Transcript Pressure Ulcers

Tissue Viability Team
ABUHB
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Brief functions of the skin
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What is a pressure ulcer?
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Why do they happen?
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What we can do to prevent pressure ulcers?
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The way forward
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Loss of self
esteem
Painful
Loss of
independence
Life threatening
Regular Repositioning to:
 Relieve Pressure
 Restore Blood Supply
 Reduce Pain and Discomfort
 Inspect the Skin
 Relieve Boredom and improve wellbeing
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Incorrect Positioning
Incorrect use of Equipment
Poor Lifting and Manual Handling Techniques
- Avoid Dragging the Patient
Inappropriate Support Surfaces - Patient
Sliding down the Bed or Chair
For skin at risk of
breakdown or for Category
I pressure ulcers, a barrier
cream or film may be used
to reduce shear forces and
minimise the risk of
contamination by microorganisms.
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A pressure ulcer is a localised 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 associated with pressure
ulcers; the significance of these factors is yet to be agreed.
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Friction
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Moisture
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And intrinsic factors
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European Pressure Ulcer Advisory Panel (EPUAP) National Pressure Ulcer Advisory Panel (NPUAP 2009)
Pressure damage can
occur anywhere on the
body but is more likely
over a boney
prominence.
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Head
Heels
Elbows
Buttocks
Hips
Ears
Shoulders
Ankles
Toes
Spine
Nose
Superficial loss of dermis and /
or dermis
Loss of epidermis and dermis –
with red shiny tissue
Superficial broken skin, which is
red and wet with areas of dryness
Moisture lesion in the natal cleft
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Assessment
Reassessment
Skin inspection regularly
Early recognition
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Non blanching erythema
Blisters
Heat
Induration
Pressure
Shear,
friction
Immobility
Other factors, include age,
medication, nutritional and
general health status,
incontinence, weight.
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Significant pain and distress
Significant impact on health,
Poor quality of life
Prolonged hospitalisation
Prolonged community care provision
Significant financial costs
Life threatening
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•Pressure ulcers happen
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•We can stop pressure ulcers
from occurring
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•Pressure ulcers should not
happen here
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All staff involved in patient care should have
the appropriate knowledge, skills and
resources to reduce the incidence of pressure
ulcers in patients admitted to care.
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Assess each patient’s risk of developing a pressure
ulcer within 4hours of admission
Indentify intrinsic and extrinsic factors which may
influence a patient’s potential to develop pressure
damage.
Skin assessment to identify early signs of pressure
damage
MUST score
Regular skin reassessment and use clinical judgement
and patient’s history
Document, Document, Document –care plans, skin
bundle, wound chart
Evaluate, Evaluate, Evaluate.
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Patients with a
Waterlow score of 15
and above
But ........
Some patients may
have a high score but
are mobile ....
Some patients may
score <15 but are
clinically judged at risk
Apply skin bundle and
document any changes
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Remember
 SURFACE
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 KEEP MOVING
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 INCONTINENCE
 NUTRITION
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Is the patient on the
right mattress/seating?
Patients need to move
or be repositioned
Skin needs to be kept
dry, avoid moisture
Keep patient hydrated
and well nourished
**If a pressure ulcer is present, a wound management chart must be used and documented in nursing documentation.
DATE & Waterlow
score
ADVISED TIME
ACTUAL TIME
SURFACE
Appropriate mattress in use
Appropriate seating
KEEP MOVING
Patient mobile
In bed on back
In bed on left side - 30º
tilt
In bed on right side 30ºtilt
Sat out in chair
Stood up from chair
Patient sleeping
Patient refusing to move
Skin checked
**Is P.U present? Y or N**
Heels checked (Remove T.E.D
stockings if necessary)
INCONTINENCE
Urine
Faecal
Continent
Catheter
Skin moist
Washed /dried
NUTRITION
N.B.M
Diet – type
Taking fluids only
Drink offered
Supplements
Signature
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0600
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1400
1800
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0600
1000
1400
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NPSA 2010 recognised that some
PUs may be unavoidable
MOST PRESSURE ULCERS ARE
AVOIDABLE
Person providing care did not do one of
the following –
 Evaluate patient’s condition and risk
factors
 Plan and implement interventions to
meet clinical needs and recognised
standards of practice
 Monitor and evaluate impact of
interventions
 Revise interventions as appropriate
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Patient developed a pressure ulcer even
though the provider of care
Had evaluated the patient’s condition and risk
factors
Had planned and implemented interventions
to meet patient’s clinical needs and the
recognised standards of practice
Had evaluated the impact of interventions
and revised as appropriate
Patient declined to adhere to care plan
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or ‘just one of those things’?
•Ill-treatment
•Impairment of, or an avoidable
deterioration in, physical or mental health
•Impairment of physical, emotional, social
or behavioural development
Grade 3-4 or multiple pressure ulcers
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Refer to TVN
Enter on DATIX
Complete SBAR
Inform & discuss with senior nurse - ? Meets
POVA threshold
If yes – initial POVA strategy meeting
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1. Has there been rapid onset and/or deterioration of
skin integrity?
2. Has there been a recent change in medical
condition e.g. skin or wound infection, other infection,
pyrexia, anaemia, high temperature, end of life care
that could have contributed to a sudden deterioration
of skin condition?
3. Have reasonable steps been taken to prevent skin
damage?
4. Is the level of damage to the skin disproportionate
to the patient’s risk status for skin damage? e.g. low
risk of skin damage with extensive injury
5. Is there evidence of poor practice or neglect?
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In order to ensure the patient of concern is
made safe
In order to keep other patients safe
In order to learn lessons and improve
practice.
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Select pressure redistribution mattress and or
cushion based on patients needs and comfort
Reassess daily or if patients condition
changes
Ensure the equipment is functioning correctly
Ensure patients with pressure ulcers have
access to pressure-relieving support surfaces
and strategies
Support surfaces alone neither prevent nor heal
pressure ulcers.
They are to be used as part of a total
programme of prevention and treatment
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Keep the skin dry and well hydrated
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Regularly inspect for signs of damage
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Mobilising, positioning and re-positioning
interventions should be determined by:
General health status
Location of ulcer
General skin assessment
Acceptability (including comfort), to the
patient
Mobilising, positioning and repositioning
interventions should be instigated for all
individuals with pressure ulcers (including
those in beds, chairs and wheelchairs).
During sleep the average
person moves 60-70 times
a night with a dozen full
turns
National Bed Federation 1995
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The 30º tilt is a method of
positioning the
patient/client to decrease
the risk of damage.
The person is not fully on
his or her side, but is
placed on pillows
positioned to angle the
pelvis at approximately 30º
to the surface of the bed
Frequency of re-positioning
should be determined by
the patient's individual
Needs and recorded – e.g. a
turning chart.
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Inspect the skin for additional damage each
time the individual is turned or repositioned
while in bed.
Do not turn the individual onto a body
surface that is damaged or still reddened
From a previous episode of pressure loading,
especially if the area of redness does not
blanch
Do not position on a pressure ulcer
Avoid pressure and shear on sacrum and
coccyx
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Position to minimize pressure and shear
Use footstool or footrest if the feet do not
touch the floor
Limit time in the chair: pressure on ischial
tuberosities
It is recommended to reduce the duration of
sitting to less than two hours at any one time
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High-risk groups
Immobile legs
Peripheral vascular
disease impairs
reperfusion
Diabetic neuropathy
Use urinary or faecal management
systems as appropriate
Use continence products when required
Manage skin temperature and humidity
to reduce sweat
Keep clean and dry
•Refer all individuals with a
pressure ulcer to the
dietician for early
assessment of and
intervention for nutritional
problems
•Assess nutrition
status
•Implement prescribed
diet/nutritional
supplement
•Keep well hydrated
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Provide enhanced foods and/or oral
supplements between meals if needed.
Provide adequate protein
Provide and encourage adequate daily fluid
intake for hydration.
Provide adequate vitamins and minerals.
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Pressure ulcers can have a negative impact on
wellbeing and quality of life.
It is essential to involve the patient and
his/her family in ensuring that individual
problems and concerns are addressed
Patients and carers
should be informed
about any potential
risks, and/or
complications, of
having a pressure
ulcer.
 Patients and carers
should be involved in
shared decisionmaking about
management of
pressure ulcers
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Leadership
Actions
Promote culture of
zero tolerance
Promote best
practice guidance
Identify local
‘champions’
Tissue viability
nurse specialist
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Frontline Actions
Risk assessment
Implement best
practice guidelines,
skin bundle &
safety cross
Patient and family
education
Measurement and
data
“Pressure ulcers have a significant impact on health
related quality of life and cause substantial burden
to patients”
(Gorecka et al 2009)
Open wounds
smell bad
I worry about
my wound
getting worse
Pressure ulcers
cause a lot of
pain
90% of elderly patients who
develop a necrotic pressure
ulcer on the trunk die
within 4 months.
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95% of pressure ulcers are avoidable
Cost to the patient – financial and personal
Cost to the organisation
Quality of life
Life and Limb threatening
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Raise awareness – everyone’s responsibility
Education – include patients and carers
( patient information leaflet)
Audit – daily data
Its about the WHOLE of
the patient !!!
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The question must be Is it worth trying to do,
not can it be done?
Allard Lowenstein
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European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of
pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009
Clarkson, A. (2007). Are pressure ulcers an act of nursing negligence? Wounds UK. 3(2), 78-85.
Clark, M. (2006). How can we make pressure ulcer prevention and management truly multiprofessional?
Journal of Wound Care. 14(5).
Fletcher, J. 2012. Wound essentials. Pressure ulcer management, how to guide. 7(1)