Pressure Ulcer Prevention Guideline

Trust Guideline All Sites Pressure Ulcer Prevention Guideline All healthcare professionals must exercise their own professional judgement when using guidelines. However any decision to vary from the guideline should be documented in the patient records to include the reason for variance and the subsequent action taken. Lead Clinician(s): Jackie Stephen-Haynes Consultant Nurse and Senior Lecturer in Tissue Viability, Worcestershire Primary Care Trusts and University of Worcester Lead Director(s): Sandra Rote Director of Clinical Development and Lead Executive Nurse Ratified by Worcestershire PCT Quality and Safety Group June 2007 This Policy should not be used after end of: June 2009 Links into Healthcare Standard: Impact Analysis (Race Equality) Impact Analysis (Mental Capacity Act)

CONTRIBUTION LIST Key individuals involved in developing the document Name Jackie Stephen-Haynes County Tissue Viability Team Rosie Callaghan Lynn Dodd Pauline Farmer Julie Shaw Lorraine Wallace Jane Hipwell Pippa Humble Nicola Ross Lisa Blick Lin Cox Cheryl Tilt Pat Adcock Jo Bayliss Sue Collett Jo Dodd Sharon Freeman Bridget Gibson Margaret Murcott Sylvia Jackson Mary James Roz Kabani Debbie Keelor Denise Moore, Lynne Moule Mandy Price, Staff Nurse Infection Control Department Designation Consultant, Lecturer/Practitioner Tissue Viability PCT Link Nurses Tissue Viability Nurse, South Worcestershire PCT Nursing Homes Staff Nurse, Wyre Forest Community Unit Team Leader, Hagley Surgery Team Leader, Aylmer Lodge, Staff Nurse, Wyre Forest Community Unit District Nurse Team Leader District Nurse Team Leader District Nurse Team Leader Community Staff Nurse Practice Nurse. Sister, Lickey Ward Team Leader, Knightwick Surgery Team Leader, Pershore Health Centre Staff Nurse, Tenbury Hospital Team leader, Evesham Staff Nurse, Malvern Health Centre Team Leader, Broadway Surgery Community Staff Nurse, Upton Clinic. District Nurse, Tenbury Hospital Team Leader, Elbury Moor Medical Centre, Worcester Staff Nurse, Haresfield House Surgery Sister, Malvern Community Hospital Team Leader, Ombersley Surgery, Worcestershire Team Leader, Ombersley Surgery, Worcestershire Pershore Cottage Hospital Pressure Ulcer Prevention Guidelines WPCT Page 2 of 29

Circulated to the chair of the following committee s / groups for comments Name Karen Hunter Sian Finn Lesley Way Designation Clinical Effectiveness Committee Clinical Effectiveness Committee Clinical Effectiveness Committee Other guidelines to be referred to: Trust Consent Policy Worcestershire Primary Care Trust Wound Management Formulary Photographing Patients: Guidance for Staff Guidelines for the Treatment of Under Nutrition in the Community Infection control guideline Pressure Ulcer Prevention Guidelines WPCT Page 3 of 29

CONTENTS 1.0 Introduction...5 2.0 Risk assessment...8 3.0 Skin assessment...9 4.0 Documentation...9 5.0 Prevention of Tissue Damage...9 6.0 Prevention Equipment...11 7.0 Management of existing pressure damage...12 8.0 Assessment of Pressure Damage...13 9.0 Treatment of Pressure Ulcers...14 10.0 Patient Centred Care...15 11.0 Clinical Audit...16 13.0 References...17 Appendix 1: Waterlow Pressure Ulcer Risk Assessment Tool (2005)...19 Appendix 2: Paediatric Pressure Area Risk Assessment Tool...22 Appendix 3: Repositioning (Modified Thompson) Chart...24 Appendix 4: Equipment Selection Flow Chart...25 Appendix 5: Wound assessment chart...27 Appendix 6: Pressure ulcer discharge/transfer information list...28 Appendix 7: Grading of Pressure Ulcers...29 Pressure Ulcer Prevention Guidelines WPCT Page 4 of 29

Pressure Ulcer Prevention Guidelines 1.0 Introduction 1.1: Purpose of the document This guideline has been developed to provide direction for staff on the prevention and management of pressure ulcers in a primary care setting. It is based on the NICE/RCN Clinical Guideline 29 The Prevention and treatment of Pressure Ulcers (September 2005) and the clinical benchmark outlined in The Essence of Care (DOH 2001). This provides clear patient focused benchmarks to help improve quality of life. This guideline also incorporates the earlier NICE/RCN Clinical Guideline 7, Pressure Ulcer Prevention, published in Oct 2003. These guidelines form part of the NICE Wound Care Suite. A multi-professional approach is needed in the prevention and treatment of pressure ulcers (Rycroft-Malone 2001).The NICE guideline (2005) for the prevention and treatment of pressure ulcers was developed for: All healthcare professionals who have direct contact with and make decisions concerning the treatment of patients who are at risk of developing pressure ulcers and those with pressure ulcers primary, secondary and specialist care Service managers Commissioners Clinical governance and education leads Patients and carers It is the responsibility of Health Care Practitioners (NMC 2002) to: be familiar with the new guideline; facilitate an integrated approach to the management of pressure ulcers across the hospital community interface; ensure continuity of care between shifts; ensure your local risk assessment tool incorporates the NICE risk factors; access training on a regular basis; give patients and carers information NICE Information for patients is available www.nice.org.uk/cg029publicinfo NICE guidance does not override the individual responsibility of health professionals to make decisions appropriate to the needs of the individual patient. 1.2: Definitions A Pressure Ulcer is an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction or a combination of these, (European Pressure Ulcer Advisory Panel 2003). They are caused by a combination of intrinsic and extrinsic factors to the patient (Defloor & Grypdonck 1999). The most common site for pressure ulcers are: sacrum, heels, hips, shoulders and elbows but may occur anywhere where a bone and skin are in contact with another surface. Pressure Ulcer Prevention Guidelines WPCT Page 5 of 29

Pressure normal body weight can squash the skin in people at risk and occlude the blood supply to the area, which can lead to tissue damage. Shearing strain forces the skin and upper layers away from deeper layers of skin. This can happen when people slide down or are dragged up a bed or chair. Friction poor lifting and moving techniques can remove the top layers of skin. Repeated friction can increase the risk of pressure ulcers. Moisture there is debate whether moisture precipitates pressure ulcer development and whether the damage seen is true pressure damage or moisture related trauma (Butcher 2005) but in clinical practice this is a significant factor to consider (Cooper & Gray 2001). Tissue damage may involve skin, subcutaneous tissue, deep fascia, muscle and bone (Bridel 1993). Pressure is considered to be the major causative factor in the development of pressure ulceration causing occlusion of blood flow to the network of vascular and lymph vessels supplying oxygen and nutrients to the tissues (Maklebust 1987). This can lead to tissue ischaemia and re-perfusion injury leading to cell destruction and tissue death (Maklebust 1987, Braden & Bergstorm 1987 and Bridel 1993). Several factors play a role in determining whether the pressure is sufficient to create an ulcer. The deciding elements are: the intensity of the pressure, the duration and the ability of tissue to tolerate pressure (Braden & Bergstorm 1987) which should be considered for each patient. Pressure Ulcer Prevention Guidelines WPCT Page 6 of 29

1.3: Patients Covered This guideline outlines the recommendations to prevent the development of pressure damage and how to treat pressure damage once it has occurred. It applies to all patient groups including adults, infants, children and young people. The guideline is to be used by all staff employed by Worcestershire Primary Care Trusts, engaged in the prevention and management of pressure damage. Whilst not mandatory it is recommended for use by all care homes across Worcestershire. 1.4: Prevalence and impact Pressure ulcers currently represent a significant problem in both the acute and primary health care settings with more than 400,000 people in the UK developing a pressure ulcer annually (Bennett et al 2004). They are considered as being preventable (Hibbs 1998 and Bennett et al 2004). The extent of pressure damage problem is unknown nationally but it is estimated that pressure ulcers affect between 10% of the UK population (DOH 1992 and Clark & Cullum 1993) and 18% (O Dea 1993). There are an increasing number of patients with complex needs being nursed in the community setting (First Assessment 1999), many of whom are at significant risk of developing Pressure Ulcers. With an ageing population and changes in patterns of Ulcers (Community Care Act 1990) it is envisaged that the number of patients with Pressure Ulcers will increase (EPUAP 1998). This has financial Implications for the NHS but more importantly Pressure Ulcers can be very detrimental to patients in terms of physical, psychological and social issues, resulting in reduction of quality of life and maybe mortality (Fox 2002). They represent a significant burden of reduced quality of life and health for patients and their carers (Franks & Moffatt 1999), with Bennett (2004) estimating the cost at 1.76 billion annually. According to the Touché Ross Report (1994), the estimated cost of preventing and treating pressure ulcers in a 600 bed general hospital costs between 600,000 and 3 million a year. More recent data suggests that treating pressure ulcers varies from 1,064 for a grade 1 pressure ulcer to 10,551 for a grade 4 pressure ulcer, equivalent to 4% of the total NHS expenditure (Bennett et al 2004). Pressure ulcer prevention can improve patient outcomes whilst reducing health service resources. We have an ageing population who are living longer and who increasingly suffer from co-morbidity. High dependency levels of patients whose needs are complex increase the risk of development of pressure damage, reduces their risk of recovery, and impinges on their quality of life. This guideline outline the recommendations to prevent development of pressure damage and how to treat pressure damage once it has occurred. 1.5: Competencies Required Registered health care professionals, who can demonstrate theoretical and practical competence. An educational programme, incorporating internal courses and accredited degree level study, is available to all staff groups. This forms part of the individual s overall professional development (Knowledge and Skills Framework). Pressure Ulcer Prevention Guidelines WPCT Page 7 of 29

2.0 Risk assessment Initial and on-going risk assessment is the responsibility of a registered healthcare professional using clinical judgement and an aide memoir risk assessment tool. A risk assessment tool attempts to identify a patient s risk status by quantifying the most common risk factors affecting a patient at a given time (Edwards 1994). The recommended tool for use in the primary care setting in Worcestershire is the Revised Waterlow Tool, (2005) (Appendix 1). This should be performed within 6 hours of the first episode of care (NICE 2005) in a community hospital/ unit setting and within 7 days for those in their own homes. 2.1: Risk factors The development of pressure ulceration is dependant upon extrinsic and intrinsic factors which affect tissue tolerance (Braden & Bergstorm 1987) The areas to be considered in relation to risk are: Health status : acute, chronic and terminal illness Co-morbidity- diabetes and malnutrition Extremes of age Level of mobility Posture pelvic obliquity and pelvic tilt Sensory impairment Level of consciousness Continence Systemic signs of infection Nutrition and hydration status Previous pressure damage Pain Psychological factors and cognition Social factors pressure shearing friction moisture to the skin 2.2: People vulnerable to developing pressure ulcers Patients undergoing surgery Patients in critical care Patients with orthopaedic conditions Patients with spinal injury People with diabetes Patients with peripheral vascular disease People with a previous history of pressure ulcers People at the extremes of age Pressure Ulcer Prevention Guidelines WPCT Page 8 of 29

2.3: Paediatric risk assessment There is not a systematic evaluation of paediatric assessment tools. Paediatric risk assessment may be recorded on the paediatric pressure area risk assessment tool (appendix 2). This was originally developed by Barnes (2004) and adapted for use in primary care in Worcestershire by Sister D. Keelor. 2.4: Assessment and re-assessment Risk assessment should be carried out by healthcare professionals who have undergone in-service or external training in the prevention and management of pressure ulcers. Patients and carers should be fully aware of their level of risk (Nice 2005). Following education, patients and carers should be encouraged to inspect the skin and take responsibility for its condition. 3.0 Skin assessment Patients at risk should have their skin assessed regularly. Frequency should be based on vulnerability and condition of the patient. Encourage individuals and carers to inspect the skin and take responsibility for its condition (NICE 2005). The areas to observe for are: persistent erythema non-blanching hyperaemia blisters localised heat localised oedema purplish/bluish localised areas 4.0 Documentation Record and document the risk assessment noting all relevant factors. Reassess on an on-going basis according to individual need, particularly if the patient s condition changes. Maximum period before re-assessment is 6 months but may be as little as 6 hours post surgery. It is expected that community hospitals will undertake reassessment at least weekly. Weekly risk assessment is mandatory in care homes. 5.0 Prevention of Tissue Damage All patients considered at risk should have 24 hour access to pressure relieving equipment and /or other strategies to relieve pressure. 5.1: Positioning and Re-positioning Patients should be encouraged to mobilise, be positioned and repositioned either with assistance, or on their own every 2-6 hours (Defloor 2000 and Defloor 2001).The patient needs to be informed of the reasons for re-positioning and their needs and the needs of their carers should be taken into consideration. Consider mobilising, positioning and repositioning interventions for ALL patients. Pressure Ulcer Prevention Guidelines WPCT Page 9 of 29

All patients with pressure ulcers should actively mobilise, change position or be repositioned dependant on their skin tolerance. Minimise pressure on bony prominences. Consider whether sitting time should be restricted to less than 2 hours at any one time. Record re-positioning (a re-positioning chart may be used). (See appendix 3) 5.2: Sitting out of bed If a patient has any signs of pressure damage particularly on the sacrum, buttocks or Ishcial tuberosities, sitting out time should be restricted to 2 hours (Defloor 2000), preferably over a meal time. Seating should be appropriate for the needs of the patient and for those at home; this is included in Equipment selection form (see appendix 4). 5.3: Re-positioning and mobilising Mobilising, positioning and re-positioning should be determined by: General health status Location of ulcer General skin assessment Acceptability to the patient The needs of the carer Staff should employ the use of the 30º tilt, whereby the patient is re-positioned using pillows on a 30º angle (Preston 1988). This should be recorded. A re-positioning/ turning chart may be utilised (See repositioning chart, Appendix 3). Passive movements should be considered for patients with pressure ulcers who have compromised mobility. Advise the patient regarding re-positioning and consult the equipment flow chart to request/utilise the appropriate pressure relieving mattress/cushion within 24 hours of assessment. 5.4: Nutrition Nutritional status has been linked to a significant influence on the development of pressure ulceration (Mathus-Viligen 2001 and Clark et al 2004), although the relationship between nutrition and pressure ulcer prevention is questioned (EPUAP 2003). The prevention and treatment of malnutrition requires assessment and the Malnutrition Universal Screening Tool (MUST) should be utilised (please se the PCT Nutritional guideline). Where assessment indicates that malnutrition may be present, nutritional intervention should be considered. The primary goal of nutritional intervention is to correct protein-energy malnutrition, ideally through oral feeding (EPUAP 2003). When considering any limitation on normal food and fluid intake, consideration should be given to the ease of access to food, social and functional issues as well as texture of the diet (EPUAP 2003). Nutritional supplements should be provided for patients who are unable to tolerate conventional meals or who have an identified deficiency. The success of nutritional intervention should be monitored and documented. Decisions about nutritional support should be based on: Pressure Ulcer Prevention Guidelines WPCT Page 10 of 29

Malnutrition Universal Screening Tool (MUST) Nutritional assessment tool (as detailed in the Trust Guidelines for the Treatment of Under Nutrition in the Community The level of pressure ulcer. Grade 3-4 will be losing protein and fluid ( EPUAP 2003) General health status Patient preference Dietetic/expert input 6.0 Prevention Equipment Health care professionals need to consider all surfaces that the patient may come into contact with, e.g. mattresses, cushions, theatre tables, stretchers, chairs etc. Pressure relieving surfaces are divided into 2 categories: 1. Continuous low pressure aim to mould around the shape of the individual, redistributing pressure over a greater surface area. These include standard foam, visco-elastic foam, air-flotation, air fluidised, low air loss, gel/fluid and combination products (NICE 2005). 2. Alternating Pressure mechanically vary the pressure beneath the individual by inflating and deflating alternate air-filled sacs. The depth of air cells, mechanical robustness, duration and sequence varies between manufacturers. All patients vulnerable to the development of pressure damage according to risk assessment. Those with grade 1-2 pressure damage (EPUAP 1998) should as a minimum provision receive a high specification foam mattress with pressure relieving properties and should be closely observed for skin deterioration. Patients with Grade 3-4 pressure ulcers should, as a minimum requirement, be nursed on an alternating pressure mattress (replacement or overlay) or a sophisticated continuous low pressure such as low air loss, air fluidised or viscous fluid. This is as per the equipment flowchart (see appendix 4). If bed rails are required the alternating pressure overlay should be placed on a reduced depth foam mattress to maintain safety. Patients undergoing surgery require high specification foam theatre mattress. 6.1: Equipment selection All continuous low pressure and alternating pressure equipment is allocated in Worcestershire Primary Care Trusts on the basis of risk assessment, level of mobility and classification of pressure ulceration ( EPUAP 1998). See Equipment flow chart for guidance (Appendix 4). Clinical judgement may override risk assessment but all health care professionals are accountable for their decision-making. Pressure relieving devices should be chosen on the basis of: - Pressure Ulcer Prevention Guidelines WPCT Page 11 of 29

Risk Assessment Pressure ulcer assessment (if present) Mobility and ability to move independently Location and cause of pressure ulcer development Skin assessment General health Lifestyle and abilities Critical care needs Comfort and acceptability by the patient Availability of carer/healthcare professional Patient s weight Height of the bed in relation to bed rails. Children s mattresses NICE (2005) state that it is essential to ensure: Appropriate cell size of mattress as small children can sink into gaps created by deflated cells causing discomfort and reduced efficacy. Appropriate position of the pressure sensors within the mattress in relation to the child. Monitoring the use of alternating pressure mattresses with a permanently inflated head in young children to avoid occipital damage. Pressure relieving devices should be changed as required in response to changes in the patient s level of risk, condition or needs. 7.0 Management of existing pressure damage 7.1 Patients with a grade 1 pressure ulcer are at significant risk of it developing further (NICE 2005). Staff who observe an area of new pressure damage should re-calculate the risk assessment, plan care accordingly and document the findings. 7.2 All at risk patients and those with pressure damage Grade1-2 should be on a high specification foam mattress as a minimum. 7.3 If the damage is graded 2-3 they should be on an alternating pressure mattress as per equipment flowchart. 7.4 Patients with Grade 3-4 pressure ulcers should, as a minimum requirement, be nursed on an alternating pressure mattress according to weight and as per equipment flowchart. 7.5 If receiving palliative care and suffering from nausea due to the mattress undulating, they should be nursed on a replacement high specification foam mattress, a low air loss system or a Roho/ Sofflex. 7.6 Patients with sacral or buttock pressure ulcers grade 2 or above should not be sat out of bed for longer than a 2 hour period and when sitting out should sit on a high specification foam cushion as a minimum. Pressure Ulcer Prevention Guidelines WPCT Page 12 of 29

7.7 All at risk patients should have a high specification foam cushion to prevent pressure damage. 7.8 Patients at high risk of developing pressure ulcers, or who have an existing pressure ulcer and are on an alternating mattress should also have an alternating cushion for their chair. 8.0 Assessment of Pressure Damage Consent Patients have a fundamental legal and ethical (Beauchamp & Childress 2001 and Edwards 1996) entitlement to determine what happens to their bodies. Valid consent to treatment is central to all forms of healthcare. Consent is a patient agreement for a health professional to provide care. Patients may indicate nonverbally (by turning over to expose the area of pressure damage), orally, or in writing. For consent to be valid the patient must be competent to take that decision, be fully informed of the action and its consequences, and not be under duress. Consent should be sought verbally and where possible in writing prior to sharp debridement of dead tissue and for photography to monitor progress of the wound. (See local Consent Policy and Photographing Patients: Guidance for Staff) If a patient declines treatment or equipment recommended by the health care professional, this should be documented in accordance with the Consent Policy. Assessment of pressure ulcers The aim of pressure ulcer assessment is to establish the severity of the pressure ulcer, assess for complications and develop a plan of care which is communicated to those involved in care. Assessment of the pressure ulcer includes Cause Site/location Dimensions EPUAP Classification Exudate amount and type Local signs of infection (EWMA 2005) Pain assessment, including cause, level, location and management interventions (Hollinworth 2005) Wound appearance/classification Surrounding skin Odour Consider undermining, tracking, sinus or fistula. The documentation of the pressure ulcer assessment should be supported by photography or tracing, calibrated with a ruler. Pressure Ulcer Prevention Guidelines WPCT Page 13 of 29

All patients will have their pressure ulcer size assessed and documented (by centimetre measurement, tracing or photography) on initial assessment and as part of the re assessment. This is to provide a baseline and to monitor improvement or deterioration and should be recorded (Appendix 6). All patients with pressure ulcer will be reassessed and documented at least weekly. Any alterations to the treatment regime will be discussed with the patient, health care professional and the rationale for this will be documented. This is to enable monitoring of the appropriateness of current treatment and to respond to any changes as a result of the re assessment. 8.1 The pressure ulcer should be graded according to the European Pressure Ulcer Advisory Panel 1-4 System. (EPUAP 1998) and should not be reverse graded. (See appendix 7). 8.2 An initial and on-going assessment of the pressure ulcer bed should be undertaken and documented on a Wound Assessment Chart (Appendix 6). 8.3 The assessment should be documented and the use of photography and/or tracings should be used to monitor progress. 8.4 Document all pressure ulcers graded as 2 and above as a Trust clinical incident so that an investigation can follow to identify cause and origin. 9.0 Treatment of Pressure Ulcers 9.1 Pressure ulcer assessment Summary of Key Areas of Wound Management - assessment - plan - management - re assess - admit, transfer or discharge - report unexpected complications - clinical audit All patients with pressure ulcers will have a holistic assessment, including environment, nutrition, assessment of the skin as a sensory organ and the patients knowledge and understanding of their wound and general condition. The wound assessment will be documented on an appropriate wound assessment tool, (appendix 5) within 24 hours of admission to a hospital setting and within one week of referral to primary care. A multidisciplinary approach is necessary to planning and implementing treatment options. Choose dressing/topical agent or method of debridement or adjunct therapy based on ulcer assessment (DoH 2005): general skin assessment treatment objective characteristic of dressing/technique previous positive effect of dressing/techniques manufacturer s indications/contraindications for use risk of adverse events Pressure Ulcer Prevention Guidelines WPCT Page 14 of 29

patient preference 9.2 Choice of dressing (Bradley et al 1999), method of debridement and the optimum wound healing environment should be created by using modern dressings (NICE 2005). The use of topical agents or adjunct therapies should be based on the current assessment of the wound and Worcestershire Primary Care Wound Management Formulary. 9.3 Anti-microbial therapy should be considered in the presence of systemic and/or local signs of infection. Reference should be made to the selection of antimicrobials in the Worcestershire Primary Care Wound Management Formulary. 9.4 Referral for surgical/plastics opinion should be made based on the needs of the patient, their health status, their risk (anaesthetic and surgical intervention), previous pressure ulcer history, the assessment of psychosocial factors regarding the risk of recurrence, the failure of previous conservative treatment and positive effect of surgical techniques. 9.5 A plan of treatment should be documented on a care plan and an evaluation form completed to monitor progress. 9.6 All patients with pressure ulcers who are transferred to any other care setting will have their treatment regime communicated to the appropriate health care professional prior to discharge (appendix 6). This can contribute to the continuity of patient care. 10.0 Patient Centred Care Patients and carers should be made aware of the potential risk and/or complications of having a pressure ulcer as well as the NICE (2005) guideline and its recommendations. They should be referred to the information for the public (NICE 2005b) and the public website www.your-turn.org.uk Treatment and care should take into account the patient s individual needs and preferences and carers and relatives should have the opportunity to be involved in discussions where appropriate. 10.1: Self care Individuals should be aware of their level of risk. Individuals and carers who are willing and able to should be taught how to re distribute their own weight Passive movements should be considered for patients with compromised mobility. Pressure Ulcer Prevention Guidelines WPCT Page 15 of 29

11.0 Clinical Audit 11.1: All patients with a grade 2 will have this recorded as a clinical incidence This information will be collated in the primary care Tissue Viability Dept and reported annually. This information will be analysed with the usage of equipment and the completion of the assessment and referral tool. This will include: Number of patients with pressure ulcers Number of patients with pressure ulcers acquired within establishment Number of patients admitted/admitted onto caseload with pressure ulcers Number of patients on mattresses that met their clinical need Grades of pressure damage Treatment regimes Presence of documentation for risk, wound assessment, and treatment care plans. 11.2: Monitoring tool (optional) STANDARDS % Clinical Exceptions Holistic wound assessment will be carried 100 out within time scale specified All patients will have their wound size 100 documented within the specified time scale Management will be in accordance with 100 wound assessment and the wound care formulary Regime of care will be communicated on 100 transfer of care setting For WHAT Patients with unexpected complications will be reported using the clinical incident forms 100 How will monitoring be carried out? When will monitoring be carried out? Who will monitor compliance with the guideline? Ongoing clinical audit, led by Tissue Viability services within primary and secondary care Ongoing Tissue Viability Services, primary and secondary care Pressure Ulcer Prevention Guidelines WPCT Page 16 of 29

13.0 References Beauchamp, T.L & Childress, J.F. (2001) Principles of Biomedical Ethics, 5th ed. Oxford: Oxford University Press Bennett, G. Dealey, C. & Posnett, J. (2004) the cost of pressure ulcers in the UK. Age and ageing, 33p230-235 Braden, B & Bergstorm, N. (1987) a conceptual scheme for the study of the aetiology of pressure sores. Rehabilitation Nursing; 12: p8-16 Bradley, M. Cullum, N. Nelson, E. Petticrew, M. Sheldon, T. & Torgerson, D. ( 1999) Systematic reviews of wound care management: (2) Dressings and topical agents used in the healing of chronic wounds. Health Technology assessment. 3 (17) pt 2. Bridel, J. (1993) The aetiology of pressure sores. Journal of Woundcare. 2, 94) pp230-238 Butcher, M (2004) NICE Guidelines: Pressure ulcer risk assessment and prevention-a review. World Wide Wounds Clarke M Cullum N (1993) Matching the needs of pressure sore prevention with the supply of pressure relieving mattresses. Journal of Advanced Nursing. 17. 310-316 Clarke, M. Schols, J. Benati, G. (2004) Pressure ulcers and Nutrition: a New European Guideline. Journal of Woundcare 13, (7) p267-272 Cooper, P. Gray, D. (2001) Comparison of two skin care regimes for incontinence. British Journal of Nursing, 10 (6 Supplement) S6, S8 S10. Defloor, T & Grypdonck, M. (1999) Sitting posture and the prevention of pressure ulcers. Applied Nursing Research. 12, 3 pp136-142 Defloor, T. (2000) Does turning patients really prevent pressure ulcers. PhD thesis, Ghent University, Ghent. Defloor, T. (2001) Manual repositioning of patients. Journal of Tissue Viability. 11, 3 p117 DoH First assessment (1999) Department of Health. London. DoH (1990) National Health Service and Community care act. DoH. HMSO. London. Department of Health (1992) The health of the nation. A strategy for health in England. HMSO. London Dept of health (2001) The essence of care, Patient focused benchmarking for health care practitioners. HMSO: Department of Health (2005) Consultation document. Arrangements for the provision of dressings, Incontinence appliances, stoma appliances, chemical reagents and other appliances to Primary and secondary care. Published 24 th October 2005 Edwards, M. (1994) Rationale for the use of risk calculators in pressure sore prevention, and the evidence of the reliability and validity of published scales. Journal of Advanced Nursing. 20:p288-96 Edwards, S. (1996) Nursing Ethics. A principle Based Approach. Wiltshire: Macmillan EPUAP (1998a) Pressure ulcer prevention guidelines. www.epuap.org EPUAP (1998b) Pressure ulcer treatment guidelines. www.epuap.org EPUAP (2003) Pressure Ulcer Prevention Guidelines WPCT Page 17 of 29

EPUAP (2003) Nutritional Guidelines for Pressure Ulcer Prevention and Treatment. www.epuap.org EWMA (2006) Position document. Management of infection. London. MEP Ltd 2006. Topical management of infected grade 3 & 4 pressure ulcers. Moore, Z. & Romanelli, M. p11-13 Fox, C. (2002) Living with a pressure ulcer: a descriptive study of patients experiences. Wound Care. British Journal of Community Nursing. June Hibbs, P. (1988) Action against pressure sores. Nursing Times 84, 13 pp68-73 Hollinworth, H. (2005) Pain at wound dressing-related procedures: a template for assessment. World Wide Wounds. WWW.worldwidewounds.com Accessed 30 th September 2005 Keelor, D. (2005) Paediatric risk assessment. Taken from original by S. Barnes of Leicester Royal Infirmary Children s Hospital (April 2004) Mathus-Vliegen (2001) nutritional status, Nutrition and pressure Ulcers. Nutrition in Clinical practice. 16, p286-291 Maklebust, J. (1987) pressure ulcers, aetiology and prevention. Nurse Clin North America: 22(2) p359-77 Malnutrition Universal Screening Tool (MUST) Nutritional assessment tool (www.bapen.co.uk). Nice (2005) Pressure ulcers: the management of pressure ulcers in primary and secondary care.http://www.nice.org.uk and http://www.doh.gov.uk/ Quick reference guide: Summary of recommendations for health professionals www.nice.org.uk/c G029Quickrefguide. (Or hard copies on 0870 1555 455) NICE (2005b) Patient information leaflet for pressure ulcer prevention and treatment. www.nice.org.uk/cg029publicinfo NICE (2006) Nutrition guidelines.http://www.nice.org.uk and http://www.doh.gov.uk/ Nursing and Midwifery Council (2002) Code of Professional Conduct. London. NMC O Dea K (1993) Prevalence of pressure damage in hospital patients in the UK. Journal of Wound Care 2. 4. 221 225 Preston, K. (1988) Positioning for comfort and pressure relief. The 30 degree alternative. Care, science and practice. 6, 4 p 116-119 Rycroft Malone, J. (2001) Pressure ulcer risk assessment and prevention recommendations. London: Royal College of Nursing. RCN. Waterlow, J. (1985) Pressure sores: a risk assessment card. Nursing Times 81 (48): p49-95 Waterlow, J. (2005) Pressure ulcer prevention manual. Revised. Taunton. www.judywaterlow.co.uk Pressure Ulcer Prevention Guidelines WPCT Page 18 of 29

Appendix 1: Waterlow Pressure Ulcer Risk Assessment Tool (2005) BUILD / WEIGHT FOR HEIGHT Average BMI=20-24.9 Above average BMI= 25-29.9 Obese BMI>30 Below average BMI<20 0 1 2 3 SKIN TYPE VISUAL RISK AREAS Healthy Tissue Paper Dry Oedematous Clammy (Temp) Discoloured BROKEN / SPOT 0 1 1 1 1 2 3 SEX AGE MALE FEMALE 14 49 50 64 65 74 75 80 81+ 1 2 1 2 3 4 5 SPECIAL RISKS TISSUE MALNUTRITION Terminal Cachexia Cardiac Failure Peripheral Vascular Disease Anaemia Smoking 8 5 5 2 1 BMI=wt (kg)/ Ht (m²) CONTINENCE MOBILITY APPETITE Complete/ Catheterised Occasion Incont. Cath/Incont. of Faeces Double Incont. 0 1 2 3 Fully Restless/fidgety Apathetic Restricted Inert/Traction Chairbound 0 1 2 3 4 5 Average Poor N.G. Tube/ Fluids Only NBM/ Anorexic Score Date Name & Signature 0 1 2 3 NEUROLOGICAL DEFICIT Diabetes, M.S., C.V.A Motor Sensory Paraplegia 4-6 MAJOR SURGERY / TRAUMA Orthopaedic: Below Waist, Spinal, On Table > 2 hours MEDICATION Cytotoxics High Dose Steroids Anti-Inflammatory 5 5 4 Pressure Ulcer Prevention Guidelines WPCT Page 19 of 29

WATERLOW PRESSURE ULCER ASSESSMENT CHART ASSESS AT LEAST WEEKLY Patients name: Date of admission: Hospital No: SCORE: 10+ at risk SCORE: 15+ high risk SCORE: 20+ very high risk DATE: Date: BUILD/WEIGHT FOR HEIGHT Total brought forward Average BMI = 20-24.9 0 Nutrition Score If > 2 refer for nutrition assessment/intervention Above Average 1 SPECIAL RISKS BMI = 25-29.9 Obese BMI >30 2 TISSUE MALNUTRITION Below Average BMI < 3 Terminal Cachexia 8 20 BMI = Wt (Kg)/Ht (m)² Multiple organ failure 8 CONTINENCE Single organ failure 5 (Resp. Renal, Cardiac) Complete/catheterised 0 Peripheral vascular 5 Disease Urine incontinence 1 Anaemia (Hb < 8) 2 Faecal incontinence 2 Smoking 1 Doubly incontinent 3 NEUROLOGICAL DEFICIT SKIN TYPE (VISUAL AREA) Diabetes, MS, CVA 4-6 Healthy 0 Motor/sensory 4-6 Tissue paper 1 Paraplegia (MAX 6) 4-6 Dry 1 MAJOR SURGERY or TRAUMA Oedematous 1 Orthopaedic/spinal 5 Clammy (raised temp) 1 On Table > 2 HR# 5 Discoloured 2 On Table > 6 HR# 8 Broken/spot 3 MEDICATION MOBILITY Cytotoxics, 4 Fully 0 Anti-Inflammatory 4 Restless/fidgety 1 Long term/high dose 4 steroids Apathetic 2 OVERALL TOTAL Restricted 3 Bed bound eg Traction 4 Is pressure ulcer present Chair bound eg 5 If yes state grade Wheelchair SEX/AGE Is wound chart in use Male 1 Female 2 Nurse/assessors 14-49 1 signature 50-64 2 65-74 3 75-80 4 81+ 5 MALNUTRITION SCREENING TOOL (MUST) (Nutrition Vol.15, No.6 1999-Australia) A. HAS PATIENTLOST ACTION WEIGHT RECENTLY SIGN AND DATE WHEN INFORMATION GIVEN YES GO TO B Assessment and NO GO TO C treatment has been UNSURE GO TO C 2 discussed with B.Weight Loss 0.5-5Kg 1 patient/carer 5-10Kg 2 Verbal information on 10-15 Kg 3 positioning given >15Kg 4 Written information given Unsure 2 Patient/carer C. Patient eating poorly Or lack of appetite understands equipment NO = 0 Comments on your YES = 1 decision re. Risk to patient Pressure Ulcer Prevention Guidelines WPCT Page 20 of 29

Item Supplier Date referred Sign Date received Sign Date returned Sign Pressure Ulcer Prevention Guidelines WPCT Page 21 of 29

Appendix 2: Paediatric Pressure Area Risk Assessment Tool Age: Hospital number: Name: Instructions for Completion of Risk Assessment 1. Answer questions below by placing Y for Yes or N for No in Column marked Y/N. 2. For all questions answered Yes, consider the interventions offered as suggestions relevant to possible risk in the last column of the table and choose appropriate interventions to be made. 3. Record intervention using code in the column marked Int. Code (intervention code). This then creates a plan for pressure area care and tissue damage prevention. 4. The first assessment should be within 6 hours of admission (NICE Guidelines) and reassessment should occur whenever there is a change in the child s condition. Possible Risk Factors 1. Does the child have any neurological deficit or loss of sensory perception? 2. Is the child sedated or is their mobility restricted so they cannot change their position? 3. Is the child regularly incontinent and are there any signs of altered skin integrity in the nappy area? 4. Does the child appear to be very under/over weight for their age? 5. Does the child have an altered level of skin integrity or abnormal skin condition? 6. Has the child been in the operating theatre/recovery for more than 4 hours? 7. Is the child required to wear a plaster cast or splints to restrict movement/position? 8. Is the child attached to any continuous monitors, tubes or lines? 9. Is the child exposed to prolonged periods of pressure, shearing or friction? 10. Any other problems that may put the child at increased risk? Please state. Date Sign Print Name Y/N Int code Y/N Int Code Y/N Int code Y/N Int code Code to Consider A, B, F, I A, E, F, K, I C, D, E G, B A, C, D, E, F, I A, E, F, I, H J, A, D, E F, J A, I D, E, K Possible Interventions to Consider to Prevent Pressure Area Damage (Intervention codes). A. Regular repositioning & turning. Use 30-degree tilt. F. Careful fixation/repositioning of leads/lines 1-4 hourly as skin dictates. K. Appropriate use of manual handling aids, don t pull out or leave equipment underneath patient. B. Spenco Overlay for comfort G. Refer to dietician. L. Other Intervention (Specify here) C. Use barrier film spray, if risk of contamination H. Pressure reducing mattress overlay. I Pressure relieving mattress. D. Keep skin clean and dry. E. To protect high risk areas use a semi occlusive dressing. J. Adequate padding and protection from pressure. Pressure Ulcer Prevention Guidelines WPCT Page 22 of 29

PAEDIATRIC PRESSURE AREA RISK ASSESSMENT TOOL Age: Hospital number: Name: Skin Integrity Assessment Assessment and Inspection of skin integrity should occur regularly. NICE (2001) Guidelines for Pressure Ulcer Risk Assessment recommend that, even if the patient is found to be at no risk of pressure damage, reassessment should recur if there is a change in the patient s condition. To Complete the section below, firstly assess child s skin for marks or changes, then record results in table below. Record any marks, (red or blue-depending on skin pigmentation), any blisters, non-blanching hyperaemia, localised heat, oedema or induration. Date Result of Skin Assessment/Inspection Date Result of Skin Assessment/Inspection Pressure Ulcer Prevention Guidelines WPCT Page 23 of 29

Appendix 3: Repositioning (Modified Thompson) Chart Please check pressure areas during the course of each shift and record findings on the chart below using a. If you are unable to assess as the patient has a dressing in place, please indicate with D. Date Areas at risk am pm n am pm n Am pm n am pm n am pm n am pm n SACRUM Normal Red and Blanching Non-blanching/purple Scuff/broken/blister black BUTTOCK Normal Red and Blanching Non-blanching/purple Scuffed/broken/blister Black LEFT HEEL Normal Red and Blanching Non-blanching/purple Scuffed/broken/blister Black RIGHT HEEL Normal Red and Blanching Non-blanching/purple Scuffed/broken/blister Black OTHER Normal Red and Blanching Non-blanching/purple Scuffed/broken/blister Black Signature June Thompson (1996) Strategy for Pressure Sore Prevention Wound Management 2, 5 8 Pressure Ulcer Prevention Guidelines WPCT Page 24 of 29

Appendix 4: Equipment Selection Flow Chart Pressure Ulcer Prevention Guidelines WPCT Page 25 of 29

Equipment Selection Flow Chart Pressure Ulcer Prevention Guidelines WPCT Page 26 of 29

Appendix 5: Wound assessment chart Pressure Ulcer Assessment Site / Type PATIENT INFO Date Commenced VAC Date Size Diameter Length Depth Photograph Appearance Necrotic Sloughy Infected Granulating Epithelialising Edge of wound Cliff edged r Rolled Flat Analgesics Pain Regular For Dressings only Surrounding skin Colour Oedematous Cellulitic Dry / eczema Maceration Exudate Colour Odour Quantity Canister Change Infection Investigations Topical anti-microbial Antibiotics Serum Albumin Blood glucose Weight Assessed By: Pressure Ulcer Prevention Guidelines WPCT Page 27 of 29

Appendix 6: Pressure ulcer discharge/transfer information list Patient details This chart is designed to assist nurses with the discharge of patients with Tissue Viability needs Length of time wound present Clinical incident form completed? Does the patient have a wound? Yes / No (circle) Location. Classification (tick) Necrotic Sloughy Infected Granulating Epithelialising Depth of Wound / Grade of Ulcer (tick) Blanching / non blanching hyperaemia or grade 1 pressure ulcer Superficial tissue loss or grade 2 pressure ulcer Wound extends to subcutaneous tissue or grade 3 pressure ulcer Wound extends to bone or joint capsule or grade 4 pressure ulcer Investigations carried out in hospital: Y / N Findings Wound Swab MSU FBC U+Es XR ABPI Tissue Biopsy Has the patient had antibiotics whilst in hospital? Has the patient been seen by / referred to a specialist? Yes / No Yes / No Specialist Referral / Appointment Date Vascular Surgeon Dermatologist Dietician Tissue Viability Nurse Chiropodist Other Current Dressing Regime Primary Dressing Secondary Dressing Bandage Frequency of Application Ordered as TTOs? Yes / No (circle) Name of Discharging Nurse (print) Equipment Is the patient using specialised equipment for the prevention & management of pressure ulcers? Name of Mattress Name of Cushion Both Ordered for Discharge? Date of Delivery Delivery Location Designation Yes / No (circle) Yes / No (circle) Signature Date Pressure Ulcer Prevention Guidelines WPCT Page 28 of 29

Appendix 7: Grading of Pressure Ulcers Grade 1 Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness can also be used as indicators, particularly on individuals with darker skin. Grade 2 Partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister. Grade 3 Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Grade 4 Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with/without full thickness skin loss. Pressure Ulcer Prevention Guidelines WPCT Page 29 of 29