Isot onicSterile non pyrog eni cSolution for infu sion
mmol per 250 ml (appr ox)Sodium 38Chloride 38
ren. Do not use unless solut ionCheck additive compatibility withr to use thorough and carefu lndatory Do not remove from )
d any unused portion after fir stbags for use unde r medical
5 0
100
15 0
20 0
oride 0.9% w/vInfusion BP
Chloridew/v 250ml
POM 07
5 4 1 3 7 6 0 2 7 7 6 9 1
10 2014
AIR
140120
100
80
60
40
20mm Hg
160180
200
220
240
260
280
300
0
0472
Pressure ulcers are the result of tissue damage caused by a diminishing blood supply to the skin, usually because the area has been placed under pressure (EPUAP/NPIAP/PPPIA, 2019). Each year in the NHS in England, just under a quarter of a million patients develop a new pressure sore with, on average, 2000 newly acquired pressure ulcers developing each month (PHE, 2015). Fortunately, pressure ulcers can often be avoided. This guide is the first of a three-part series on pressure ulcers. This part, and Part 2, “Pressure ulcers: repositioning and early mobilisation”, deal with prevention. The third part covers “Treatment of pressure ulcers”.
A timely and thorough risk assessment assists healthcare professionals in recognising early on which patients are at risk of developing pressure ulcers, and is an essential part of pressure ulcer prevention (Guy, 2012). It is important to assess the patient holistically, taking into account their health status, medication, social history and psychological needs (NHS Improvement, 2018). National guidance (NICE, 2014) specifies who needs to have an assessment of pressure ulcer risk (see below).
When conducting the risk assessment, follow local guidelines and adjust the procedure according to the patient’s condition. Use a validated scale to support your clinical judgment and assessment, e.g., the Pressure Ulcer Risk Primary Or Secondary Evaluation Tool (PURPOSE-T), the Braden scale, the Waterlow score, or the Norton risk assessment scale. Useful online resources include the
websites run by the campaigns Stop the Pressure and React to Red Skin (see Key reading for details). Following the initial assessment, repeat the holistic skin inspection regularly (Institute for Healthcare Improvement, 2011); it is often possible to carry this out at opportune moments, such as when assisting with personal hygiene or during position changes. In many acute settings, a registered nurse will perform a comprehensive skin assessment on the patient’s admission to the unit, then daily, and then on transfer or discharge. It may be appropriate to have more frequent assessments on units where pressure ulcers may develop rapidly, such as in critical care units, or when a patient has been identified as having one or more risk factors.
Encourage patients who care for themselves at home but who may have potential risk factors to check regularly for signs of pressure damage, including their back and buttocks, with the use of a mirror.
Healthcare staff should regularly inspect the skin of patients who are incontinent, as they may be at increased risk of developing moisture lesions (EPUAP/NPIAP/PPPIA, 2019). These lesions result from exposure to excessive wetness, not from pressure or shear. Other factors that can cause the skin to break down include irritation by bodily fluids and prolonged or inappropriate skin cleansing regimes. Refer patients to the tissue viability team and continence team for assessment and guidance if symptoms persist and/or worsen (NHS Midlands and East, 2013).
Page 1 of 5
Wound CareAdults
Pressure ulcers: Risk assessment, skin assessment and care
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Categories of patients who must have an assessment of pressure ulcer risk (NICE, 2014)
Guidance from the National Institute for Health and Care Excellence states that people admitted to hospital or a nursing home should have a pressure ulcer risk assessment within 6 hours of admission (NICE, 2015). However, it may be beneficial to carry out the assessment sooner. NICE recommends that people with a risk factor for developing pressure ulcers who are referred to community nursing services have a pressure ulcer risk assessment at the first face‑to‑face visit (NICE, 2015). The nurse or student nurse/assistant who inspects the skin and pressure areas and who has been involved in the personal hygiene of the patient should provide a comprehensive clinical handover. It is important to document in the nursing notes that a skin inspection has taken place and that the condition of the pressure areas has been checked. This record should be dated, timed and signed legibly.
Those who have any of the following: significantly limited mobility, significant loss of sensation, a previous or current pressure ulcer, nutritional deficiency, the inability to reposition themselves or significant cognitive impairment.
Those receiving care in other settings (such as primary and community care and emergency departments) if they have a risk factor.
Those being admitted to secondary care or care homes.
VanessaWoodallMatronOutpatients
The Royal Surrey County Hospitals NHS
DAT
E OF
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H.........
NAM
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........
....
........
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D.....
........
.........
....
CHANGE IF PINK
THERAPY EQUIPMENPIPELINE PROTECTE
AIR
AIROxygen
o2
15
10
5
1OXYGEN
per MINUTE
LITRES
0
20
4060
80
100
HIGH VACUUMHIGH FLOWo2
15
10
OXYGEN
LITRES
perMINUTE
5
1
o2o 2
pH 5.5 (approx) IsotonicOsmolarity 308 mOsm/l (approx) Sterile non pyrogenicSingle dose Solution for infusion
Formula for 250 ml mmol per 250 ml (approx)SodiumChloride 2.25 g Sodium 38W ater for injections Chloride 38
For intravenous administrationStore out of reach and sight of children. Do not use unless solutionis clear and container undama ged Check additive compatibilitywithboth thesolution and containe r prior to use thorough and carefulasepticmixing of any additive is mandatory Do not remove from)overwrap until ready for use D iscard any unused portion after firstuse Do not reconnect partially used bags for use under medicalsupervision
50 50
100 100
150 150
200 200
Sodium Chloride 0.9% w/vIntravenous Infusion BP
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POM 07
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Inspect the skin
Common pressure sore sites
Assess for blanching
Young patients are also at risk Preparation for skin inspection
The majority of pressure ulcers appear on the sacrum and heels but the skin overlying any bony prominence is at particular risk of developing pressure damage. It may be useful for patients to keep a diary of any changes they observe. Communication and education with care givers and family is also important.
Wound Care
Adults
Pressure ulcers: Risk assessment, skin assessment and care Page 2
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Heel Sacrum and coccyx
Elbow Dorsal thoracic
Malleolus Anterior knee
TrochanterIschium
Gain consent from your patient and explain that you wish to inspect all of their skin for any signs of pressure ulcers or skin damage. Explain that you will be paying particular attention to bony prominences such as the heels and sacrum. Maintain the patient’s privacy and dignity throughout the procedure. Wash your hands and put on gloves and an apron according to local policy. Gloves should be worn if there is a risk of contact with body fluids or if you or the patient has broken skin; follow local policy.
Although most pressure ulcers develop in patients over 70 years (Lyder & Ayello, 2008), it is crucial to remember that young patients who are normally mobile but who are acutely unwell, or who are living with a long-term condition, may also be at risk of developing pressure ulcers.
If you discover an area of redness (erythema), gently press it for 3 seconds (main image). It should blanch, but the erythema should return when you remove your finger. This blanchable erythema can be a sign of impending tissue damage, resulting from the dilation of capillaries near the skin’s surface. If the area remains white (inset), this indicates pressure damage in the underlying tissue, which can develop into a more severe wound if left unrecognised and untreated (Lindgren et al., 2006).
Inspect the skin for temperature, colour, moisture, integrity and turgor. Note any areas of swelling, hardness, bruising, discoloration, indentation and any rashes. Ask the patient if they are experiencing pain or altered sensation. A structured skin care routine for patients with incontinence can reduce the risk of the development of category 1 pressure ulcers (Bale et al., 2004). This routine should include the correct cleansing, protection and, if required, restoration of the skin (Beeckman et al., 2015).
Page 2 of 5
A gentle soap-free foam
FOAM
Shiloh
SKIN CLEANSING
for cleansing and protection of sensitive, sore or dry skin
san emollient
EMO
LLIENT SKIN CLEANSER FOAM
clini
Soap-free foam to
SKIN FOAM
150ml
Vernacare
CLEANSING
cleanse and protect sore sensitive skin
SENSET SENSET
LOT EXP
3355
Durable Barrier
Cavilon3M
CreamDimethicone Skin Protectant• Protects from incontinence • Resists wash off • Concentrated • Allows tape to stick
NDC17518 028
Net weight 3.25 oz • 92g
LOT EXP
3354
Durable Barrier
Cavilon3M
CreamDimethicone Skin Protectant• Protects from incontinence • Resists wash off • Concentrated • Allows tape to stick
NDC17518 028 02
Net weight 1 oz • 28 g
Wound Care
Adults
Pressure ulcers: Risk assessment, skin assessment and care Page 3
Identifying erythema on darker skin Observe for skin damage caused by medical devices
Patients with incontinence Use a barrier cream to prevent skin damage
VanessaWoodallMatronOutpatients
The Royal Surrey County Hospitals NHS
Apply barrier cream to all affected areas Do not rub the skin
Ask patients if they have any areas of discomfort or pain that could be attributed to skin damage, especially areas of risk that have minimal adipose covering, or none, such as the ears and bridge of the nose. Pain over the site may be a sign of early tissue breakdown. Observe the skin for pressure damage caused by medical devices such as catheters, oxygen tubing or drains, especially mouth, tongue, lips, nostrils and genitalia.
Page 3 of 5
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
As it is not always possible to identify erythema on darkly pigmented skin, areas of localised heat (inset), oedema (main image) and a change in tissue consistency are important indications of early pressure damage to skin in patients with darker skin tones (Clark, 2010). Be aware of changes in old scar tissue caused by previous pressure damage, or skin changes that may relate to moisture, and document accordingly.
Do not massage or vigorously rub the skin with the aim of preventing pressure ulcers. As well as being painful, the friction can cause impairment to blood vessels or cause mild tissue damage (NICE, 2014). Refer patients to the tissue viability team and continence team for assessment and guidance if symptoms persist and/or worsen (NHS Midlands and East, 2013).
Apply barrier products according to the manufacturer’s guidelines. Check that they are compatible with any other products being used. The skin protector should cover all skin that has or could potentially come into contact with urine and/or faeces (Beeckman et al., 2015). Check for signs of fungal growth (thrush), which will require medical examination and treatment.
To help avoid moisture lesions in patients with incontinence, clean the skin with a specialised gentle cleanser or cleansing wipe, instead of using normal soap and water which can alter the skin’s natural pH. See Key reading (NHS Midlands and East, 2013) for more information.
Consider using a barrier cream to protect the skin and prevent further skin damage in patients who are at risk of developing a moisture lesion or incontinence-associated dermatitis (NHS Midlands and East, 2013). Barrier products can come in the form of creams, pastes, lotions or films and should be applied after cleansing.
• Regularly rotating or repositioning devices where possible;
• Removing the device as soon as clinically possible; and
• Protecting the skin under the device (EPUAP/NPIAP/PPPIA, 2019).
To avoid device-related pressure injuries, consider:
Wound Care
Adults
Pressure ulcers: Risk assessment, skin assessment and care Page 4
Page 4 of 5
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Use a pressure ulcer classification tool
Assess any areas of pressure damage using a classification tool, ideally one based on the international pressure ulcer classification system, such as that published by NHS England (EPUAP/NPUAP/PPPIA, 2019). Document your findings and communicate them to the team to ensure that the care plan is appropriate and will allow for monitoring the progress of the wound(s) (NMC, 2018). Many organisations require staff to report any ulcers of category 2 or above for monitoring purposes. Many organisations also require staff to measure, monitor and analyse the prevalence of pressure ulcers within care settings as part of patient safety audits and quality measures.
Category 1: The skin is intact but a red localised area that does not blanch is present. Patients with darkly pigmented skin may not have visible blanching but the skin may appear a different colour from the surrounding area. The patient may also experience pain in the area, which may also feel firmer, softer, warmer or cooler than the surrounding tissue.
Category 4: Full-thickness tissue loss, with exposed bone, tendon or muscle that is visible or directly palpable. Slough or eschar may be present on some parts of the wound bed. Category 4 pressure ulcers often include undermining and tunnelling. The damage may extend into muscle or other supporting structures, such as tendons or joint capsules, raising the risk of osteomyelitis.
Category 2: There may be a shallow open wound, with partial-thickness loss of the dermis. The patient may also present with an intact or open serum-filled blister. The surrounding skin may be shiny but without bruising. Category 2 does not include skin tears, tape burns, dermatitis, maceration or excoriation.
Unstageable: Because the base of the ulcer is covered with slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black), it is not possible to determine how deep it penetrates and therefore what category the ulcer is. Staging may be possible after removing the overlying material.
Category 3: Full-thickness tissue loss. Some subcutaneous fat may be visible, but bone, tendon or muscle are not exposed or directly palpable. The wound may contain slough and may have undermining and tunnelling. The depth of a category 3 ulcer will depend on the location of the ulcer. For example, the bridge of the nose or the ear do not have subcutaneous tissue, so category 3 ulcers can be shallow. Areas with a considerable amount of adiposity can develop deep category 3 ulcers.
Suspected deep tissue injury of unknown depth: This type of damage may appear as purple or maroon localised areas of discoloured intact skin or blood-filled blister, where the underlying soft tissues have been damaged by pressure and/or shear forces. The first signs may be an area that is painful, firm, mushy or boggy, as well as warmer or cooler than adjacent tissue. It may develop into a thin blister over a dark wound bed. In people with darker skin, this type of injury may only be possible to detect by palpating the patient’s skin. Suspected deep tissue injury may evolve to rapidly expose underlying tissue, due to underlying tissue damage.
Name:
RiO Number:
Date & Time
SURFACE
Care delive
red? √ or x or NA
(not applicable
)
Mattress is in use
Cushion is in use
Equipment is in
good working
order
Service user decl
ines to use
equipment
Risk and conseq
uence of non‐
use of equipment expl
ained to
service user/care
r
SKIN INSPECTION
Frequency
_____________
___________
N= Normal, RB=
Red, Blanching,
C1=Category 1,
C2=
Category 2
C3= Category
3, C4= Category
4, ML= Moisture Lesion
D= Dressing in
place, R= Refuse
d, SDTI=Suspecte
d Deep Tissue
Injury
DU=Dep
th Unknown
Sacrum
Left Buttock
Right Buttock
Left Heel
Right Heel
Left Ankle
Right Ankle
Left Hip
Right Hip
Left Shoulder
Right Shoulder
Left Elbow
Right Elbow
Other………..
Other………..
KEEP MOVING
Care delivered
? √ or x or NA (n
ot applicable)
Service user is rep
ositioning self
as assessment indic
ates.
Sta� repositionin
g as
assessment indic
ates.
Use of reposition
ing chart.
INCONTINENCE/MOISTURE
Care delivered
? √ or x or NA (n
ot applicable)
Urine
Bowels
Skin is excoriate
d
NUTRITION
Care delivered
? √ or x or NA (n
ot applicable)
Service user is tak
ing diet well
Service user is tak
ing �uids well
Service user is tak
ing dietary
supplements as p
lan
Completed by
Sign
Print
Designation
4480353909Dolly Day
5/4/21
Patient SURNAME:Patient NAME:DOB:Hospital Number:
FIAT LUX UNIVERSITY OFLIVERPOOL
Daily Repositioning & Skin Inspection Chart
Date: 5/4/21
4480353909
7/4/46Dolly
Day
14.00 B L Sacrum blanching reposi�on in 4 hours
Time
Action taken
Code: L = left, R = right, B = back, P = prone (front), M = mobilised, U = up to sit
Signature
Repositioning(Using codes)From To
Skin inspectionCommentsEg:
08:00 Left hip non-blanchingReassess at next positional
change
L U
Patient SURNAME:Patient NAME:DOB:Hospital Number:
FIAT LUX
UNIVERSITY OFLIVERPOOLAssessment Chart for Wound Management
Ward/Department
Wound Location
Wound Location
Wound Bed Condition - Estimate Percentage Wound Type (please tick)
Length of wound (cm)
Factors which could delay wound healing (please tick) Referral and date
Health Granulation (Red)Pressure ulcer Grade Burn
%Slough (Yellow/Brown)Leg ulcer
Surgicakl wound
%Necrotic (Black)Diabetic foot ulcer
Abrasion
%Infected (Green)
Immobility
Tissue viability nurseIncontinence
DieticianAnaemia
PodiatryInfection
Plastic surgeonDiabetes/and or neuropathy
DermatologyPeripheral vascular disease
EquipmentMedication (steroids, chemotherapy, inotropes, NSAIDs Other - please stateAny allergies?
Traumatic woundLaceration
%CelluliticSkin tear
Other - please state
%
Width of wound (cm)Depth of wound (cm)Wound swab taken?
VolumeTypeColourOffensive colour
MediumSerous
LowPusYellow Brown Green
No
HighHaemoserousRedYes
Yes No
Wound Exudate (please tick)
RIGHT SIDE
LEFT SIDE
LEFT
LEFT RIGHT RIGHT
BACKFRONT
Initial woundassessment Date Initial wound assessment completed by
WD1
3cm2cm0.5cm
90210
5/4/21C. WALKER
4480353909
DayDolly7/4/46
mattress upgrade 5/4/16
5/4/215/4/21
WOUND: ID#DATE: INITIALS
CM 1 2 3 4 5
Assess the pressure ulcer Dress the wound
If pressure damage or a pressure ulcer is present, record its anatomical location. If unsure, confer with a colleague. Consider its possible cause. Assess and document its category, dimensions, appearance, presence of exudate or odour, the condition of the surrounding skin, any signs of infection, the presence of tunnelling or any related pain.
Dress the wound in accordance with the local dressing formulary (see also Part 3 of this series, “Treatment of pressure ulcers”). Recommendations (EPUAP/NPUAP/PPPIA, 2019) include assessing the pressure ulcer at every dressing change, documenting your findings, following the manufacturer’s recommendations on how long the dressing can remain in place without being changed, and considering the patient’s comfort and preference.
Prophylactic dressings (a) (b) Continue to assess the skin at least daily
Where you are concerned that the patient is at high risk of developing a pressure ulcer, consider using a prophylactic dressing in accordance with local policy. This type of dressing should be easy to apply and remove. A prophylactic sacral dressing should have the ability to absorb moisture, reduce friction and relieve potential shear forces by creating a barrier between the patient’s skin and the support surface (Brindle & Wegelin, 2012).
When using a prophylactic dressing, assess the skin for pressure damage at each dressing change or at least daily. Replace the dressing if it becomes damaged, displaced or excessively moist. While using prophylactic dressings, continue to use other preventative measures as appropriate (Clark et al., 2014).
Wound Care
Adults
Pressure ulcers: Risk assessment, skin assessment and care Page 5
Documentation(c) Consider dressings for bony prominences and heels
Page 5 of 5
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Consider applying a foam dressing to bony prominences at risk of pressure, shear or friction, in conjunction with other preventative measures (Haesler, 2014). Follow local policy and guidance. Consider use of a multi-layer, soft silicone foam dressing for the heels, in cases where the patient is undergoing a prolonged procedure, is at risk of shear injury, or cannot be easily moved from supine (Black et al., 2015). Again, follow local policy and guidance.
Complete documentation after each assessment. Follow local policy. All healthcare organisations will have policies relating to assessment, documentation, the communication processes for informing the wider healthcare team, the educational process for assisting staff in the assessment of pressure ulcers and documentation to help monitor the individual’s progress.
If pressure damage or a pressure ulcer is present, record its anatomical location. If unsure, confer with a colleague. Consider its possible cause. Assess and document its grade, dimensions, appearance, presence of exudate or odour, the condition of the surrounding skin, any signs of infection, the presence of tunnelling or any related pain.
Dress the wound in accordance with the local dressing formulary (see also Part 3 of this series, “Treatment of pressure ulcers”). Recommendations (EPUAP/NPUAP/PPPIA, 2014) include assessing the pressure ulcer at every dressing change, documenting your findings, following the manufacturer’s recommendations on how long the dressing can remain in place without being changed, and considering the patient’s comfort and preference.
