Standard Operating Procedure Title of Standard Operation Procedure (SOP): The Prevention and Management of pressure ulcers in Special Needs Schools. Reference No: SS6 Version No: 1 Issue Date: March 2017 Review Date: March 2019 Purpose and Background Pressure ulcers are caused when an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair its blood supply. Pupils who attend the Special schools are more susceptible to pressure damage as they usually have a number of the identified risk factors: significantly limited mobility significant loss of sensation use of wheelchairs/corsets/splints nutritional deficiency the inability to reposition themselves significant cognitive impairment. This procedure is to be used in conjunction with the East Cheshire NHS Trust (ECNHST) 2012 Pressure Ulcer Prevention and Treatment Guidelines to promote maximum educational, physical and emotional development for this identified group. Scope (i.e. organisational responsibility) Vital functions affected by this SOP: This procedure has been developed for East Cheshire NHS Trust Special Needs School Nursing staff for use in the following schools: Park Lane School, Macclesfield, SK11 8JR The above school is a Special Needs Schools for pupils with a Learning Disability, Physical disability or Complex medical needs. The vital function affected by this SOP is the assessment of risk, prevention and management of pressure ulcers in the children and young people attending the schools listed above. Monitoring Compliance Requirement to be monitored. Process to be used for eg. audit Audit Supervision individual/ committee for carrying out Complex Care Team Leader Frequency of individual/ committee for reviewing the results 2 Yearly Complex Care Team Leader individual/ committee for developing an action plan Complex Care Team Leader individual / committee for the action plan Complex Care Team Leader
Escalations (if you require any further clarification re the process outlined please contact): Author: Jane Kinealy Complex Care Team Leader Jane Fox Special Needs Nurse Co-ordinator Updated by Jane Kinealy Complex Care Team Leader Approval Record: Received for information: Committee/Group Women and Childrens SQS Committee Tissue Viability Lead Nurse Date 24.10.2014 22.10.2014
1. Clinical Assessment 1.1 Risk assessment is to be undertaken using the modified Braden Q scale. Appendix 1 1.2 Initial assessment should be completed with the parent/carer when each pupil starts school, and annually reviewed (or sooner if clinical assessment or information is received which alters the risk assessment) 1.3 The risk assessments must be documented in the Child Health Records. 2. Prevention/ Care Planning 2.1 Following assessment, if the risk is scored at risk, medium or high, the school nurse should provide tailored information to parents/carers. This must be documented in the Child Health Records. Information should include: why the child is most likely to be at risk of developing a pressure ulcer how to identify early signs of pressure damage and damage due to moisture what steps to take to prevent new or further pressure damage/moisture lesions who to contact for further information and for further action verbal information to be followed up by written information 2.2 The School nurse should provide annual update training for educational staff. Educational staff in the settings are identified as having appropriate opportunity for visual assessment of vulnerable areas on the skin and should therefore be informed of pupils who score medium or high risk. Records of training must be kept for evidence. Training should include: who is most likely to be at risk of developing a pressure ulcer how to identify pressure and moisture damage what steps to take to prevent new or further pressure/moisture damage including how to reposition who to contact for further information and for further action. 3. Management 3.1 When concerns are raised regarding a pupil s skin integrity, the School nurse should complete an initial wound assessment on the Paediatric Risk Assessment tool within the Pressure Ulcer Prevention and Treatment Guidelines ECNHST guidelines. 3.2 The parent/carer should be informed of the assessment if they are not aware. Parental consent to refer to the community team/tissue viability should be gained and documented in the Child Health Records. 3.3 Advice regarding management is to be provided to the educational staff as per the ECNHST guidelines. This may also require liaison with physiotherapy/ot regarding reassessment of any aids such as wheelchairs/splints etc. 3.4 The School nurse can liaise with the Tissue Viability team for advice and support for Stage 2 and above (complex wounds and those not responding to treatment) and refer as appropriate. 3.5 The school nurse will liaise with appropriate teams e.g. home care team regarding the care of any dressings. Two types of dressing will be available in each school for this purpose. 3.5 The school nurse should consider any concerns regarding safeguarding e.g. neglect, and discuss with the safeguarding team as appropriate. 3.6 Ulcers that are identified as Stage 2 and above must be reported as an incident on DATIX, and the safeguarding team contacted to inform them this has been completed 3.7 The School nurse must document all observations, contact and advice provided in the Child Health Records in addition to copies of the initial assessment and any referrals.
Responsibilities Heads of Service, Divisional Heads and Community Service Managers are responsible for ensuring the services they manage are aware of this Standard Operating Procedures for The prevention and management of pressure ulcers in Special schools and that amendments are cascaded in a timely manner. Tissue Viability Team are responsible for supporting the Special Needs School Nurse Coordinator with the review of SOPs periodically. In conjunction with Risk Management, they will be responsible for investigating failures in procedures when advised of them. Complex Care Team Leader is responsible for ensuring that all team members are fully aware of the SOP. Also responsible for ensuring that all new starters to the Special Needs School Nursing Team are made aware of its existence and the intranet site where the most up to date version will be available. Team Leaders are responsible for ensuring the relevant specifications outlined in the SOP are adhered to in practice. Registered Nurses All professionals are personally and professionally accountable for their actions and omissions in their practice and must always be able to justify their decisions and ensure compliance to East Cheshire NHS Trust operating procedures/policies. Individual professionals are personally responsible for reporting any skill deficit or training requirements to their line manager or service manager. Any incidents, errors or issues arising from this SOP should initially be discussed with the line manager and referred to or discussed with the Tissue Viability Team when appropriate. Parents/Carers have overall responsibility for their child s care. It is the responsibility of the parent/carer to inform the School Nurse of any concerns regarding their child s skin integrity on initial assessment and any subsequent reviews, or as concerns arise. References Department for Education (2014). Supporting Pupils at School with Medical Conditions. Retrieved from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 349435/Statutoryguidance_on_supporting_pupils_at_school_with_medical_conditions.pdf East Cheshire NHS Trust. (2012). Pressure Ulcer Prevention and Treatment Guidelines. East Cheshire NHS Trust. National Institute for Health and Care Excellence (2014). Pressure ulcers: prevention and management of pressure ulcers. Retrieved from http://www.nice.org.uk/guidance/cg179 Nursing and Midwifery Council. (2009). Record keeping. Guidance for nurses and midwives. London, United Kingdom: NMC. Audit & Reconciliation Appropriate administration records will enable auditing of risk assessment. These should take place annually and more frequently if the need is identified
APPENDIX 1 Mobility The ability to change and control body position Activity The degree of physical activity Sensory Perception The ability to respond in a developmentally appropriate way to pressure related discomfort Moisture Degree to which the skin is exposed to moisture Friction/Shear Friction: Occurs when skin mores against support surfaces Shear: Occurs when skin and adjacent bony surface slide across one another Nutrition Usual food intake pattern Tissue Perfusion and Oxygenation Modified Braden Q East Cheshire Risk Assessment (Paediatrics) Intensity and Duration of Pressure 1. Completely immobile Does not make even slight changes in body or extremity position without assistance 1. Bedfast Confined to bed 1. Completely Limited Unresponsive to painful stimuli sue to diminished level of consciousness or sedation or limited ability to feel pain over most of body surface 1. Constantly moist Skin is kept moist almost constantly by perspiration, urine, drainage, etc. Dampness is detected every time the patient is moved or turned 1. Significant problem Spasticity, contracture, itching or agitation leads to almost constant thrashing and friction 1. Very Poor Nil by mouth and/or maintained on clear liquids, or IV s for more than 5 days OR albumin < 2.5 mg/dl OR Never eats a complete meal. Rarely eats more than ½ of any food offered. Protein intake includes only 2 servings of meat or dairy products per day. Takes fluids poorly. Does not take a liquid dietary supplement. 1. Extremely Compromised Hypotensive (MAP<50mmhg<40 in new born) OR the patient does not physiologically tolerate position changes 2. Very Limited Makes occasional slight changes in body or extremities position but unable to completely turn self independently 2. Chair fast Ability to walk severely limited or non existent. Cannot bear own weight and/or must be assisted into chair or wheelchair 2. Very limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has sensory impairment which limits the ability to feel pain or discomfort over half of the body Tolerance of the Skin and Supporting Structure 2. Very Moist Skin is often, but not always moist. Linen, nappy/pad or dressing changes every 2 to 4 hours 2. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequent slides down in bed or chair, requiring frequent repositioning with max. assistance 2. Inadequate Is on liquid diet or tube feedings/ TPN which provide inadequate diet and minerals for age OR Albumin < 3 mg/dl OR rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. 2. Compromised Normotensive; Oxygen saturation may be < 95% OR haemoglobin may be < 10 mg/dl OR capillary refill may be > 2 seconds : serum ph is < 7.40 3. Slightly limited Makes frequent though slight changes in body or extremity position independently 3. Walks Occasionally Walks occasionally during day but for very short distances, with or without assistance. Spends majority of each shift in bed or a chair 3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or need to be turned OR has some sensory impairment which limits the ability to feel pain or discomfort in one or two extremities 3. Occasionally moist Skin is occasionally moist, Nappy/pad changes as routine. Dressing/linen change every shift (every 12hrs) 3. Potential problem Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, or other devices. Maintains relative good position in chair or bed most of the time but occasionally slides down 3. Adequate Is on tube feedings or TPN which provide adequate calories and minerals for age OR eats over ½ of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered 3. Adequate Normotensive; Oxygen saturation may be< 95% OR haemoglobin may be< 10 mg/dl OR capillary refill may be above 2 secs: serum ph is normal 4. No Limitations Makes major and frequent changes in position and without assistance 4. All patients too young to ambulate OR walks frequently. Walks frequently (at least every 2 hours) 4. No Impairment Responds to verbal commands Has no sensory deficit, which limits the ability to feel or communicate pain or discomfort. 4. Rarely Moist Skin is usually dry. Routine nappy changes or patient continent. Dressing changes as routine, linen changed every 24 hrs 4. No apparent problem Able to completely lift patient during a position change, moves in bed and chair independently and has sufficient muscle strength to completely lift during move. Maintains good position in bed or chair at all times 4. Excellent Is on a normal diet providing adequate calories for age. For example: eats/drinks most of every meal/ feeding. Never refuses a meal usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. 4. Excellent Normotensive, Oxygen saturation > 95%, normal haemoglobin and capillary refill <2 secs.
Name: NHS Number: DOB: Scoring 25 + low risk 21 + medium risk 16 + high risk Time/date Mobility Activity Sensory Perception Moisture Friction/Shear Nutrition Tissue perfusion & oxygenation Total Signature/designation Initial assessment