please contact the Community Equipment Service for advice on alternative surfaces. Individuals identified as at risk should be sat on an appropriate pressure relieving cushion. In choosing a cushion consideration should be given to postural alignment, balance and stability. Those considered to be acutely at risk of pressure ulcer development should restrict chair sitting to less than 2 hours until their general condition improves. In most cases it would be advised that patients with deep grade 3 or 4 pressure ulcers to sacrum or buttocks do not sit out and that a suitable pressure relieving surface is chosen for the bed. Use of the 30 degree tilt can be used to avoid positioning patients directly onto bony hip prominences. Avoid positioning individuals directly onto an area of pressure damage. Pillows / foam wedges can be used to avoid direct contact of bony prominences with each other along with the use of bed cradles to reduce weight of bed clothes and reduce pressure from heels. Use correct manual handling techniques and devices to minimise friction and shear forces e.g. long length sliding sheets, or hoists. Profiling beds should be obtained to help reposition heavy or difficult to move patients. Where appropriate and following education, individuals (and carers in the community) should be encouraged to both redistribute their weight to reduce pressure and routinely inspect their skin.

37 APPENDIX G - Foot Wound / Ulcer Reporting Guideline Foot Wound / Ulcer Reporting Guideline Podiatry service provides assessment and/or input for wounds occurring below the ankle and that require Podiatry skills of sharp debridement and/or off-loading Clinical judgement is required in the implementation of these guidelines Pressure Ulcers Wounds caused by pressure and shear All pressure ulcers should be graded 1-4 using the EPUAP system. The professional diagnosing the wound as a pressure ulcer is responsible for completing the clinical incident report. Wounds caused by external factors on the heel or lateral border (styloid process) eg beds/footstools/wheelchairs/manual handling issues and EPUAP grade 2 and above. Wounds caused by therapeutic appliances eg prescribed footwear/hosiery/orthotic devices, insoles, casts, braces, callipers. Pressure ulcers referred into Liverpool CH teams from external sources, eg Aintree Hospital, RLUH. Consider Safeguarding Diabetic Foot Ulcers Patients with diabetic complications of neuropathy and/or vascular disease resulting in a foot ulcer. ALL foot wounds to be referred via diabetic foot ulcer pathway Manage as diabetic foot ulcers unless confirmed as pressure ulcer by specialist clinician. If pressure is primary cause of ulcer must be reported via Datix Wounds caused by the following: Intinsic factors - foot deformity and/or abnormal gait leading to altered pressure distribution. Eg Rheumatoid arthritis foot deformity Inappropriate choice of footwear or hosiery by the patient Self treatment by patient eg blades/graters/files/caustics Physical activities eg sports/running /hiking Dermatology lesions eg heel fissures, eczema. psoriasis, fungal infections Wounds where the primary cause is not related to pressure such as: Surgical wounds Burns chemical/thermal Dermatology lesions eg heel fissures, eczema. psoriasis, fungal infections Wounds due to trauma Primary ischaemic wounds eg black necrotic toe. Ingrowing toenails Wounds due to venous/lymphatic disease or moisture excoriation. If pressure is primary cause of ulcer must be reported via Datix Consider safeguarding issues. Follow diabetic foot ulcer pathway in line with NICE guidelines for ALL diabetic foot wounds. Refer for MDT assessment at Aintree/RLUH Diabetes Centre. Not reported as clinical incident (Datix) if confirmed as a diabetic Clinical incident report required Not reported as clinical incident (Datix) foot ulcer. Document rationale for not reporting.

38 APPENDIX H - SSKIN BUNDLE Check List Patient Details NHS No:.. Surname.. Forename Date of Birth SSKIN BUNDLE CHECK LIST Bundle to be completed*;. (*Frequent skin inspection will support early detection of skin damage) Answer YES, NO, or NA. If NO, provide details of further actions with rationale in patient records Date and Time Name Signature Designation S Surface: Equipment & Manual Handling All pressure relieving & manual handling equipment as detailed on care plan checked, in use and suitable for patients level of risk/ weight including any mattress settings? S - Skin inspection Have you visually assessed all skin at risk of pressure ulcers? Are any existing pressure ulcers improving? All other at risk areas free of any indications of pressure damage? K Keep Moving: Repositioning Frequency of repositioning as identified on care plan/repositioning chart is being maintained and suitable for patient need? I Incontinence /Moisture. Any current management appropriate for patient need? (moisture lesions should not be classified as pressure ulcers) N Nutrition and Hydration needs have been reassessed? Date and Time Name Signature Designation S Surface: Equipment & Manual Handling All pressure relieving & manual handling equipment as detailed on care plan checked, in use and suitable for patients level of risk/ weight including any mattress settings? S - Skin inspection Have you visually assessed all skin at risk of pressure ulcers? Are any existing pressure ulcers improving? All other at risk areas free of any indications of pressure damage? K Keep Moving: Repositioning Frequency of repositioning as identified on care plan/repositioning chart is being maintained and suitable for patient need? I Incontinence /Moisture. Any current management appropriate for patient need? (moisture lesions should not be classified as pressure ulcers) N Nutrition and Hydration needs have been reassessed? NPUAP- EPUAP (2014) Pressure Ulcer Classification System Category/Grade I: Non-blanchable redness of intact skin Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, oedema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. Category/Grade II: Partial thickness skin loss or blister Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum or sero-sanguinous (blood and serum) filled blister. Category/Grade III: Full thickness skin loss (fat visible) Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Some slough may be present. May include undermining and tunnelling. Category/Stage IV: Full thickness tissue loss (muscle/bone visible) Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunnelling. Pressure Ulcers Should Not Be Reverse Graded Rev Oct 13

39 Patient Details NHS No:.. Surname.. Forename Date of Birth I N T E N T I O N A L R O U N D APPENDIX I - SKIN CARE BUNDLE / INTENTIONAL ROUND DATE:.. /.. /. Round to be completed: 2hrly SSKIN Bundle to be completed:.. COMMEMCED BY Time of Check Greeting & introduction of self & purpose of round Skin inspection: All at risk areas are free of pressure damage? S S Surface: Equipment and Manual Handling All equipment as detailed on care plan checked and in use? KEEP MOVING / POSITIONING B E K D CHAIR STAND INCONTINENCE / TOILETING Urine I Bowels Toileted NUTRITION / HYDRATION N Right Side Left Side Back Drink offered (including prescribed supplementary drinks) Nutrition and fluid needs as per care plan checked and meets patient needs? ENVIRONMENT / PATEINT COMFORT Clutter free? Mobility aids to hand / including footwear? (if applicable) Call bell to hand & working? Patient asked if they are comfortable, anything they need? Patient off ward? Signature*Note: form to be completed by RGN minimum of once per shift Discontinued by:. Date.. KEY Y=YES N=NO NA= NOT APPLICABLE D= DECLINE

40 APPENDIX J - Pressure Ulcers Referral to Skin Care Service