Stop the Pressure!
Pressure Ulcer
Prevention
and
Management
Suffolk Community Healthcare Training
Judith Brewer BSc (Hons) BAOT HPC
Pressure Ulcer CQUIN Lead
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Overview of the Session
• Costs, Prevalence,
Definition
• Causes & Risk Factors
• Grading, Assessment &
Prevention
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
But Before We Begin……..
Let’s take a few moments to think
about what a pressure ulcer
means for the people affected
Imagine that ANY of these people could be
someone you love or care for ……
Warning: the
following slides
contain images of
real pressure ulcers
people and their families
trusted their professional
carers to look after them and
protect them from harm….
This is why we must stop the
pressure!
Costs - financial
Treatment costs vary depending on the grade of ulcer:
• from £1,064 for a grade 1 ulcer To £24,214 for a
grade 4
• The total cost in the UK is estimated to be £1.4 - £2.1
billion annually
This is 4% of total NHS
expenditure!
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Costs - individual
•
•
•
•
reduced quality of life
difficulties for patients, their carers and families
even a grade one pressure ulcer is very painful
estimated that up to 30% patients in nursing and
residential homes may be affected
• increased risk of secondary infection
• ~ 4 x increase of risk of death in older people in ICU
• increased morbidity
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Negative Publicity
Litigation
The bottom line is….
95% OF ALL PRESSURE
ULCERS ARE
PREVENTABLE!
Hibbs 1987
Skin matters
You should take action to ensure that
there are ….
“No avoidable pressure
ulcers in
your provided care”
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Avoidable
pressure ulcers…
Means that the care provider did not
do one or more of the following:
Evaluate the patient’s clinical condition and risk
factors
Plan and implement interventions consistent with
the patients needs, goals and recognised standards
of practice
Monitor and evaluate the impact of the interventions,
or revise the interventions as appropriate
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
What is a
pressure ulcer?
A Pressure Ulcer is Defined as:
“an area of localised damage to the
skin and underlying tissue caused by
pressure, shear, friction and/or a
combination of these factors”
European Pressure Ulcer Advisory Panel EPUAP
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Pressure
• Pressure is an external force where soft
tissue is compressed between a bony
prominence and a hard surface e.g. a
mattress or a chair
• The capillaries become occluded and the
tissues starved of vital nutrients and oxygen,
and become ischaemic
• If pressure is unrelieved, tissue necrosis will
take place
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Shear
• Shear is an external force which causes
distortion, stretching and eventual tearing of
the blood vessels
• Shearing occurs if the patient slides down in
the bed or chair
• The skeleton moves, but the skin stays still
• The tearing of blood vessels can also lead to
ischemia and cell death
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Friction
• Friction is a surface force which occurs
when two surfaces rub together e.g.
– dragging the patient up the bed
– rubbing vigorously when washing
• Friction leads to superficial damage
– the uppermost layers of epithelial cells are
scraped off, leading to skin grazes
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Friction and Shear Forces
Risk Assessment
• Effective risk assessment can prevent pressure
ulcer development
• The Waterlow Score is a risk assessment tool used
throughout the country to identify patients who are
at risk of developing pressure ulcers
• Recognising patients at risk of pressure damage:
– enables resources to be effectively allocated,
such as pressure reducing equipment
• Holistic assessment increases the effectiveness of
the care being delivered
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Risk Assessment
Initial risk assessment should take
place within 6 hours of admission
using the Waterlow risk assessment
tool and clinical judgement
If not at risk initially, reassessment
should occur if there is a change in
the patient’s condition
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Risk Assessment
Risk factors include:
•
•
•
•
level of mobility
sensory impairment
continence
level of
consciousness
• acute, chronic and
terminal illness
• Co-morbidity (blood
supply, infection,
pain, medication)
• posture
• cognition
• previous pressure
damage
• extremes of age
• nutrition and
hydration status
• moisture to the skin
REMEMBER!
Reassess on an on-going basis
Which areas are prone to
pressure ulcers?
Assessment
- Continence
• Continent/Catheterised – patients are
less likely to develop skin damage due
to moisture
• Incontinent – patients are at high risk of
developing moisture lesions, and
developing infections
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Assessment
- Mobility
• Patients with reduced mobility
– Are at higher risk of pressure damage due
to their inability to alter their position
themselves
• Patients who are Bed-bound
– Are at higher risk of pressure damage
– But in areas different from those in a
wheelchair
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Positioning
• All patients with pressure ulcers should actively
mobilise and change position if able OR Be
repositioned
• Minimise pressure on bony prominences
Do not position a patient
directly on a pressure ulcer
• Consider restricting sitting time
• Aids, equipment and positions – seek specialist advice
• Record using a repositioning chart/schedule
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Assessment
- Nutrition
• Malnutrition is: a major contributing factor to
pressure ulcer development
• Patients who are malnourished are: at very high risk
of pressure damage due to the increase in pressure
over bony areas
• Poor food and fluid intake: effects the patient’s
ability to heal
• Patients with wounds:
– require a high protein diet to enable the body to
heal
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Assessment
- Medication
• Particular medications can have an
– effect on healing rates
• Steroids and other anti-inflammatory
medications:
– reduce the skin’s elasticity and tensile
strength increasing the risk of damage
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Assessment
- Pain
• Pain:
– should always be assessed when
determining risk
– often causes reduction in mobility
– affects the patient’s mental status which
affects healing
– may require analgesics which slow down
the healing process
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Skin Care
•
Skin of vulnerable patients should
– be inspected daily
– any changes skin condition documented and
reported to a senior member of staff
•
Skin should be:
– moisturised at least once a day
– particularly for patients with very dry skin
•
Barrier cream should be:
– applied to patients at risk of moisture damage
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Assessment
 Cause/Site/Location/Wound appearance
 Dimensions/Category/Stage/Odour
 Exudate/sign of infection/Pain
 Surrounding skin/Undermining/tracking
 Support with photography
 Document all pressure ulcers categorised Grade II and
above as a clinical incident
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
European Pressure Ulcer
Advisory Panel Classification
(EPUAP)
• Category/Stage I Discolouration of
intact skin (nonblanching erythema)
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Category/Stage II
• Stage/Category II –
Partial-thickness skin
loss or damage
involving epidermis
and/or dermis
• The pressure ulcer is
superficial and
presents as a blister,
abrasion or shallow
crater
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Category/Stage III
• Category/ Stage III –
Full thickness skin loss
involving damage of
subcutaneous tissue
but not extending to the
underlying fascia
• This presents as a deep
crater with or without
undermining of
adjacent tissue
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Category/Stage IV
• Category/Stage IV –
Full thickness skin
loss with extensive
destruction and
necrosis extending
to underlying tissue
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Pressure relieving devices
Initial and on-going ulcer assessment is the
responsibility of a
registered healthcare professional
Consider all surfaces used by the patient
Patients should have 24 hour access to
pressure relieving devices and/or strategies
Change pressure relieving device in
response to altered level of risk, condition
or needs
Equipment Selection
• All patients vulnerable to pressure
ulcers should as a minimum be placed
on a high specification foam mattress
• Patients with category/stage III-IV
pressure ulcers should be:
- placed on a high specification alternating
pressure relieving mattress replacement
system or overlay
- a sophisticated continuous low pressure
system
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Pressure Ulcer Pathway
http://www.stopthepressure.com/path/
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Five simple steps to
prevent and treat
pressure ulcers
© NHS Midlands and East 2012
Expected Benefits
Financial
– If fewer Grade II and above Pressure Ulcers occur in
residential care homes
i.e. ‘Prevention’
– And if pressure ulcers are identified at an earlier
stage
i.e. ‘Management’
Then it follows that:
Each Pressure Ulcer prevented/well managed
means:
• Savings on costs of repeated visits by SCH clinicians
• Savings on costs of treatment
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
• Savings on hospital admissions
Expected Benefits
Public Perception
– Service users will experience quality care
– Complaints and possible litigious claims
will be avoided
– Greater public awareness of pressure
ulcer prevention
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.
Scroll and click your way
along the Pressure Ulcer
Path, using SSKIN.
www.stopthepressure.com
© NHS Midlands and East 2012
Thank you
Any Questions?
A service delivered on behalf of the NHS by Serco,
South Essex Partnership University NHS Foundation
Trust and Community Dental Services CIC.