Scope

  • Policy Statement

  • The Policy

  • Grading of Pressure Ulcers
  • Unstageable: Depth Unknown
  • Suspected Deep Tissue Injury: Depth Unknown
  • Moisture Lesion: Not a Pressure Ulcer
  • Pressure Ulcer Risk Assessment
  • Predisposing Factors to Pressure Ulcer Formation
  • Prevention of Pressure Ulcers
  • Treatment of Pressure Ulcers
  • Evaluation/Audit
  • Investigations
  • Regulation 20: Duty of Candour

  • Related Policies

  • Related Guidance

  • Training Statement

Policy Statement

Service users generally are becoming frailer, yet being looked after at home. Multi-agency working is becoming more and more part of day-to-day working. The management of pressure ulcers should be viewed as a multi-agency approach where early intervention is paramount for the health and wellbeing of our service users. A pressure ulcer prevention care plan will be developed from the pressure ulcer assessment process where indicated

The Policy

A pressure ulcer is localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to medical or other devices), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful. A pressure ulcer that has developed due to the presence of a medical device should be referred to as a ‘medical device-related pressure ulcer’.
Pressure ulcers at end of life should be classified in the same way as all pressure ulcers, and not be given a separate category.
As an organisation, we work closely with health professionals and our service users to prevent the development of pressure ulcers.

Pressure ulcers are graded according to their severity and have been classified by NHS as follows.

Grading of Pressure Ulcers

Category/Stage I: Non-blanchable Erythema

A grade one pressure ulcer is the most superficial type of ulcer. The affected area of skin appears discoloured: it is red in white people and purple or blue in people with darker-coloured skin. Grade one pressure ulcers do not turn white when pressure is placed on them. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at-risk individuals (a heralding sign of risk)

Category/Stage II: Partial Thickness Skin Loss

Some of the outer surfaces of the skin (the epidermis) or the deeper layer of skin (the dermis) are damaged, leading to skin loss. The ulcer presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury), or a serum-filled blister. Category/Stage II should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Category /Stage III: Full Thickness Skin Loss

In Category/Stage III pressure ulcers, skin loss occurs throughout the entire thickness of the skin. The underlying tissue is also damaged, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling.

Category/Stage IV: Full Thickness Tissue Loss

Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunnelling.

The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The underlying muscles or bone may also be damaged.
People with Category/Stage IV pressure ulcer have a high risk of developing a life-threatening infection.

Unstageable: Depth Unknown

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore category/stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body’s natural (biological) cover and should not be removed.

Suspected Deep Tissue Injury: Depth Unknown

Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Moisture Lesion: Not a Pressure Ulcer

Redness or partial thickness skin loss involving the epidermis, upper dermis, or both. Caused by excessive moisture to the skin from urine, faeces or sweat, this is not a pressure ulcer and must not be confused with a Category/Stage II pressure ulcer, which is caused by pressure not moisture

Pressure Ulcer Risk Assessment

Many service users will be somewhat at risk of developing pressure ulcers, especially those unable to get out of bed, those with little mobilisation, or those in wheelchairs. Therefore, it is inevitable that the use of a recognised assessment tool is incorporated into the initial and subsequent care planning process. If a service user has a pressure ulcer when our service commences record of its size and position is made (a photograph is taken if appropriate) and the health professional informed.

The initial calculation and score should be ascertained, if possible, either before the commencement of the service or within eight hours; this reading to be comprehensive and thorough.

Sphere Specialist Healthcare use the Waterlow assessment tool. The assessment tool is not a substitute for sound clinical judgement; it is an adjunct and a means of helping to identify those service users at risk and informing the district nurse as soon as possible.

Predisposing Factors to Pressure Ulcer Formation

The following may be contributory factors to pressure ulcer formation:

  • Undue or prolonged pressure.
  • Friction.
  • Shearing forces, e.g. ill-fitting shoes.
  • Repeated forces
  • Incontinence.
  • Poor nourishment or dehydration.
  • Chronic illness, e.g. vascular disease and diabetes.
  • Simple moving and/or washing.
  • Rubbing together of skin surfaces.
  • Immobility/reduced mobility.
  • Impaired circulation, e.g. related to smoking or blood disorders (i.e. anaemia).
  • Shock.
  • Age.
  • Decreased consciousness/mental awareness.
  • Reduced sensation, e.g. multiple sclerosis.
  • Medications, e.g. steroids, sedatives.
  • Pain.

Prevention of Pressure Ulcers

As an organisation, we are committed to supporting the React to Red Skin campaign. This means that we are committed to:

  • Training all of our staff in the basic principles of pressure ulcer prevention.
  • Making pressure ulcer prevention part of our induction programme.
  • Monitoring the risks for our service users daily and any necessary action is taken to prevent pressure ulcers from occurring.
  • Referring to a registered nurse when we are concerned about a person who we are caring for.
  • Ensuring that we talk to service users about pressure ulcer prevention and how they can help themselves.
  • Talking to family members about any concerns around the skin of the person we are caring for.
  • Distribute information leaflets about pressure ulcer prevention to our service users and their families.
  • Daily monitoring incidents of pressure ulcers or days free from pressure ulcers.
  • Ensuring all our service users have appropriate care plans in place that take into account pressure ulcer prevention.
  • Timely access to specialist pressure relieving equipment where it is required.
  • Investigating the causes of any pressure ulcers that our service users/services users acquire and taking appropriate action to change future behaviours and procedures.
  • Reporting all pressure ulcers of Category/Stage II and above that are acquired in our service users.

By working with families, friends and other parts of the health service, we believe that we can play a positive and healthy part in the prevention of pressure ulcers, not only for those people we are caring for but also for our community at large.

Skin and Tissue Assessment

With the consent of the individual

  • In individuals at risk of pressure ulcers, conduct a comprehensive skin assessment as part of the assessment of needs.
  • Include skin assessment as part of every risk assessment.
  • Increase the frequency of skin assessments in response to any deterioration in overall condition.
  • Conduct a head-to-toe assessment with a particular focus on the skin overlying bony prominences, including the sacrum, ischial tuberosities (sitting bones), greater trochanters (hip) and heels.
  • Ongoing assessment of the skin is necessary to detect early signs of pressure damage, especially over bony prominences.
  • Each time the service user is repositioned is an opportunity to conduct a brief skin assessment.
  • Inspect the skin for erythema in individuals identified as being at risk of pressure ulceration.
  • Differentiate whether the skin redness is blanchable or non-blanchable.
  • Avoid positioning the individual on an area of erythema wherever possible.
  • Document the findings of all comprehensive skin assessments.
  • Ensure ongoing assessment with a final assessment before ending the service or transfer.
  • Include the following factors in every skin assessment: skin temperature, oedema, and change in tissue consistency concerning surrounding tissue.
  • Assess localised pain as part of every skin assessment.
  • Inspect the skin under and around medical devices at least twice a day, more when generalised or localised oedema is present.
  • Daily or at each visit foot observations/assessments of all diabetic residents is essential and referrals to podiatrist or district nurse if a potential or actual ulcer occurs.

When conducting a skin assessment in an individual with darkly pigmented skin prioritise assessment of:

  • Skin temperature.
  • Oedema.
  • Change in tissue consistency concerning surrounding tissue.

As it is not always possible to identify erythema on darkly-pigmented skin, localised heat, oedema and change in tissue consistency concerning surrounding tissue (e.g., induration/hardness) are important indicators of early pressure damage to the skin in individuals of darker skin tone.
As discussed previously, record skin inspection and documentation using a recognised scoring system. Record the presence of or potential for a pressure ulcer in the care plan and report to the manager/district nurse/tissue viability nurse.

The district nurse/tissue viability nurse will advise how the following will be carried out concerning individual service users

Diet

Nutrition is an essential factor in the prevention and treatment of pressure ulcers. The following aspects will need consideration:

  • A good fluid intake, unless otherwise indicated.
  • Sufficient calories to meet energy requirements, increased when wounds present.
  • Sufficient protein intake; additional vitamins and extra fibre can also be useful.
  • Food supplements/fortification of food should be used for service users whose appetite is poor. Consultation with the GP and family may be useful in this instance.
  • Development of an individualised nutrition care plan with/or at risk of a pressure ulcer plan, with an appropriate health professional.

Nutritional Screening

Nutritional screening is carried out during the initial assessment and at any time there is a concern in their physical or mental wellbeing, to identify those at risk of malnutrition and to identify obesity; it is undertaken by a staff member trained to understand the process, and who liaises closely with other healthcare professionals such as dieticians, speech and language therapists, or the healthy living nurse.
The early identification and treatment of individuals who are malnourished or at a risk of malnutrition is vital to prevent pressure ulcer development and promote wound healing when pressure ulcers occur.

Nutrition assessment and screening is an integral part of pressure ulcer risk assessment and screening.
An assessment for signs of dehydration is included and any concerns will lead to fluid balance being monitored
Also visibly assess the service users clothing, jewellery, dentures etc, in consideration of recent weight loss.
In the screening it is also important to assess an individual’s ability to eat and drink independently and to assess the likelihood of poor nutrition because of any of the following:

  • The individual is on a restricted or modified diet and/or fluids.
  • Have ascites or oedema making bodyweight difficult to measure accurately.
  • Obese (body mass index is >30).

The five-step Malnutrition Universal Screening Tool (MUST) is used.
Service users and family are given access to nutrition and hydration information leaflets as required.

Movement

Movement is the body’s natural defence against pressure. Develop a schedule for progressive sitting according to the individual’s tolerance and pressure ulcer response.

Repositioning may be required more frequently depending on the condition of the service user. This applies to all service users who spend much of their time in bed or in their chair unable to move. Establish pressure relief schedules that prescribe the frequency and duration of weight shifts. When possible, teach service users to do pressure relief lifts or other pressure-relieving manoeuvres as appropriate.

Reposition the individual in such a way that:

  • Pressure is relieved or redistribute and avoid positioning the individual on bony prominences with existing non-blanchable erythema.
  • Always avoid subjecting the skin to pressure and shear forces.
  • Use manual handling aids to reduce friction and shear.
  • Lift – do no drag – the individual when repositioning.
  • Do not leave moving and handling equipment under the individual after use, unless the equipment is specifically designed for this purpose.
  • Avoid positioning the individual directly onto medical devices, such as tubes, drainage systems or other foreign objects.
  • Do not leave the individual on a bedpan longer than necessary.

The repositioning frequency will be determined with consideration to the individuals:

  • Tissue tolerance.
  • Level of activity and mobility.
  • General medical condition.
  • Overall treatment objectives.
  • Skin condition.
  • Comfort.

Care of the Skin

Skin integrity should be maintained where possible. The skin only needs careful washing as necessary. Frequent washing will remove the skin’s natural oils, which form a barrier to infection. A mild soap can be used to minimise the change of pH in the skin. The skin must be dried by patting.
Only specific, prescribed emollients and creams may be used. These should only be used where necessary, and sparingly, as they can interfere with the effectiveness of incontinence products.
All creams and emollients must be documented on the service user’s MAR.

Continence Planning

Moisture-associated skin damage (MASD) should be counted and reported in addition to pressure ulcers where required. Where skin damage is caused by a combination of MASD and pressure, it should be reported based on the category of pressure damage

A thorough assessment must be undertaken by qualified professionals for any incontinent individual; this is to ensure that a comprehensive programme is formulated for keeping moisture associated skin damage or pressure ulcer formation to a minimum, maintaining skin integrity.

  • Complete a full continence assessment.
  • Ensure the individual is toileted regularly.
  • Reassess continence status.
  • Ensure pads and pants are worn and fit correctly.
  • Consider if pads need to be changed more often.
  • Cleanse the moist area of skin with water only and clean cloths.
  • Do not use soap but clean with an appropriate cleanser or emollient.
  • Apply no sting barrier films & durable barrier creams.

Establish the cause of faecalis incontinence:

  • Consider infection and stool sample.
  • Cleanse the soiled area with an appropriate cleanser or emollient and clean cloths.
  • Apply no sting barrier films and durable barrier creams.

To contact District Nurses in Northumberland is via the service user’s GP

Aids/Support

These are chosen on an individual basis depending on the needs of the individual for pressure redistribution and other therapeutic functions. These will be identified by the district nurse or occupational therapist (OT). In all cases, the manufacturer’s recommendations for the use and maintenance should be followed. Pressure relief aids should:

  • Provide a surface that conforms to body weight.
  • Reduce frictional ulcers.

Treatment of Pressure Ulcers

Dressings

These dressings include:

  • Alginate dressings: these are made from seaweed and contain sodium and calcium, which are known to speed up the healing process.
  • Hydrocolloid dressings: contain a special gel that encourages the growth of new skin cells in the ulcer, while keeping the surrounding healthy skin dry.
  • Other dressing types, such as foams, films, hydrofibres/gelling fibres, gels and antimicrobial (antibiotic) dressings may also be used.

Gauze dressings are not recommended for either the prevention or treatment of pressure ulcers.

Creams and Ointments

Topical antiseptic or antimicrobial (antibiotic) creams and ointments are not usually recommended for treating pressure ulcers but barrier creams may be needed to protect skin that’s been damaged or irritated by incontinence. Follow medication plan for creams

Treatment: Antibiotics

Antibiotics may be prescribed to treat an infected ulcer or if there is a serious infection, such as:

  • Blood poisoning (sepsis).
  • Bacterial infection of tissues under the skin (cellulitis).
  • Infection of the bone (osteomyelitis).

Evaluation/Audit

This must be according to criteria identified within the Care Plan and incorporating the same assessment tool used in the initial assessment. The tissue viability nurse/district nurse/and GP should be involved as required.

Systems and procedures are in place:

  • To monitor those who are at risk of developing pressure ulcers.
  • To work with health professionals to promote, the prevention of or treating of pressure ulcers.
  • To compile individualised care/support plans, incorporating the rationale to prevent the formation of pressure ulcers.
  • To encourage the service users’ co-operation in the objectives of prevention.
  • To make available current information on pressure ulcers for service users in an accessible format.
  • To encourage healing where a pressure ulcer is established.
  • To monitor the healing process using clinical judgement by a health professional, supported by pressure ulcer assessment tools and digital photography.
  • To monitor all aspects of the preventative measures taken.
  • To assess and monitor levels of pain.
  • To manage and reduce pain.
  • To monitor the incidence of pressure ulcers.
  • To continually reassess/review service users deemed at risk or if the ulcer is not healing.

Investigations

The Department of Health and Social Care’s definition of avoidable/unavoidable should no longer be used (NHS Improvement 2018 Publication code: CG 73/18). Ceasing these terms will lead to all incidents being investigated by the organisation to support organisational learning and actions being taken

Regulation 20 Duty of Candour

When a pressure ulcer, Category/Scale III or above develops, after the person has started to use the service, a notification must be sent to CQC, as required under Regulation 20: Duty of Candour

Related Policies

Diabetes
Duty of Candour
Infection Control
Moving and Handling
Nutrition, Hydration and Food Safety
Notifications

Related Guidance

Safeguarding Adults Protocol Pressure Ulcers and the Interface with a Safeguarding Enquiry issued by Department of Health and Social Care:
https://www.gov.uk/government/publications/pressure-ulcers-safeguarding-adults-protocol
Pressure Ulcers: Prevention and Management, Clinical Guideline CG179:
https://www.nice.org.uk/guidance/cg179
NICE Quality Standard [QS89] Pressure Ulcers:
https://www.nice.org.uk/guidance/qs89
NICE Quality Standard [QS24] Nutritional Support in Adults:
https://www.nice.org.uk/guidance/QS24
Waterlow:
http://www.judy-waterlow.co.uk/pressure-sore-symptoms.htm
NHS Improvement: Pressure Ulcers: Revised Definition and Measurement: https://improvement.nhs.uk/documents/2932/NSTPP_summary__recommendations_2.pdf
International Guidelines Prevention and Treatment of Pressure Ulcers: Quick Reference Guide:
http://internationalguideline.com/guideline
React to Red Skin
www.reacttoredskin.co.uk
ASSKING:
https://oska.uk.com/journal/nhs-improvement-guidelines-update-to-the-sskin-model-called-assking

Training Statement

All staff, during induction, are made aware of the organisation’s policies and procedures, all of which are used for training updates. All policies and procedures are reviewed and amended where necessary, and staff are made aware of any changes. Observations are undertaken to check skills and competencies. Various methods of training are used, including one to one, online, workbook, group meetings, and individual supervisions. External courses are sourced as required.

Date Reviewed: May 2021
Person responsible for updating this policy: Carly Fortune
Next Review Date: May 2022