Pressure Ulcer Prevention and Management Policy and Associated Guideline
for Adults
Version
4
Name of responsible (ratifying) committee
Nursing & Midwifery Group
Date ratified
09.05.2013
Document Manager (job title)
Tissue Viability Clinical Nurse Specialist
Date issued
11th September 2013
Review date
June 2015
Electronic location
Corporate Clinical Guideline
Related Procedural Documents
Key Words (to aid with searching)
Pressure ulcers, pressure ulcer prevention, grade of
pressure ulcers, Braden, medical equipment, nutrition
Pressure Ulcer Prevention and Management Policy and Associated Guideline for Adults:
Version 4 Issue Date: 11/09/2013
(Review date June2015 (unless requirements change)
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CONTENTS
1. QUICK REFERENCE GUIDE …………………………………………………………………...3
2. INTRODUCTION ………………………………………………………………………………….4
3. PURPOSE …………………………………………………………………………………………4
4. SCOPE …………………………………………………………………………………………….4
5. DEFINITIONS ……………………………………………………………………………………..4
6. RESPONSIBLITIES..……………………………………………………………………………..5
7. PROCESS …………………………………………………………………………………………6
8. TRAINING REQUIREMENTS ………………………………………………………………….12
9. REFERENCES AND ASSOCIATED DOCUMENTATION ………………………………….13
10. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENSS OF, PROCEDURAL
DOCUMENTS ………………………………………………………………………………………18
Pressure Ulcer Prevention and Management Policy and Associated Guideline for Adults:
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QUICK REFERENCE GUIDE
Key principles of pressure ulcer prevention and management include the following:
Structured Assessment
+
Clinical Judgement
All patients to undergo daily assessment
Skin inspection for patients at risk
Use mirror to inspect heels
Implement pressure ulcer prevention
strategies for at risk patients
Address nutritional needs and any
moisture/incontinence
Prevention equipment including mattress,
cushion, glide sheets, heel protectors
Repositioning and limited seating
+
Patient and carer education
Skin marking: indicates need to review
strategy
Re-assessment
Evaluate strategy and adjust strategy
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INTRODUCTION
Pressure ulcers are an economic burden on the National Health Service (NHS) equating to 4% of the NHS budget
(Bennett et al 2004). More importantly, pressure ulcers are detrimental to patients in terms of their physical,
psychological and social well being resulting in reduced quality of life and maybe mortality (Fox 2002). The
calculated cost of grade 1 pressure ulcer is £1214 rising to £14108 for a grade 4 pressure ulcer (Dealey et al 2012).
Portsmouth Hospitals NHS Trust should have an integrated, multidisciplinary approach to the prevention and
management of pressure ulcers with a clear strategy supported by senior management (NICE 2005, RCN 2005).
Care should be delivered within the context of continuous quality improvement where improvements are identified by
regular audit, feedback and review of each Clinical Service Centre Action Plans by the Pressure Ulcer Working
Group.
Patients should receive an initial pressure ulcer risk assessment within 4 hours of admission and if identified at risk a
pressure ulcer prevention strategy must be implemented to reduce or remove risk factors. Daily ongoing risk
assessments should be carried out or more frequently if the patient’s condition deteriorates and pressure prevention
strategies adjusted accordingly.
All pressure ulcers should be categorized or graded using European Pressure Ulcer Advisory Panel (EPUAP)
Classification System (2009) and reported via the Trust’s DATIX reporting system.
It is the aim of this Trust to eliminate all avoidable pressure ulcers.
1. PURPOSE
The aim of the High Impact Action - Your Skin Matters (2009) is to have “No avoidable pressure ulcers in NHS
provided care”. It is the purpose of this policy to ensure all staff adopt a zero tolerance of hospital acquired pressure
ulcers. All patients admitted to hospital will be assessed within 4 hours of arrival and pressure ulcer prevention
strategies will be immediately implemented to prevent pressure damage occurring. Ongoing re-assessments will
continue daily throughout the patients’ stay and strategies adjusted accordingly to meet individual needs.
2. SCOPE
This policy and guideline is intended to be used by all members of staff using a multidisciplinary team approach in
the prevention and management of pressure ulcers
3. DEFINITIONS
Pressure ulcers are also known as ‘pressure sores, bed sores and decubitus ulcers’. A pressure ulcer is defined as
“localised injury to the skin and/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 also associated with
pressure ulcers; the significance of these factors is yet to be elucidated” (EPUAP 2009). Pressure ulcers occur when
a bony prominence is in contact with a surface for prolonged periods of time. The most common sites include the
buttocks, hips and heels but they can occur over any bony prominence (NICE 2005).
Avoidable and Unavoidable Pressure Ulcers
The Department of Health (2010) has recognized that, while most pressure ulcers are avoidable, there are those few
which may be unavoidable. Their definition of ‘Avoidable’ pressure ulcers is:
Avoidable Pressure Ulcer: For a pressure ulcer to be considered avoidable, the care-provider did not:
 Evaluate the person’s clinical condition and pressure ulcer risk factors
 Plan and implement interventions that are consistent with the persons needs and goals, and recognized
standards of practice
 Monitor and evaluate the impact of the interventions; or revise the interventions as appropriate
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Unavoidable Pressure Ulcer: For a pressure ulcer to be considered ‘Unavoidable’, the person receiving care
developed a pressure ulcer even though the care-provider had:
 Evaluated the person’s clinical condition and pressure ulcer risk factors
 Planned and implemented interventions that are consistent with the persons needs and goals and
recognized standards of practice
 Monitored and evaluated the impact of the interventions and revised the approaches as appropriate
 The individual person refused to adhere to prevention strategies in spite of education of the consequences
of non-adherence
To determine whether pressure ulcers are unavoidable, there must be documentary evidence demonstrating the
actions taken to prevent pressure damage during the patient’s episode of care (NHS 2012).
For consistency, it is recommended that the EPUAP (2009) (Fig 1) classification system is used to identify pressure
damage. Deep Tissue Injury is a purple or maroon localised area of discoloured intact skin and will be classified as
grade 3 with the potential to deteriorate to a grade 4 (NHS 2012).
Fig 1: EPUAP & NPUAP (2009) Pressure ulcer grading or categories:
Definition of Moisture Lesions (Appendix 1)
Moisture lesions will be present when there is a history of moisture on the skin due to urinary or faecal incontinence
or combination of both. It can also be related to sweating resulting in increased friction between skin folds or from
excessive wound exudate in contact with the skin for prolonged periods. The moisture lesions manifests as
redness, with or without blistering or erosions often with irregular shaped edges (Guy 2012). There are diffuse areas
of partial thickness skin loss that can bleed or ooze serous fluid. Moisture lesions can occur in skin folds, over the
buttocks and around the perineum. If the damage is caused by moisture, it should not be recorded as a pressure
ulcer.
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Combined moisture and pressure lesions are a result of pressure and moisture where there is necrotic or sloughy
tissue present within the area of skin damage. This should be reported as combined moisture and pressure
damage.
Skin Care At End Of Life: The skin is the largest organ of the body and can fail. End of life is a phase of life when
a person living with an existing illness, can deteriorate leading to death. It is acknowledged that during this period,
vital organs will gradually cease functioning. The skin will reflect this and show loss of integrity and can result in
spontaneous skin damage despite preventative measures (SCALE 2009).
4. DUTIES AND RESPONSIBILITIES
All members of the multi-disciplinary team should be involved in the prevention and management of pressure ulcers.
As the majority of pressure ulcers are preventable and costly to treat, it requires a high level of awareness within the
multi-disciplinary team and each member is accountable for his or her own practice.
Chief Executive
As the accountable officer, the Chief Executive has a responsibility to ensure that there are robust systems in place
in relation to patient safety and pressure ulcer prevention and management. Responsibility with regard to the
systems and processes related to pressure ulcer prevention and management must be delegated to appropriate
Executive Director.
Director of Nursing
The Chief Nurse or Director of Nursing, provides Board Level representation, and is responsible for ensuring that
safe clinical systems are in place with regard to the prevention and management of pressure ulcers. This is
delegated to be overseen by the Pressure Ulcer Working Group and Patient Safety Group.
Midwifery & Nursing Group
Nursing & Midwifery Group is responsible for approval of this policy and associated guidelines for pressure ulcer
prevention and management
Pressure Ulcer Working Group
The Pressure Ulcer Working Group is responsible for strategic implementation of the pressure ulcer prevention and
management strategy
Senior Nurse
The Senior Nurse is responsible for developing, implementing and evaluation Clinical Service Centre Action Plan for
the prevention and management of pressure ulcers. The Senior Nurse, or their deputy, will also support the
activities of the Pressure Ulcer Working Group
Modern Matron
The Modern Matron is responsible for ensuring the implementation and audit of their Clinical Service Centre Action
Plan.
Ward Manager
The ward manager is responsible for implementation of this policy and associated guideline at ward level ensuring
that all staff have read and understood the contents. It is also the responsibility of each ward manager to ensure
that the correct information on the incidence of pressure ulcers is recorded on DATIX. The ward manager is also
responsible for ensuring that staff maintain their competencies for pressure ulcer prevention and management.
Registered Nurse
It is the responsibility of registered nurses to:
 Carry out a structured risk assessment within 4 hours of admission
 Inspect skin if patients identified at risk daily or more frequently if their condition deteriorates
 Implement, evaluate and document pressure ulcer prevention strategy for those patients identified at risk from
pressure damage
 Continue to daily risk assess patients during their hospital stay including skin inspection for those at risk
 Address nutritional needs
 Provide patient and/ carer education
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

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Report the incidence of pressure ulcers as a clinical incident on DATIX system a
Assess any existing pressure ulcers on admission and report on DATIX and re-assess weekly
Ensure all grade 3 and 4 pressure ulcers to be photographed
Ensure all patients with a pressure ulcer should have a wound care plan
Ensure all patients with diabetes or with diabetic foot ulcers are assessed and referred (Appendix Diabetes inpatient assessment proforma)
Tissue Viability Team
The Tissue Viability Team is responsible for planning, implementing and evaluating a strategic approach within the
Trust to reduce the occurrence of avoidable pressure damage through education and guidelines. The Tissue
Viability Team is also responsible for ensuring policies, practice guidance and advice is based on best available
evidence and to provide accessible and responsive service to wards and departments.
Tissue Viability Link Nurse:
The Tissue Viability Link will act as a resource with all health care professions in their area to increase the
awareness and dissemination of tissue viability information. They will also be available to ward staff in the clinical
area to give advice and support.
Health Care Support Workers
Under the supervision of a Registered Nurse, Health Care Support Workers are responsible for implementing the
pressure ulcer prevention and management plan, for example: repositioning of patients, reporting changes in skin
condition and obtaining relevant equipment.
Medical Staff
The Consultant has overall responsibility to plan and co-ordinate the patient’s medical treatments and are
responsible for maintaining the patient’s optimum, physiological condition especially hydration, nutrition and
infection. The Consultant should ensure referral to other healthcare professionals to utilize specialist knowledge in
assessing and treating patients. Medial staff should be aware of patients with pressure ulcers ensure that the
patients are receiving the optimum care
Dietician
Although the registered nurse is responsible for carrying out a nutritional screen using the MUST screening tool,
further advice may be need from the Dietician
Occupational Therapist
The occupational therapist will advise on the suitability and correct use of specialist pressure relieving devices, for
example cushions, seating and wheelchairs to reduce the risk of pressure ulcer development
Physiotherapist
The physiotherapist has a role in teaching patients and other professionals to move and reposition patients to
minimise trauma to the skin and promote recovery and early mobilization
Podiatry
Podiatrists have an active role in the care of diabetic foot ulcers, will review patients in the community and provide
devices to off load pressure from vulnerable areas of the feet. All patients with diabetic foot ulcers should be
referred to Podiatry on discharge
5. PROCESS
6.1a. Patient-centered care
Patients and their carers must be made aware of this policy and guideline and provided with an information leaflet.
They should be informed of the potential risks of developing pressure ulcers in hospital and participate in the
decision-making process when planning, implementing and evaluating their care (NICE 2005)
6.1b. Risk Assessment
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The aim of a risk assessment is to identify the presence of predisposing and precipitating factors that may influence
pressure ulcer development. An individual’s potential to develop pressure ulcers is influenced by the following
extrinsic and intrinsic factors and must be considered when undertaking a risk assessment (RCN 2005).
Extrinsic risk factors involved in tissue damage are pressure and/ or shear and can include other variables such
as friction and moisture. These risk factors should be removed/diminished by the utilization of appropriate
equipment and/or turning regimes planned according to individuals (NHS 2009).
Pressure that causes compression and possible capillary occlusion, can lead to tissue ischaemia. The intensity and
duration of pressure varies according to individuals’ tissue tolerance
Shearing occurs when the skeleton and deep fascia slide downwards with gravity and the upper fascia remain in the
original position. This can result in deep tissue necrosis and occurs when patients slide down or are dragged up a
bed/chair
Friction occurs when two surfaces move across each other and usually involves superficial layers of skin.
Mechanical forces and/or poor moving and handling techniques often cause this
Moisture such as urine, faeces or wound exudate alters the resiliency of the epidermis to external forces (Beldon et
al 2006). Moisture lesions should be differentiated from pressure ulcers. If a lesion is limited to one spot it is likely
to be a pressure ulcer, however diffuse superficial areas are likely to be moisture lesions (TVS 2008). To prevent
moisture damage, skin should be kept clean, dry and hydrated.
Intrinsic Factors include:
 Acute illness: this may be due to heart failure, vasomotor failure, vasoconstriction due to pain, low
blood pressure and temperature changes, i.e. during and after anaesthesia
 Chronic illness
 Unstable diabetes
 Level of consciousness: reduced awareness and /or ability of the need to move to relieve pressure a
prolonged pressure is a key factor in pressure ulcer development (NICE 2001)
 Reduced mobility/immobility is also a key factor in pressure ulcer development due to prolonged
pressure (NICE 2003)
 Medication: eg steroids mimic the ageing process by thinning the skin
 Sedatives/hypnotics: can cause excessive sleepiness thus reducing mobility
 Analgesics: can dampen the normal stimulus to move
 Inotropes: cause peripheral vasoconstriction and tissue hypoxia
 Non-steroidal anti-inflammatory (NSAID) such as ibuprofen impair inflammatory responses to pressure
injury
 Sensory impairment: neurological disease can reduce sensation, thus insensitivity to pain or
discomfort, this results in reduced or lack of stimulus to move to relieve pressure, i.e. patients with
diabetes or spinal injuries (Michael & Gillot 1991)
 Extremes of age: advancing age has increase risk of cardiovascular and neurological problems,
changes to elasticity and resilience of skin
 Neonates and very young children have an increased risk due to maturing skin; however sites and
nature of injury may differ. Neonates are morel likely to develop tissue damage in the occipital region
(back of head), ears and heels (Michael & Gillot 1991)
 Vascular disease: reduces total blood flow, impairs the micro-circulation thus increasing the potential
for pressure necrosis (NICE 2001)
 Malnutrition/dehydration: malnutrition can increase risk of multi-organ failure and serious illness.
Dehydration may reduce the elasticity of the tissues, thus increasing tissue deformability under
pressure or friction. Both obese and emaciated patients are vulnerable to malnutrition (Michael & Gillot
1991)
An initial assessment provides a baseline assessment that identifies individual’s level of risk as well as identifying
any existing pressure damage. For each episode of their care, all adult patients will undergo a structured risk
assessment including a skin assessment, which will be carried out within 4 hours of admission. The Braden Risk
Assessment Tool will be used as an aide memoire (Appendix 2) to identify each individual’s level of risk however it
does not replace clinical judgement (NICE 2005).
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On admission a patients who have existing pressure ulcers or must have a wound assessment completed indicating
the location and grade of the pressure ulcer, photograph taken and appropriate treatments implemented.
Reassessment of existing or hospital acquired pressure ulcer wounds must be carried out weekly (Guy 2012).
Structured risk assessments and ongoing reassessments is the responsibility of the Registered Nurse and will be
undertaken daily or if the individual’s condition changes. The outcome of the risk assessment will enable the
Registered Nurse to identify and adjust the strategies needed to prevent and manage pressure ulcers.
The outcome of each assessment must be clearly documented in the medical/nursing records if a patient is
identified as not at risk. Reassessment must occur if there is a change in the patient’s condition (NICE 2005. Those
patients identified, as “at risk” of pressure damage must have an immediate prevention plan initiated (NHS 2009).
Patients who have had previous pressure damage must be considered high risk regardless of their Waterlow or
Braden score and a prevention plan initiated to reduce the risk of a re-occurrence as scar tissue does not regain full
tensile strength, which may result in tissue damage occurring faster.
All structured risk assessments must be documented and made accessible to all members of the multi-disciplinary
team as accurate documentation provides a record of patient progress. A prevention plan should include details
indicating equipment to be supplied (mattress type, foot protectors etc) repositioning and seating regimes, patient
advice, etc.
6.1d Skin Inspection
The interpretation of signs and symptoms of a skin assessment forms the basis of pressure ulcer prevention and
treatment (RCN 2005). Patients identified at risk of developing pressure ulcers should undergo skin inspection on
admission and then daily. If the patient’s condition deteriorates, their skin should be inspected at least once during
each shift. If a patient’s condition is stable, they should be re-assessed every day throughout hospitalization and
inter-hospital transfers.
Anti-embolitic hosiery (eg TED stockings) should be removed daily so that heels can be inspected. Reddened areas
on an immobile patient can be observed when repositioning occurs. Patients with darker skin should be examined
closely as the presence of non-blanching erythema, which appears as a darker area of skin, perhaps with a bruised
appearance may otherwise be missed (NICE 2005).
Pressure ulcers can also develop under medical devices such as plaster casts, Bipap masks and foot pumps,
orthotic devices, and therefore the skin should be inspected when the devices are removed to ensure there is no
pressure damage. If a patient is admitted to a ward with a plaster cast, the Fracture Clinic should be contacted.
Results of skin inspections should be clearly documented. It is essential that detailed descriptions of any pressure
ulcer be recorded including site, size and grade and supported by photographic evidence if possible. Patients
admitted with existing pressure ulcers should have undergo a wound assessment on admission and subsequent
assessments should be carried out weekly.
A skin tolerance test can give an indication of the amount of time tissue can tolerate sustained pressure without
damage. Complete a skin tolerance test by:
 Pressing a finger lightly onto the area the patient has been turned from
 The skin should blanch (go white) and then return to its normal colour (blanching erythema).
 This colour return should take no longer than twice the length of the time the pressure was applied for (i.e. 1-2
seconds) indicating an intact micro-circulation (RCN 2005)
Signs that may indicate incipient pressure ulcer formation include:
 Blisters
 Discolouration
 Localized heat
 Localized oedema
 Localized induration (EPUAP 2009)
Pressure ulcers should be graded or categorized using the European Pressure Ulcer Advisory Panel (EPUAP 2009)
classification system. Patients who have existing pressure ulcers or who develop pressure ulcers during their
hospital stay must have a wound assessment completed indicating the location and grade of the pressure ulcer and
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appropriate treatments implemented. Reassessment of existing or hospital acquired pressure ulcer wounds must be
carried out weekly (RCN 2005).
6.1e Positioning and Repositioning
Positioning of patients should ensure that prolonged pressure on bony prominences is minimised, bony prominences
are kept from direct contact with one another, friction and shear damage is minimized (RCN 2005). Avoid
positioning individuals directly on pressure ulcers or bony prominences (commonly the sites of pressure ulcer
development)
When patients are nursed on a pressure redistributing/relieving device, repositioning should occur to ensure patient
comfort, skin inspection, hygiene needs etc. (NICE 2005). The frequency of repositioning of patients should be
based on the results of a skin inspection, patient comfort (6.1c) and individual needs; tissue damage can occur as
the intensity of pressure can vary with each individual repositioning reduces the duration of pressure and thus the
intensity (NICE 2005, RCN 2005, Bryant 2000).
A repositioning schedule should take into consideration other aspects of the patient’s condition, i.e. comfort,
support, overall plan of care. Individual needs should be identified and appropriate action taken to ensure that
regular change of position occurs (Beldon et al 2006). Patients may not tolerate frequent repositioning due to pain;
etc therefore further assessment may be required (NICE 2005). A written/recorded re-positioning schedule should
be established for every patient “at risk” and this should include actual position changes.
To encourage patient independence, reduce the risk of shear and friction forces, whenever possible patents should
be encouraged to redistribute their own weight (RCN 2005). Correct lifting and handling techniques reduce the risk
of injury to carers and staff so manual handling devices should always be used to minimize shear and friction
damage. All handling equipment should be removed after use as equipment left in situ may result in tissue damage
(NICE 2005).
6.1f Seating
Prolonged seating can cause pressure ulcers especially if patients are immobile or are unable to feel discomfort due
to injury or disease (TVS 2008). The physical effects of inappropriate sitting times should be considered. Lower
limb pooling and in adequate venous pooling contribute to:
Reduced renal perfusion
Reduced gut perfusion
Reduced cerebral perfusion
Development of oedema
Development of pressure ulcers
Chair sitting should be based on a skin assessment (see 4.1) and limited to no longer than 2 hours at any one time
for patients identified ‘at risk’. This will minimise pressure over bony prominences and avoid positioning over
existing pressure ulcers (NICE 2003). Immobile patients in a chair are at greater risk of developing pressure ulcers
than those patients who remain in bed (NHS 2009). Patients who are immobile or have reduced mobility should not
be left sitting in chairs for prolonged periods of time and restricted chair sitting should be incorporated in a repositioning regime (RCN 2005). Poor posture can result in an increased incidence of pressure ulcers therefore a
patient’s height, posture, weight etc should be taken into consideration before being sat in a chair (NHS 2009). The
use of either an alternating cushion or static cushion should be supplied to patients identified ‘at risk’ or higher and to
patients with pressure ulcers (TVS 2008). Attention must be paid to the implementation of pressure
relieving/reducing cushions as they may increase the height of the chair, which can be detrimental, as chairs too
high will not allow the feet to reach the floor. This will result in increased pressure being exerted through the thighs
and buttocks as seated patients take the majority of pressure through the buttocks and thighs (Gebhardt & Bliss
1994). If possible, patients must be encouraged to reposition themselves without causing shear and friction.
6.1g Nutrition
There is a clear link between poor nutrition and the development of pressure ulcers (Stephen-Haynes 2006) and
regular assessment of patient’s dietary intake enables timely interventions. All adult patients admitted to PHT
(excluding Maternity) are screened for their nutritional status and assessed regularly for adequate dietary intake
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using the MUST screening tool. Depending on the outcome of the MUST screen, a relevant management plan
should be implemented and evaluated weekly.
All patients should have their ability to eat and drink noted on nursing assessment. Patients who require assistance
in feeding or whose intake is suspect should be highlighted using a red tray. Nutritional support should be given to
patients with an identified nutritional deficiency Guy (2012). Snack boxes, mid morning and afternoon snacks are
available for patients who have missed meals etc and supplemental drinks are available at ward level for trained
staff to issue for those who are struggling to eat a whole meal. Nursing staff should develop First Line Action Plans
for those patients who score 2 above in the MUST screen. Those patients not improving on this score can be
referred to a dietician. All patients who are at are at risk of pressure ulcers should be referred to the Dietician if
nutritionally compromised (NHS 2009).
6.1h Pressure Relieving Devices
As a first line of defense against pressure ulcer damage, high quality, pressure reducing mattresses are used in
combination with electric profiling beds. The provision of pressure relieving devices requires a 24 hour approach
and this applies to all support surfaces (NICE 2003). Patients identified “not at risk” or “at risk” are suitable to be
placed on a foam pressure redistributing mattresses. The use of pressure relieving mattresses should reflect the
patients ‘risk’ status (appendix for list of equipment available).
All patients with pressure ulcers should have access to appropriate pressure relieving support surfaces and
strategies e.g. mattresses, cushions and repositioning 24 hours a day. Patients with either grade 1 or 2 pressure
ulcers can be nursed on a high specification foam mattress (NICE 2005) and an electric profiling bed. As a
minimum, all patients with grade 3 or 4 pressure ulcers will be placed on an alternating pressure relieving mattress
(RCN 2005).
Where ever possible, preventative measures must be implemented i.e. surgical patients. A patient’s risk increases
during and immediately after surgery therefore equipment must be upgraded following prolonged surgery while the
patient is immobilized. Patients with complex needs, including Bariatric patients, may require specialised equipment
should be referred to the Tissue Viability Team For specialist advice.
The request for equipment should be registered with the Medical Equipment Library and documented in the nursing
notes. Whenever equipment is not available or there is a delay in obtaining the requested equipment, reasons for
the delay and preventative measures taken should be summarized in the nursing notes and escalated to the Bleep
Holder. This action will identify difficulties in accessing equipment resources and also ensure preventative
measures have been taken to reduce patient’s risk (Beldon et al 2006).
A repositioning regime using the 30-degree tilt combined with regular skin inspection must be undertaken. To
ensure the stock of pressure relieving mattresses are utilized effectively and efficiently, patients should be
reassessed so that equipment can be downgraded if the patient’s condition improves. To make certain that the
patient is nursed safely and receives the optimum pressure relief from equipment used, equipment must be kept in
full working order at all times.
6.1i Prevention of heel pressure ulcers
The second most common site for pressure ulcers are the heels. Patients with Diabetes are especially vulnerable.
All patients with Diabetes must therefore undergo daily foot inspection regardless of their mobility. Some patients
may not be able to lift their heels easily to have them inspected. It is recommended that a hand held mirror is used
to inspect the heels.
When patients with Diabetes are nursed in bed, Repose boots or pillows placed length ways to alleviate pressure
under heels must be used. The knee break on the electric profiling should also be used to alleviate pressure under
heels.
It may not be possible to inspect patients with bandages to legs and/feet on a daily basis so appropriate medical
devices designed to off-load pressure, for example Repose boots, to prevent heel damage should be used. When
bandages are changed, the feet should be closely inspected to ensure there is no pressure damage.
Anti-embolytic stockings should be removed daily and feet inspected to ensure no pressure damage has occurred.
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6.1j Classification of pressure ulcers and Reporting
All pressure damage, Grade 1, 2, 3 and 4 pressure ulcers must be reported as a clinical incident. .All pressure
ulcers will be categorized or graded using the EPUAP Classification System (see 4). When pressure ulcers are
healing they should not be reverse graded, for example: a grade 4 pressure ulcer does not become a grade 3 as it
heals. As ulcers heal, they should be described as healing as the original tissue cannot be replaced (NICE 2005).
Patients admitted with pressure ulcers: All pressure ulcers present on admission will be assessed and
documented within 4 hours and reported as a clinical incident on DATIX system. A photograph of each grade 3 or 4
pressure ulcer must be taken either by the admitting area, Medical Photography or Tissue Viability Nurse. Patients
with category or grade 3 and 4 will be reported to Safeguarding Team and referred to the Tissue Viability Team.
Hospital acquired pressure damage: All nurses are responsible for reporting if a patient develops pressure ulcers
during their hospital stay. A wound assessment will be carried out and plan of care documented. A photograph of
each grade 3 or 4 pressure ulcer must be taken either by the admitting area, Medical Photography or Tissue Viability
Nurse. A Serious Incident Requiring Investigation (SIRI) will be undertaken if a patient develops a grade 3 or 4
pressure ulcer. The patient will also be referred to the Safeguarding Team and Tissue Viability Team.
Deteriorating pressure ulcers: must be reported on DATIX system. A wound assessment must be carried out
and plan of care documented. A Serious Incident Requiring Investigation (SIRI) will be undertaken if the pressure
ulcer deteriorates to a grade 3 or 4. A photograph of each grade 3 or 4 pressure ulcer must be taken either by the
ward, Medical Photography or Tissue Viability. The patient will also be referred to the Safeguarding Team and
Tissue Viability Team and a photograph taken.
6.1k Patient and Carer Education
To raise awareness of causes of pressure ulcers and inform patients, their families and/carers on prevention
strategies and what they can do to help reduce the risk of pressure damage4 and should be provided with a
“Pressure Sore Prevention” leaflet on admission. Wherever possible, patients should be encouraged, following
education, to inspect their own skin.
There are occasions when individuals may refuse pressure ulcer prevention interventions. This should be clearly
documented in the medical/nursing notes and the risks explained of non concordance however it may be possible to
adapt the strategies to suit the individual. The individual should be referred to the Tissue Viability Team. Patients
should also be provided with the Pressure Ulcer Prevention Advisory leaflet.
A patient exercise leaflet is available for patients. This exercise leaflet is not suitable for all patients and should only
be given to patients at the discretion of the ward staff.
6.1l Preparation for discharge of patients at risk of pressure damage or with existing pressure
damage
If patients are discharged and still require pressure relieving/reducing equipment at home, a request must be made
via the District Nurses at least one week prior to discharge to ensure continuity of care and ensure equipment is
available and in situ prior to discharge
6.1m Training
All Registered Nurses and Health Care Support Workers undertaking patient assessment must have received
appropriate training in the management and prevention of pressure ulcers and also be aware of the limitations of risk
assessments tools, and be able to use their professional judgment.
All Registered Nurses and Health Care Support Workers should receive appropriate training and keep updated
(NHS QIS 2009) and work through competency levels 1-4 as appropriate. To accurately assess the extent of tissue
damage, nursing staff must have a sound knowledge in the grading of pressure ulcers and recognize the differences
between pressure damage and moisture lesions.
To raise awareness and improve clinical practice in all areas, all Registered Nurses and Health Care Support
Workers trained in the prevention and management of pressure ulcers should cascade their knowledge and skills in
their clinical areas
Pressure Ulcer Prevention and Management Policy and Associated Guideline for Adults:
Version 4 Issue Date: 11/09/2013
(Review date June2015 (unless requirements change)
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6. TRAINING REQUIREMENTS
All staff completing risk assessments should have received appropriate training either through the Trust in-house
courses facilitated by the Tissue Viability Team or through a suitable tissue viability course specific to pressure ulcer
prevention and management.
After initial training, competency needs to be maintained by attending refresher up-dates at least every 3 years
7. REFERENCES AND ASSOCIATED DOCUMENTATION
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
BENNETT G, DEALEY C, POSNETT J (2004) The cost of pressure ulcers in the UK Age ageing 33: 230-5
BRYANT R (2000) Acute and Chronic Wounds Nursing Management 2nd Edition Moseby, London
BELDON P, COOPER P, WILSON M (2006), Pressure Ulcers Wound Care Essentials Vol 1 pp67-81
DEALEY C, POSSNETT J & WALKER A (2012) Cost of Pressure Ulcers in the United Kingdom Journal of Wound
Care Vol 21 No 6 pp261-266
DEFLOOR T, SCHOONHOVEN L, FLETCHER J, et al (2005) Statement of the European Pressure Ulcer Advisory
Panel — Pressure Ulcer Classification Differentiation Between Pressure Ulcers and Moisture Lesions. J Wound
Ostomy Continence Nursing 32(5): 302–06
DEPARTEMENT OF HEALTH (2010)
EUROPEAN PRESSURE ULCER ADVISORY PANEL ((EPUAP) 2009) Pressure Ulcer Prevention: Quick
Reference Guide http://www.epuap.org
EXPERT PANEL (2009) Skin Changes At Life’s End (SCALE): Final Consensus Document
FOX C (2002), Living with a pressure ulcer: a descriptive study of patients’ experiences, British Journal of
Community Nursing 7(6; Supplement) S10-S22
GEBHARDT K & BLISS M (1994) Preventing Pressure Sores in Orthopaedic Patients: Is Prolonged Chair Nursing
Detrimental? Journal of Tissue Viability Vol 4 No 2 pp51-54
GUY H (2012) The difference between moisture lesions and pressure ulcers Wound Care Essentials Vol 1 pp3644
MICHAEL C & GILLOT H (1991) Macrovascular mechanisms in stasis and ischaemia In Pressure Sores, Clinical
and Scientific Approach Bader DL Macmillan London
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2005) Pressure Ulcers: The Management of Pressure
Ulcers in Primary and Secondary Care: A Clinical Guideline CG029 NICE London
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (NICE (2003)) Pressure Ulcer Prevention Clinical
Guidelines 7 NICE London
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2001) Pressure ulcer risk assessment and prevention
NICE
NHS INNOVATION And IMPROVEMENT (2009) High Impact Actions – Your Skin Matters
NHS SOUTH OF ENGLAND (2012) The South of England Quality Improvement Framework for the Prevention and
Management of Pressure Ulcers
NHS QIS (2009) Best Practice Statement: Pressure Ulcer Prevention NHS Quality Improvement Scotland
Edinburgh
NIX D , HAUGEN V (2010) Prevention and management of incontinence-associated dermatitis Drugs Aging 27 (6):
491-96
NURSING & MIDWIFERY COUNCIL (2009) Record Keeping Guidance for Nurses & Midwives NMC London
ROYAL COLLEGE OF NURSING & NATIONAL INSTITUTE for HEALTH & CLINICAL EXCELLENCE 2005 The
Management of Pressure Ulcers in Primary & Secondary Care London NICE
STEPHEN-HAYNES J (2006) Implementing the NICE pressure ulcer guidelines, British Journal of Community
Nursing in association with Wound Care Society: Wound Care September, S16 - S18
TISSUE VIABILITY SOCIETY (2008) Seating and Pressure Ulcers: Clinical Practice Guideline
http://www.tvs.org.uk
An Organisation-Wide Policy for the Development and Management of Procedural Documents:
NHSLA, May 2007. www.nhsla.com/Publications/
8. EQUALITY IMPACT STATEMENT
Pressure Ulcer Prevention and Management Policy and Associated Guideline for Adults:
Version 4 Issue Date: 11/09/2013
(Review date June2015 (unless requirements change)
13
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
All policies must include this standard equality impact statement. However, when sending for
ratification and publication, this must be accompanied by the full equality screening assessment
tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy
Documentation
Pressure Ulcer Prevention and Management Policy and Associated Guideline for Adults:
Version 4 Issue Date: 11/09/2013
(Review date June2015 (unless requirements change)
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Appendix 1
Moisture Lesions*
Pressure Ulcer
Incontinence Associated Dermatitis (IAD)
Cause
Pressure and/or shear must
be present
Moisture must be present (for example, look for shining, wet skin,
caused by urinary incontinence or diarrhoea)
Location
A wound over a bony
prominence is likely to be a
pressure ulcer
Equipment related – under a
device/tube
Skin fold (combination)
IAD may occur over a bony prominence. However, pressure and shear
should be excluded as causes, and moisture should be present
Perineum, buttocks, inner thighs, groins
Skin folds
Shape
If the lesion is limited to one
spot, it is likely to be a
pressure ulcer
Circular wound
Regular shape
Diffuse, different superficial spots are more likely to be IAD
Kissing ulcer
Anal cleft - linear
Depth
Partial thickness and full
thickness skin loss
Superficial (partial thickness skin loss)
Necrosis
A black necrotic scab on a
bony prominence is a
pressure ulcer grade 3 or 4.
If there is no limited muscular
mass underlying the
necrosis, the lesion is a
pressure ulcer grade 4
No necrosis
Edges
Distinct edges
Diffuse or irregular edges
Colour
If redness in non blanchable,
this is most likely a pressure
ulcer grade 1
Blanchable or non blanchable erythema
Pink or white surrounding skin due to maceration
*Adapted from Defloor et al (2005), Nix & Haugen (2010)
Pressure Ulcer Prevention and Management Policy and Associated Guideline for Adults:
(Review date June2015 (unless requirements change)
Version 4 Issue Date: 11/09/2013
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Appendix 2
Braden Risk Assessment Chart
Undertake and document risk assessment within 4 hours of admission and then daily.
Individuals with a total score of 15-18 are at risk score of 13-14 are at moderate risk score of 10-12 are at high risk score of 9 or below are at very high risk.
Patient’s name: ……………………………………………….
Sensory
Perception –
Ability to respond
meaningfully to
pressure related
discomfort
1. Completely Limited
Unresponsive (does not
moan, flinch or grasp) to
painful stimuli, due to
diminished level of
consciousness or
sedation or limited ability
to feel pain over most of
the body surface.
Moisture –
Degree to which
skin is exposed to
moisture
1. Constantly Moist
Skin is kept moist almost
constantly by perspiration,
urine etc. Dampness is
detected every time
patient / client is moved or
turned.
1. Bedfast
Confined to bed.
Activity –
Degree of
physical activity
Mobility –
Ability to change
and control body
position
1. Completely Immobile
Does not make even
slight changes in body or
extremity position without
assistance.
Nutrition –
MUST score
Friction and
Shear
1. Very High
MUST score >2
1. Problem
Requires moderate to
maximum assistance in
moving.
DOB:……………..
Hospital No…………………….
Date
2. Very Limited
Responds only to painful
stimuli. Cannot
communicate discomfort
except by moaning or
restlessness. OR has a
sensory impairment that
limits the ability to feel pain
or discomfort over half of
body.
2. Very Moist
Skin is often, but
not always, moist.
Linen must be
changed at least
once a shift.
3. Slightly Limited
Responds to verbal
commands, but cannot
always communicate
discomfort or need to be
turned. OR has some
sensory impairment that limits
ability to feel pain or
discomfort in 1 or 2
extremities.
3. Occasionally Moist
Skin is occasionally moist,
requiring an extra linen
change approximately once a
day.
4. No Impairment
Responds to verbal commands.
Has no sensory deficit that
would limit ability to feel or voice
pain or discomfort.
Score 1,2 or 3
Ensure repositioning regime in use
and chart. Use pressure relieving
mattress, Repose Boots, glide
sheets, skin assessments when
turned, remove stockings inspect
heels daily.
4. Rarely Moist
Skin is usually dry. Linen only
requires changing at routine
intervals.
Score 1 or 2
Use a soap substitute for washing,
pat dry, apply barrier cream/ film,
offer regular toileting, use continence
aids, and consider flexi seal for liquid
diarrhoea.
2. Chairfast
Ability to walk severely
limited or non-existent.
Cannot bear own weight
and / or must be assisted
into chair or wheelchair.
2. Very Limited
Makes occasional slight
changes in body or
extremity position but
unable to make frequent or
significant changes
independently.
2. High
MUST score =2
2. Potential Problem
Moves feebly or requires
minimum assistance during
a move, skin probably
slides to some extent
against sheets, chair
restraints, or other devices.
Maintains relatively good
position in chair or bed
most of the time but
occasionally slides down.
3. Walks Occasionally
Walks occasionally during
day, but for very short
distances, with or without
assistance. Spends majority
of each shift in bed or chair.
3. Slightly Limited
Makes frequent though slight
changes in body or extremity
position independently.
4. Walks Frequently
Walks outside the room at least
twice a day and inside the room
every two hours during waking
hours.
Score 1 or2
Ensure patient changes position
regularly, use individualised
repositioning chart ie 2 hr. turns.
Pressure relieving mattress, glide
sheets, Repose boots
Score 2 or 3
Limit sitting to 1 to 2 hours use
dynamic chair cushion
3. Medium
MUST score =1
3. No Apparent Problem
Moves in bed and in chair
independently and has
sufficient muscle strength to
lift up completely during
move. Maintains good
position in bed or chair at all
times.
4. Low
MUST score =0
4. No Limitations
Makes major and frequent
changes in position without
assistance.
Score 1,2 or 3
Follow MUST action plan
Score 1 or 2
Use profile bed frame, use knee
brace to reduce sliding or raise foot
of bed 10’ , teach patient to adjust
bed, use glide sheets to reposition,
reduce sitting time if patient slumps
in chair, refer to physiotherapist.
Total score
Signature
Pressure Ulcer Prevention and Management Policy and Associated Guideline for Adults:
(Review date June2015 (unless requirements change)
Version 4 Issue Date: 11/09/2013
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Appendix 3
Pressure Ulcer Prevention Guidance on Pressure Relieving Equipment
Allocation of Pressure Relieving Equipment



Implement and document pressure ulcer
prevention strategy
Undertake daily risk assessment or more
frequently if change in condition
Use Clinical Judgement
At High to Very High Risk
At Moderate Risk- High Risk
At Risk – Moderate
Risk
Pressure Reducing
Foam Mattress
 Fully mobile
 No pressure damage
 Patients with unstable
spinal or pelvic injuries
Author: Tissue Viability Team
April 2013





Pressure Reducing Foam Mattress
+/-Repose Mattress*
Reduced mobility
Underweight
Diabetic /+ vascular disease
Grade 1 or 2 pressure ulcer
(superficial skin loss)
Patients with previous pressure
damage
Seating: 2 hours per session
Consider using pressure relieving
cushion
Repositioning: 2 hourly
*Do not use: if patient weight above
19 stone or if patient has plaster
cast, external fixator metal work or
metal frame in bed
Pressure Ulcer Prevention and Management Policy and Associated Guideline for Adults:
(Review date June2015 (unless requirements change)






Pressure Relieving Mattress
Patients with:
Existing grade 3 & 4 pressure ulcers
Who have had long lie following fall
At risk that weigh 130Kg or more or
who are too wide for Repose
Immobile patients due to illness or
paralysis
Multiple underlying health problems
Being nursed at home on an air
mattress
Seating with pressure ulcer: seek
Tissue Viability Advice
Seating: with no pressure damage: up
to 2 hours
Use pressure relieving cushions
Repositioning: 2 hourly or more
frequently depending on individual
patient need
Version 4 Issue Date: 11/09/2013
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9. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement
to be monitored
Lead
Tool
Action Plan
All relevant Clinical
Service Centres will
develop and implement
Action Plans
Senior Nurse
Audit of nursing
documentation
Modern
Matron/Ward
Manager
Patient Records
All grade 2, 3 and 4
pressure ulcers are
reported as clinical
incident
Ward Manger
DATIX
Frequency of
Report of
Compliance
Quarterly
Reporting arrangements
Policy audit report to:

Weekly
Monthly
Pressure Ulcer Prevention and Management Policy and Associated Guideline for Adults:
(Review date June2015 (unless requirements change)
Modern Matrons
Pressure Ulcer Working Group
Policy audit report to:

Senior Nurses
Pressure Ulcer Working Group
Policy audit report to:

Lead(s) for acting on
Recommendations
Risk Department
Pressure ulcer Working Group
Version 4 Issue Date: 11/09/2013
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