RM72 Pressure Ulcer Prevention and Management Policy – Version 3 1
Policy Title
Pressure Ulcer Prevention and Management Policy
Policy Number
RM72
Version Number
3.1
Ratified By
Nursing and Midwifery Professional Forum
Date Ratified
27/06/2017
Effective From
02/04/2019
Author(s) (name and designation)
Nichola Russell, Nurse Consultant for Tissue Viability and Patient Safety
Sponsor
Hilary Lloyd, Director of Nursing, Midwifery and Quality
Expiry Date
26/06/2020
Withdrawn Date
Unless this copy has been taken directly from Pandora (the Trust’s Sharepoint document management system) there is no assurance that this is the most up to date version This policy supersedes all previous issues
RM72 Pressure Ulcer Prevention and Management Policy – Version 3 2
Version Control
Version Release Author/
Reviewer
Ratified By/ Authorised By
Date Changes (Please identify page no)
1.0 Oct 2010 M Bainbridge SafeCare Council
Jun 2010
2.0 February 2014
N.S Russell Nursing and
Midwifery
Professional
Forum
February 2014
Rewritten
3.0 June 2017 N.S Russell Nursing and
Midwifery
Professional
Forum
June 2017 Rewritten
3.1 02/04/2019 N.S Russell Y.Evans
Deputy Director
of Nursing
Midwifery and
Quality
29/03/2019 Pages 8 - 10
RM72 Pressure Ulcer Prevention and Management Policy – Version 3 3
CONTENTS
Section Page Number
1 Introduction 5
2 Policy Scope 5
3 Aims of the Policy 5
4 Roles and Responsibilities 6
4.1 The Chief Executive 6
4.2 Divisional Directors 6
4.3 Assistant Divisional Managers 6
4.4 Modern Matron 6
4.5 Ward Manager / Designated Deputy 6
4.6 Tissue Viability Team 6
4.7 Clinical Ergonomics 6
4.8 Nursing Staff 6
4.9 Patients and Cares 6
5 Pressure Ulcer Definition 8
5.1 Pressure Ulcer Classification 9
5.2 Moisture Lesion 10
5.3 Kennedy Ulcer 11
6 Prevention and Management of Pressure Ulcers 11
6.1 Extrinsic Factors 11
6.2 Intrinsic Factors 11
6.3 Risk Assessment 11
6.4 Save Our Skin 11
6.5 The SSKIN Bundle 11
6.6 Skin Assessment 11
6.7 Support Surface 12
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6.8 Keep Moving 12
6.9 Incontinence 13
6.10 Nutrition 13
6.11 Preventative Aids 13
6.12 Gel Heel Pads 13
6.13 Slipper Socks 13
6.14 Heel Cushions 14
6.15 Chair cushions 14
6.16 Slidesheets 14
6.17 Documentation 14
6.18 Intentional Rounding Chart 14
6.19 Care Standard 15 / Pictorial Guide to Mattress
Selection
15
6.20 Wound Management Booklet 15
6.21 Bariatric Patients 15
6.22 Datix 15
6.23 Safeguarding 16
6.24 Root Cause Analysis 16
6.25 Safety Cross 16
6.26 Advice for Patients and Relatives 17
6.27 Discharge 17
7 Training 17
8 Equality and Diversity 18
9 Monitoring Compliance and Effectiveness of the
Policy
18
10 Consultation and Review 18
11 Implementation of Policy 18
12 References 18
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Appendices
1 Pressure Ulcer Risk Assessment Tool 20
2 Care Standard 15 22
3 Flow Chart for the Selection Of Pressure relieving
Equipment in Community
25
4 Pictorial Guide for the Selection of Mattress and
Cushion Selection in Community
26
5 Seating Assessment Tool For Community 28
6 Non Concordance In Community 29
7 Integrated Intentional Rounding Chart 30
8 Wound Management Booklet 34
9 Orthotics Devices / Splint Guidance – Prevention of
Pressure Ulcers
38
10 Mini Root Cause Analysis Tool 40
11 Pressure Ulcers – Advice for Patients and Relatives 42
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Pressure Ulcer Prevention and Management Policy
1. Introduction: Preventing pressure ulcers remains one of the greatest healthcare challenges today in terms of reducing patient harm. Despite progress being made in the management of pressure ulcers since 2012, they remain a significant healthcare problem affecting 700,000 people per year. They are associated with reduced quality of life, affecting an individual’s physical, social and emotional wellbeing. Estimates on pressure ulcer incidence and prevalence from hospital-based studies vary widely according to the definition and category of ulcer, the patient population and care setting. Reported prevalence rates range from 4.7% to 32.1% in hospital populations in comparison to 22% in nursing home populations (AHSN 2015).Treating a pressure ulcers cost the NHS more than £3.8 million every day (NHS Improvement 2016), In the most severe cases the cost can range from £11,000 to £40,000 per person. Pressure ulcer prevention can improve patient outcomes and reduce the cost to the NHS. When combined with the human suffering there is an increased need to find innovative and simple ways for all members of the multi-disciplinary team to address this fundamental aspect of nursing care into everyday clinical practice.
2. Policy Scope:
This is a Trust wide policy which applies to all clinical staff both qualified and unqualified who are involved in the direct care of the patient within Gateshead Health NHS Foundation Trust. It reflects a multi-disciplinary approach to the prevention and management of pressure ulcers across both hospital and community. 3. Aim of the Policy
The purpose of this Policy is to standardise care and aims to be equitable and accessible to all healthcare professionals and carers by;
Preventing the development of pressure ulcers where ever possible and implementing individualised treatment plans to effectively manage existing pressure ulcers
Standardising the assessment and management of individuals who are at risk of developing pressure ulcers or who have existing pressure ulcers
Supporting families, carers and healthcare professionals with a framework for the prevention and management of pressure ulcers
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4. Duties – Roles and Responsibilities
Roles Responsibility
4.1 Chief Executive Has the overall responsibility for the implementation of this policy, however the day to day accountability for the provision of pressure ulcer prevention and management is the sole responsibility of the individual practitioner
4.2 Directors Ensuring that this policy is adhered to within all areas across the Trust covering both hospital and community
4.3 Associate Directors Ensuring the implementation of this policy and ensuring that adequate resources are available for staff to deliver care to the appropriate standard.
4.4 Modern Matrons
Ensuring the implementation of this Policy at ward level
Ensuring that staff attend training on a regular basis regarding the Prevention and Management of Pressure Ulcers
4.5 Ward Managers / Departmental Managers
Ensuring that all nursing staff adheres to the Policy for Pressure Ulcer Prevention and Management within their own clinical area / base
4.6 Tissue Viability Team
Act as a specialist resource for all aspects of Tissue Viability incorporating evidence based practice at the bedside
Monitoring and reporting prevalence and incidence rates of pressure damage
Validate all Trust reported incidence of pressure damage within the hospital setting.
Validate all Category 3 and 4 Community related pressure damage incidence within the hospital setting.
Validate all Category 3 and 4 Trust reported incidence of pressure damage within the community setting.
To deliver a comprehensive training programme of the prevention and management of pressure ulcers
4.7 Clinical Ergonomics
Act as specialist advisors in Manual Handling on behalf of the Trust
4.8 Nursing Staff
Are aware of the risks of pressure ulcer formation and development and ensure that no action or omission on his/her part leads to either pressure ulcer development or deterioration of an existing pressure ulcer (NMC 2008)
Report all incidence of pressure damage via the Datix reporting system
4.9 Patients and carers Patients have a responsibility to comply with pressure prevention strategies as initiated by the nursing team and inform staff of any discomfort.
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5.0 Pressure Ulceration Definition:
5.1 Pressure Ulcer Classification:
The National Pressure Ulcer Advisory Panel (NPUAP, 2016) classification of pressure ulceration is the validated tool used to categorise the severity of the pressure damage across the Trust.
‘A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue’ (NPUAP 2016 / NHS Improvement 2018)
Category 1 Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury
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Category 4
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Category 3 Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Category 2 Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD)
Unstageable Damage
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Category 3 or Category 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed.
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Please do not use the classification system in reverse order to describe
improvement Any pressure ulcer that has developed as a result of a medical device should be referred to as a medical device related pressure ulcer.
Where skin damage is caused by a combination of moisture associated skin damage and pressure it should be reported based on the category of damage All wounds are required to be dressed appropriately with products available on the Wound Formulary. Special care and attention should be taken to the vulnerable heel area. All diabetic patients with an ulcer on their foot should be kept dry and referred to a Podiatrist for an assessment. For those patients with suspected reduced arterial blood flow it is essential to not hydrate necrosis and refer to the Vascular Service for expert advice. 6. Prevention and Management of Pressure Ulcers:
Recognising which patients’ are at risk of developing pressure damage early is an essential part of our Prevention Pathway. According to NICE 2014 neonates, infants, children, young people and adults at risk of developing pressure damage. However there are many external factors which predispose an individual to develop a pressure ulcer. The
5.2 Moisture Associated Skin Damage
A combination of moisture and friction may cause moisture lesions in skin folds, but most commonly they are present in the anal cleft. Moisture lesions are superficial (partial thickness skin loss). In cases where the moisture lesion becomes infected, the depth and extent of the lesion can be enlarged.
An appropriate barrier product should be applied
Deep Tissue Injury (DTPI) Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Category 3 or Category 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.
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critical determinants of pressure ulcer formation are the intensity and duration of pressure, and the tolerance of the skin and its supporting structure for pressure, shear and friction. The factors that contribute to pressure ulcer development are divided into two groups: extrinsic and intrinsic factors:
6.3 Risk Assessment:
Within the organisation it is an essential requirement that all patients’ have a pressure ulcer risk assessment (PURS assessment) undertaken within 6 hours of admission based on the adapted ‘Waterlow Score’ and the appropriate action taken (Appendix 1 ). Within Paediatrics the adapted Glamorgan risk assessment tool should be used. However before a PURS assessment can be undertaken a Malnutrition Risk Score must be completed. This assessment is required to be repeated on transfer / if the patients’ condition changes and on a weekly basis. Within the community setting patients’ assessed at risk should be reassessed weekly or if/ when the patient’s condition changes. Patients at high or very high risk should be reviewed
6.1Extrinsic Factors External Forces
Pressure Pressure damage occurs when the skin and other tissues are directly compressed between bone and another surface, the capillary blood flow is cut off and over time the skin will die.
Shear Shear occurs when tissues are wrenched in opposite directions such as when reclining: external skin stays in contact with the chair but internally the tissues are sliding down resulting in disruption or angulation of capillary blood vessels.
Friction Friction occurs when the skin has rubbed against another surface. This most often produces a blister or scuffed‟ area as a result of poor moving and handling techniques or involuntary movement of limbs.
Moisture Moisture can be caused by incontinence, sweating, high temperature and wound exudate
6.2 Intrinsic Factors Factors within the Patient
Malnutrition Malnutrition caused by chronic disease major surgery, being nil by mouth or deprived of food
Dehydration Dehydration slows down the body’s metabolism, reduces skin turgor making it more vulnerable to new wounds
Immobility Immobility caused by, sedation, anaesthesia, pain paralysis, major trauma and disease
Age Age causes a loss of sensation in the tissues
Medical Condition Medical conditions such as congestive cardiac failure, chronic respiratory disease, diabetes, anaemia and neurological disease
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at each visit. If any form of pressure damage is detected then a Datix must be completed, the wound dressed appropriately and a wound management chart completed in order to monitor any improvement or deterioration of the wound. Risk assessment tools should only be used as a guide to action and should not replace clinical judgement (NICE, 2003) and are the responsibility of a registered health care profession.
6.4 Save Our Skin Strategy:
Once a patient has been identified as requiring assistance to change their position as part of the Trust’s ‘Save our Skin Strategy’ within the hospital setting an SOS sticker is required to be placed on the patients white board above the patient’s bedside as a visual prompt to staff that the patient requires intervention and that they are at high risk of developing pressure damage or may have existing pressure damage.
Red clip boards are also being used to highlight to staff those patients’ are at risk 6.5 The SSKIN Bundle: Within the Trust an Integrated Intentional Rounding Chart has been devised to incorporate the SSKIN bundle: a five step model to prevent pressure ulcers: S = Skin inspection S = Support surface K = Keep moving I = Incontinence N = Nutrition 6.6 Skin Assessment: An initial skin inspection is an essential part of your assessment when a patient is admitted to your department or onto your case load. All dressings including compression bandaging are required to be removed to enable a full skin assessment to be undertaken.
Refusal to allow a skin to be inspected needs to be clearly documented. 6.7 Support Surface:
The anatomy of the heels provide very little protection against the applied forces of pressure, shear and friction as there is only a thin layer of subcutaneous tissue between the skin and the bone (Wilson 2012). The heels are the second most common site of pressure damage. A mirror can be used when inspecting the heels to aid all round visualisation of any potential or existing damage
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As an organisation all patients are placed on a high specification foam mattress on admission within the hospital setting which is endorsed by the European Pressure Ulcer Advisory panel for those patients who are at risk of developing pressure damage / or have Category 2 pressure damage (EPUAP, 2014) To enable the safe repositioning of patients and to minimise pressure and shear forces (EPUAP, 2014) all ward areas store a provision of slide sheets appropriate to meet the individual patients’ needs. 6.8 Keep Moving: For those patients who have been deemed at risk of developing pressure damage they are required to have their position changed at least every 2 hours. A 30 degree tilt using pillows can be used to spread the pressure over a larger surface area rather than over bony prominences.
An effective repositioning regime will be indicated by the absence of persistent erythema over bony prominences. If persistent erythema occurs this may indicate that more frequent repositioning is required and that the current support surface is perhaps not optimal for the patient. A range of chair cushions (Appendix 2) are also available for those patients who require additional protection whilst sitting out in their chair. For those patients with Category 3 or 4 pressure damage their time spent up in the chair is limited to 1 hour usually at meal times.
Heels can be floated off the bed using a pillow which must be used along the full length of the calf avoiding the Achilles heel whilst flexing the knee slightly to avoid popliteal vein compression and reducing the risk of developing a deep vein thrombosis (NPUAP, 2014)
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6.9 Incontinence: It is essential that those patients’ who are incontinent of either urine or faeces are kept clean and free from moisture by washing the skin with octenisan and applying an appropriate barrier product. 6.10 Nutrition: It has been estimated that 40% of patient’s on admission to hospital are malnourished (Stratton et al, 2005) and are at greater risk of developing pressure damage. The skin becomes inelastic, fragile and prone to breakdown due to reduced tissue perfusion at the wound site. Skin repair is impaired in people whose diets are deficient in protein, vitamin C, or zinc. All patients’ on admission are required to be nutritionally assessed whereby their dietary intake may be monitored throughout the patient’s hospital stay and a referral to a dietician triggered. Patients’ who have had surgery and are at risk / or have existing pressure damage are offered a cooked breakfast and additional snacks on a daily basis to provide additional nutrients. A patients’ fluid intake may also need to be monitored as Dehydration causes the skin to become inelastic, fragile and more susceptible to breakdown reducing tissue perfusion by the blood supply limiting the supply of both oxygen and nutrients (Johnston, 2007).
6.11 Preventative Aids:
Early detection of skin damage and implementation of adequate preventative strategies can prevent tissue damage altogether or reduce the seriousness of the ulceration. Staff must react to the appearance of red skin and take the appropriate action. 6.12 Gel Heel Pads:
The anatomy of the heels provide very little protection against the applied forces of pressure, shear and friction as there is only a thin layer of subcutaneous tissue between the skin and the bone (Wilson 2007). Pressure relieving gel heel pads are utilised across the organisation as clinically proven to be an effective pressure ulcer prevention device and form part of our # NOF Pathway. As a preventative measure gel heel pads are applied to both heels which are made from a unique polymer gel have been designed to redistribute pressure away from the heels whilst simultaneously transferring friction forces away from the skin (Hampton et al. 2011).They are designed to be worn 24 hours per day throughout the patients hospital stay and post discharge until they have regained their optimal level of mobility. 6.13 Slipper Socks:
Slipper socks are to be used as a ‘Falls Prevention Strategy’ and are not used as bed socks except on the Mental Health In patient areas.
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6.14 Heel Cushions:
6.15 Chair Cushions: A range of chair cushions are also available from the Equipment Library throughout the twenty four hour period for those patients who require additional protection whilst sitting out in their chair (Appendix 2). For those patients with category 3 or 4 pressure damage their time spent up in the chair will be limited to 1 hour per session usually at meal times. 6.16 Slide sheets:
6.17 Documentation: Good record keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow (NMC 2009). Photographic evidence of pressure damage may also be recorded by using a Trust camera following consent from the patient or relative by completing a consent form from the Clinical Photography and Audio Visual Recording of Patients Confidentiality and Consent Policy (IG09). However photographs must only be stored in a confidential envelope in the patients’ medical notes and be clearly identified on the reverse by using a black pen recording the patient’s name / date of birth; date / time the photograph was taken and exact location of the wound and size. 6.18 Intentional Rounding Chart:
The concept of Intentional rounding can be described a structured process where nurses on the wards carry out regular checks with individual patients at set intervals. During these checks, nursing staff carrying out scheduled tasks or observations with patients; addressing patients’ pain, positioning and toilet needs; assessing and attending to the patient’s comfort, dietary intake and checking the environment for any risks to the patient’s comfort or safety. During these checks nursing staff are required to complete their actions on the Intentional Rounding Chart (Appendix 3) concerning positional changes as it is essential that nursing staff are vigilant at the patient’s bedside. If an Orthotic device / Splint has been applied it is essential that a Orthotic Monitoring Chart is completed (Appendix 5).
To enable the safe repositioning of patients and to minimise pressure and shear forces (EPUAP, 2014) all ward areas will use a slide sheet (Manual Handling Policy (RM 06). Slide sheets can be obtained from the Trust Laundry Facility.
Heel cushions are available from the Equipment Library for patients at high risk of pressure damage to their heels whilst sitting up in the chair in order to aid the redistribution of pressure away from the vulnerable heel area.
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6.19 Care Standard 15 / Pictorial Guide to Mattress Selection:
Care Standard 15 ‘Prevention and Treatment of Pressure Ulceration’ is required to be initiated on admission regarding the expected standard of care to be provided at the bedside (Appendix 2). A pictorial guide has been incorporated into this document to act as an aide memoire to staff regarding the appropriate selection of mattresses or cushions available in house across the 24 hour period according to the patient’s level of risk or severity of pressure damage. For Community staff please refer to Appendix 3 contact for the appropriate equipment which is available. 6.20 Wound Management Chart: It is an essential requirement that a comprehensive wound assessment is undertaken (Appendix 4) and appropriate dressing regime initiated and documented on the Wound Management Chart or Wound Care Document. 6.21 Bariatric Patients: The Trust’s Bariatric Guidelines define a Bariatric patient or larger patient as one who weighs over 160 kg (25 stone).It should be remembered that if a person requires the use of bariatric equipment e.g., beds, commodes, hoists etc that the person will have enhanced Tissue Viability needs. A patient can be nursed in a seated position if they are on an electric bed however the safe working load of the mattress must be checked to ensure that it is sufficient to accommodate the patient’s weight in order to maintain the integrity of pressure areas. Careful consideration should all be given to the following;
Assessing and monitor for cellulitis
Assessing and managing skin folds from skin breakdown from perspiration and friction particularly under the breasts, in the groin, neck, abdominal, and perineal areas as these are high risk for bacterial and fungal infections.
Check that lines, catheter tubing and equipment are not caught in skin folds
Check skin folds are not pressing against or caught in safety sides of bed frame
Frequent turning and repositioning is required often requiring additional staff Further advice can be sought from the Clinical Ergonomics Team. If out of hours and at weekends staff are required to contact the 1200 bleep holder for further advice. 6.22 Datix: If any form of pressure damage is detected then a Datix must be completed, the wound dressed appropriately and a Wound Management Chart completed in order to monitor any improvement or deterioration of the wound. Validation of this damage is then verified at the bedside by the Tissue Viability Service for all Trust damage Category 1 – 4 and Community damage Category 3 – 4. 6.23 Safeguarding:
If a member of staff believes that any form of skin damage has been caused as a result of neglect either in hospital or community it is essential that their concerns are raised via the
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Trust’s Safeguarding Procedures (Safeguarding Policy OP75d). Neglect is the deliberate withholding or unintentional failure to provide appropriate and adequate care and support, where this has resulted in, or is highly likely to result in preventable skin damage. 6.24 Root Cause Analysis: A mini root cause analysis is required to be undertaken for all Category 2 Trust related pressure damage (Appendix 6) for Hospital staff and for Community staff the attached mini root cause analysis on the Datix system. A full in depth root cause analysis for all Category 3 and 4 Trust related damage is required to be undertaken; the findings of which must be presented to the Director or Deputy Director of Nursing within 2 weeks of its occurrence. The findings are required to be shared at ward level / sector base so lessons can be learnt. For all Trust related Category 3 and 4 pressure damage the patient will be informed that a full investigation into the cause of the pressure damage will be undertaken as part of our Duty of Candour process. 6.25 Safety Cross: As part of the Pressure Ulcer Prevention Strategy across the organisation staff are required on a daily basis to completed a pressure ulcer calendar in the form of a ‘Safety Cross’ which graphically shows how many days since the last pressure ulcer on the ward.
6.26 Advice for Patients and Relatives: It is vital that patients are encouraged to take an active role in their care and devise a mutually agreed management plan; which according to Moore and Cowan (2009) has a positive effect on patients as they feel they have been part of the decision making process. However if the patient is non-compliant this must be clearly documented. For Community staff please refer to Appendix 6.
Safety Cross
1 2
Month
3 4 March 2017
5 6
7 9 11 13 15 17 19 21
8 10 12 14 16 18 20 22
23 24
25 26
Days without incident
27 28
29 30
10
31
Trust Damage
Community Damage
No damage
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All in patients will be informed of the Trusts Information Leaflet ‘Pressure Ulcers’. The information is available in leaflet format on all ward areas or can be downloaded from Trust Patient Information Website (Appendix 7). 6.27 Discharge: If it has been identified that pressure relieving equipment is required for discharge it is the discharging nurses’ responsibility to ensure that this has been arranged prior to discharge.
Patient to be discharged home Discharging nurse to arrange pressure relieving
mattress / cushion if required and inform
Community Nursing service
Patient to be transferred to a
Residential Home
Discharging nurse to arrange pressure relieving
mattress / cushion if required and inform
Community Nursing service
Patient to be transferred into a
Nursing Home
Matron from home to visit ward to complete
assessment to ensure they can meet the patients
nursing needs and provide equipment required
prior to transfer
Ward nursing staff must complete a Primary Care Nursing Service Referral Form when planning to discharge a patient with pressure damage into the community (Please refer to the Trusts Discharge Policy OP13 for further guidance).
7. Training:
The Tissue Viability Team will be responsible for the delivery of training across the organisation on a formal basis. Pressure Ulcer Prevention and Management Day Wound Assessment and Management Day Preceptorship Programme for Allied health Care Professionals / Midwives / Nurses / Pharmacists Care Certificate Programme Divisional Training events Clinical Leads Link Nurse Forums Away Days Bite size training sessions at ward level / sector bases
8. Equality and Diversity:
The 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.
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9. Monitoring compliance and effectiveness of the policy:
Annual monitoring of the effectiveness and implementation of Pressure Ulcer Prevention and Management Policy including documentation requirements across the organisation will be the responsibility of the Tissue Viability Team which will reported to the Nursing and Midwifery Professional Forum.
Additional monitoring measures in place:
Daily Pressure Damage Datix Dashboard based on individual incident of harm
Monthly Safety Thermometer prevalence audit
Root cause analysis report / action plans
10. Consultation and review:
This policy has been devised by adopting a collaborative approach using a multi professional and multi-agency focus on Pressure Ulcer Prevention and Management for all patients across the organisation. The views and opinions of these professionals have been sought and this policy has been devised based on their expert knowledge, experience, and the relevant legislation and supporting guidance documents.
11. Implementation of the Policy (including raising awareness) :
This policy will be embedded across the organisation following its ratification by the Tissue Viability Team via a number of forums:
Away Days for Modern Matrons / Ward Mangers
Link Nurses for Pressure Damage
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12. References
Academic Health Science Network (2015) Patient Safety Collaborative: Preventing Avoidable Pressure Ulcers
Gateshead Health NHS Foundation Trust (2015) Clinical Photography and Audio Visual Recording of Patients – Confidentiality / Consent policy (IG09). Gateshead Health NHS Foundation Trust (2016) Hospital Discharge Policy (OP 13) Gateshead Health NHS Foundation Trust (2016) Manual Handling Policy (RM 06) Gateshead Health NHS Foundation Trust (2017) Safeguarding Policy (OP 75d) Johnson, E (2007) The Role of Nutrition in Tissue Viability Wounds Essential (2), pp.10-12 International Guidelines (2009) Pressure ulcer prevention: prevalence and incidence in context. London: MEP Ltd, 2009. Available from www.woundsinternational.com Hampton, S. Tadejond, M. Young, S. (2011) An evaluation of Gel Heel Pads. Eastbourne: Wound Healing Centre. National Institute for Health and Clinical Excellence (2005). Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary Care. London: NICE.
The National Pressure Ulcer Advisory Panel redefined the definition of a pressure injuries during the NPUAP 2016 Staging Consensus Conference that was held April 8-9, 2016 in Rosemont (Chicago), IL NICE (2014) Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary Care: A Clinical Guideline. National Institute for Health and Clinical Excellence, London
NHS Improvement (2016) Stop The Pressure Campaign NHS Improvement (2018) Pressure Ulcers: revised definitions and measurement NMC (2008). Record Keeping: Guidance for Nurses and Midwives. London, Nursing and Midwifery Council.
Stratton RJ, Elia M (2005) A review of reviews: a new look at the evidence for oral nutritional supplements in clinical practice. Clin Nutr Suppl. 2: 5 pg.23
Wilson M (2012) Managing patients vulnerable to pressure ulceration. Wounds Essentials 7(1):45-8
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Pressure Ulcer Risk Assessment Score in Hospital Appendix 1
PRESSURE ULCER RISK SCORE Every section must be completed to obtain a score
Date Date Date Date Date Date Date
Time Time Time Time Time Time Time
Sex/Age
Male 1 1 1 1 1 1 1
Female 2 2 2 2 2 2 2
14 – 49 1 1 1 1 1 1 1
50 – 64 2 2 2 2 2 2 2
65 – 74 3 3 3 3 3 3 3
75 – 80 4 4 4 4 4 4 4
81 + 5 5 5 5 5 5 5
Build / Weight for height
Average (BMI= 20 – 24.9) 0 0 0 0 0 0 0
Above average (BMI= 25 -29.9) 1 1 1 1 1 1 1
Obese (BMI>30) 2 2 2 2 2 2 2
Below average(BMI<20) 3 3 3 3 3 3 3
Continence
Continent/catheterised 0 0 0 0 0 0 0
Occasionally incontinent 1 1 1 1 1 1 1
Cath/incontinent of faeces 2 2 2 2 2 2 2
Doubly incontinent 3 3 3 3 3 3 3
Skin Type / condition
Healthy 0 0 0 0 0 0 0
Tissue paper 1 1 1 1 1 1 1
Dry 1 1 1 1 1 1 1
Oedematous 1 1 1 1 1 1 1
Clammy 1 1 1 1 1 1 1
Discoloured ( Grade / Category 1 ) 2 2 2 2 2 2 2
Broken area ( Grade / Category 2 – 4 ) 3 3 3 3 3 3 3
Mobility
Fully 0 0 0 0 0 0 0
Restless / Fidgety 1 1 1 1 1 1 1
Apathetic or loss of interest 2 2 2 2 2 2 2
Restricted 3 3 3 3 3 3 3
Bedbound e.g.traction 4 4 4 4 4 4 4
Chair bound e.g. wheelchair 5 5 5 5 5 5 5
Nutrition Score
0-3 0 0 0 0 0 0 0
4-5 ( 4 or above Implement Care Standard ) 1 1 1 1 1 1 1
6-15 (Refer to dietician) 2 2 2 2 2 2 2
Major Surgery / Trauma ( This admission only)
Not applicable Spinal or orthopaedic surgery or surgery below the waist On theatre table for > 2hrs
0 0 0 0 0 0 0
5 5 5 5 5 5 5
5 5 5 5 5 5 5
On theatre table > 6 hrs 8 8 8 8 8 8 8
Tissue Malnutrition
Not applicable Terminal cachexia
0 0 0 0 0 0 0
8 8 8 8 8 8 8
Cardiac failure 5 5 5 5 5 5 5
Peripheral vascular disease 5 5 5 5 5 5 5
Anaemia 2 2 2 2 2 2 2
Smoking 1 1 1 1 1 1 1
Medication
Not applicable 0 0 0 0 0 0 0
Anti-inflammatory or high dose steroids or cytotoxics drugs 4 4 4 4 4 4 4
Neurological deficit
Not applicable 0 0 0 0 0 0 0
Motor /sensory loss, eg CVA. MS / Paraplegia / Diabetes 6 6 6 6 6 6 6
TOTAL SCORE
INITIALS
10 + AT RISK 15+ HIGH RISK 20+ VERYHIGH RISK
RM72 Pressure Ulcer Prevention and Management Policy – Version 3 22
Pressure Ulcer Risk Score (PURS)
Intervention Guidance Notes
10 + AT RISK
Implement Care Standard Prevention and Treatment of Pressure Ulcer
Implement Intentional Rounding Chart
PURS assessment to be completed: On admission / on transfer / if the patient’s condition deteriorates / weekly. Mattress / cushion selection guide: Category / Grade 1 : Foam mattress and Prima 3 foam cushion Category / Grade 2: Foam mattress and Primagel cushion Category / Grade 3 or 4 : Primo mattress / reflex cushion Category / Grade 4: Clinactiv mattress ( additional heel protection) / reflex cushion Duo 2 mattress also available for those patients at very high risk- please contact Tissue Viability for further advice. Datix to be completed if pressure damage found for all Category / Grades (1 – 4) Community and Trust related. Nutritional snacks / hot breakfast can be offered to those patients who are at high risk or have pressure damage.
15+ HIGH RISK
Implement Care Standard Prevention and Treatment of Pressure Ulcer
Implement Intentional Rounding Chart
Offer nutritional snacks / hot breakfast
20+ VERY HIGH RISK
Implement Care Standard Prevention and Treatment of Pressure Ulcer
Implement Intentional Rounding Chart
Offer nutritional snacks / hot breakfast
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Appendix 2 Gateshead Health NHS Foundation Trust
PREVENTION AND TREATMENT OF PRESSURE ULCERATION Care Standard 15
1. Ensure a Nutrition Risk Score is completed at the time of the patients’ admission and take the
appropriate action if required. (Care Standard 9C). 2. Ensure a Pressure Ulcer Risk Score (PURS) assessment is recorded within 6 hours of the patients’
admission or transfer to your Ward / Dept or if the patient’s condition changes and take the appropriate
action. 3. Ensure a full head to toe skin inspection is undertaken as part of the admission process whilst
maintaining the patient’s privacy and dignity and record any abnormalities. 4. For those patients’ with pressure damage a detailed wound assessment must be undertaken and the
findings recorded in the Wound Management Booklet and an appropriate dressing regime exercising
clinical judgement initiated. 5. All pressure damage must be categorised using the European Pressure Ulcer Advisory Panel
Classification System (pressure ulcers cannot be reverse graded). 6. Report all pressure damage irrespective of Category as a clinical incident via the Datix system and
record ID number 7. Ensure that the appropriate pressure relieving mattress and / or chair / floor cushion is selected and
ordered using the pictorial guide overleaf. 8. For those patients’ with existing pressure damage or who are at risk of developing damage please use
an SOS sticker at the bedside as a visual prompt to clinical staff indicating that the patients’ position is
required to be changed every 2 hours. All positional changes must be recorded within the Integrated
Intentional Rounding Chart. 9. For those patients’ with existing pressure damage or who are at risk of developing damage or who will
be undergoing surgery please offer a cooked breakfast on a daily basis 10. Ensure all patients’ skin integrity is checked on a daily basis and record any abnormalities
11. Involve the patient and their relatives / carers in the decision making process around their care needs
and that they are aware of their condition / disease process. 12. Ensure you have considered making reasonable adjustments to meet the needs of patients with
disabilities
For further advice and support please contact the Tissue Viability Team on Ex 2787
References: European Pressure Ulcer Advisory Panel (2009) www.epuap.org/grading.html Gateshead Health NHS Foundation Trust (2014) Pressure Ulcer Prevention and Management Policy NICE (2014) Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary Care: A Clinical Guideline. National Institute for Health and Clinical Excellence, London The Royal Marsden Manual of Clinical Nursing procedures (Ninth Edition , 2015)
WMF823 Version 2: Review April 2019 KEY- Specialist Nurse Only - SNO Tissue Viability / Vascular Nurse LP71875
Category of Damage Category 1 or 2
Mattress Selection Guide
Pressure Reduction Foam Mattress NP150 / Thermocontour mattress
*For those patients’ with multi areas of Category 2 damage please consider the use of
an alternative mattress*
Category 3 or 4
Can be ordered via I Tracker
Primo Continuous Low-pressure system suitable for patients’ medium to high risk / Category 3 or 4 tissue damage. Max Weight Limit: 150kg (23.5 stone) Min Weight Limit: 30kg (4 stone 10lbs)
Category 4 Can be ordered via
I Tracker
Clinactiv
Continuous Low-pressure system suitable for patients high to very high risk / Category 4 tissue damage. Specialist heel section. Max Weight Limit: 180kg (28 stone) Min Weight Limit: 30kg (4 stone 10lbs)
Category 4 *Can only be authorised by Tissue Viability*
Duo®2 Mattress
Dual therapy system suitable for patients high to very high risk. Therapeutic Weight limit: 150kg (23.5 stone) Min weight limit: 30kg (4 stone 10lbs)
Category 1 Category 2 Category 3 Category 4
Chair Cushion A chair cushion can be ordered via Equipment Library EXT 3871 / Bleep 2780 Prima 3 Foam Primagel Reflex Reflex
All Categories of heel damage
Floor Cushion A floor cushion can be ordered via Equipment Library EXT 3871 / Bleep 2780
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Flowchart for the Selection of Pressure Relieving Equipment To be used alongside Clinical Judgement, Pressure Ulcer Policy and Patient/Carer Education
For patients who are at risk of or have existing pressure damage to HEELS ONLY unable to reposition
independently?
Yes
No
Currently NO risk Yes No Equipment required
No
Currently LOW Risk
(No existing pressure damage
Yes
Can the patient re-position
independently?
Yes
Prevention Equipment:
Mattress
Level 1
Pressure Reduction
No
Currently MEDIUM Risk
(No existing pressure damage
No
Yes
Yes
No
Is the patient likely to be at risk
for a short time?
No Yes
No Damage
Does the patient have?:
Yes
Yes
Patient weight
in excess of 20 No
stone
Yes
Patient weight
in excess of 20 No stone
Prevention Equipment:
Mattress
Level 1
Pressure Reduction
Treatment/Prevention
Equipment: Mattress
Level 2
Pressure Relief
Treatment/Prevention
Equipment: Mattress
Level 2
Pressure Relief
And
And
And
And
Currently HIGH Risk (or existing pressure damage) Yes
Non blanching erythema - Category 1
Partial skin loss - Category 2 BUT CAN TURN INDEPENDENTLY
Treatment Equipment:
Mattress
And
Yes
Does the Patient have?:
Full thickness skin loss - Category 3
Full thickness tissue loss - Category 4
Yes
No
Yes
Level 3
Pressure Relief
No
Is the patient very difficult
to move or able to lie in
only one position
Yes
And
CONSIDER:
Treatment Equipment:
Mattress and Cushion
Level 3
Pressure Relief
plus Profiling Bed
Consider
Leg Trough
Aderma Heel Pad
via TVN or FP10
Refer to the seating
checklist for the provision
of cushions
Regular Position Changes
Patient and Carer
Education
Delegation of Care
Use of Moving and
Handling AIds
(this is not an exhaustive
list)
Appendix 3
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Mattress / Cushion Selection for Community Staff Appendix 4
Level One
Dyna-Form Mercury
(Direct healthcare)
Designed for patients considered to be
‘at high risk’ of pressure ulcer
development
Castellated cut CMHR foam
Weight limit: 40 stone, no minimum
weight limit
Side wall construction enables primary
stability
Level One
Permaflex Plus
Advance (Park house
Healthcare)
Contoured Mattress Surface
Castellated foam surface
Side Formers and Base Support
Designed for patients considered to be
‘at high risk’
Weight Limit: 39 Stone
Level Two
Dyna-Form Static Air
HZ (Direct Healthcare)
Designed for patients considered to be
‘at very high risk’ of pressure ulcer
development
A new ‘air only’ intelligent heel zone
Incorporates air and foam and air only
cells in the unique low pressure heel
zone
Weight limit: 40 stone no minimum
weight limit
Level Two
Elite (Park House
Healthcare)
Designed for patients considered ‘at
very high risk’
Alternating cell cycle
Adjustable Weight Settings
Weight limit: 30 Stone
CRP tag
Level Three
Dyna-Form Mercury
Advance (Direct
Healthcare)
Designed for patients considered to be
‘at high risk’ of pressure ulcer
development
Weight limit: 40 Stone no minimal
weight limit
Can be upgraded/downgraded
depending on patient clinical
requirements
Level 3 with pump
Equivalent to level 1 without pump
Level Three
Phase III (Park House
Healthcare)
Designed for patients considered to be
‘at very high risk’
20 figure of 8 cells, 3 static head cells
Weight limit: 39 stone
Alternating mode automatically self
regulates to suit patients weight
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Level One Dyna-Tek Pad Cushion
Designed for patients considered to be ‘at risk’ of pressure ulcer development
Castellated cut CME foam surface
Multi-stretch, vapour permeable cover and non-slip base
Weight limit: 20 Stone
Colour: Light Blue
Level Two Dyna-Flex Cushion
Combination of visco elastic & CME foam technology
Temperature sensitive memory foam
Suitable for patients considered to be at ‘High Risk’ of pressure ulcer development
Weight limit: 24 Stone
Colour: Wine
Level Three Dyna-Tek Gel Cushion
Designed for patients who are considered to be at ‘Very high risk’ of pressure ulcer development
Designed using the latest polyurethane gel and CME foam
Enhances postural management
Weight Limit: 25 Stone Colour: Dark Blue
Please note that this is designed as visual aid memoire for staff and all patients should have a full holistic assessment
including risk assessment and clinical judgement should be used when assessing for all types of equipment.
All requests for wheelchair cushions and recliner chair cushions must be requested via Lucy Goy (Clinical Specialist
Occupational Therapist) [email protected]
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Seating Assessment Tool in Community Appendix 5
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Non concordance in Community Appendix 6
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Appendix 7 Integrated Intentional
Rounding Chart
Intentional Rounding
Intentional rounding is a structured process where nurses on the wards carry out regular checks with individual patients at set intervals.
During these checks, nursing staff carrying out scheduled tasks or observations with patients; addressing patients’ pain, positioning and
toilet needs; assessing and attending to the patient’s comfort; and checking the environment for any risks to the patient’s comfort or
safety.
This form has been devised to incorporate the SSKIN bundle: a five step model to prevent pressure ulcers
S = Support surface S = Skin inspection K = Keep moving I = Incontinence N = Nutrition
and also Incorporates measures staff can take as part of our falls prevention strategy.
F = Footwear O = Observation level C = Call bell U = Understanding patient needs S = Sensor
SSKIN FOCUS Save our Skin (SOS) Stickers Action to be Taken Falls
Please place a SOS sticker on the patients’ white name board at the bedside for those patients who require assistance to change their position.
Visual prompt to staff
Please refer to Care Standard 15 for
appropriate action to be taken for the prevention and
treatment of pressure ulcers.
“Remember react to red skin”
If patient is identified as at risk of falls please place a falling star on the patients white board as a visual prompt for staff.
Please ensure patient are risk assessed using the falls assessment and intervention pathway. Please be reminded that care standard 21 has been integrated within the pathway and all documentation relating to falls prevention should be written in this document.
Equipment in Place: (Please tick) Mattress
Support Surface
NP 150 / Thermocontour
Protecta
Primo
Clinactiv
Duo 2
Dolphin
Other:
Bed and chair sensor
(please refer to Bed and chair sensor guidelines prior to use)
Please remember disposable pads are for single patient use to be changed after 14 days of first use
Date bed and chair sensor in use
Date:
Preventative Products Gel products: Other:
Date for change of disposable pads
Chair Cushion: Prima 3 Foam
Primagel
Reflex
Date: Heel Floor Cushion ( not to be used in bed)
Invacare
Other:
File in section 3 medical notes
References Gateshead Health NHS Foundation Trust (2015) Slips, Trips and Falls Policy (RM 50) Gateshead Health NHS Foundation Trust (2014) In-Patient Falls Assessment and Intervention Pathway NICE (2015) Falls in Older People Quality Standard 86 National Institute for Health & Care Excellence. Orsted, H. L. Ohura. T (2010) Pressure, shear, friction and microclimate in Context International Review. European Pressure Ulcer Advisory Panel (2009) National Pressure Ulcer Advisory Panel (2009) www.healthcareimprovementscotland.org (2011) Gateshead Health NHS Foundation Trust (2014) Pressure Ulcer Prevention and Management Policy The Royal Marsden Manual of Clinical Nursing Procedures (Ninth edition, 2015) NICE (2014) Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary Care: A Clinical Guideline. National Institute for Health and Clinical Excellence, London
WMF823 Version 2: Review April 2019 KEY- Specialist Nurse Only - SNO Tissue Viability / Vascular Nurse LP71875
If Pressure area care is not
required staff nurse please sign
Signature: If Falls Focus is
not required
staff nurse
please sign
Signature:
name:
name:
Date
:__
___
___
___
___
_
Reco
rd t
ime o
f in
terv
en
tio
n
S K I N F O C U S
Skin
In
sp
ec
tio
n
Y –
Yes N
– N
o
1
Ple
ase
re
cord
any c
ha
ng
es in d
aily
care
reco
rd a
nd r
ep
ort
to t
he
nu
rse
in
ch
arg
e
Kee
p M
ovin
g
2
L –
Le
ft s
ide
C
- C
hair
R
– R
ight
sid
e
W –
Walk
ed
B –
Ba
ck
P -
Physio
S –
Sto
od
O
– O
ther
ple
ase s
tate
Inc
on
tin
en
ce
3
I – I
nco
ntin
ence/s
kin
cle
aned
barr
ier
pro
du
ct u
sed
T –
Toile
t / C
om
mod
e/ B
ed p
an
N
A –
No
t a
pplic
able
C –
Cath
ete
r C
hecked
S –
Sto
ma
Ch
ecke
d
Nu
trit
ion
Ple
ase c
om
ple
te fo
od c
hart
4
D –
Drink
F -
Food
N –
Nil
by m
outh
M –
mo
uth
ca
re g
iven
Fo
otw
ear
5
Y –
Yes
N –
No
R –
Pa
tien
t re
movin
g f
ootw
ea
r
N/A
– P
lease e
xpa
nd
in F
alls
Assessm
ent
an
d I
nte
rve
ntio
n P
ath
wa
y
reason
Ob
serv
ati
on
Lev
el
6
I – I
nte
ntio
nal ro
un
din
g
C –
Coho
rt /
Bay /
Zon
e N
urs
ing
O –
On
e to
On
e o
bserv
atio
n
Call B
ell
Is c
all
bell
within
re
ach o
f patient
7
Y –
Yes
N –
No
N/A
- P
lease e
xpa
nd w
ithin
Falls
Assessm
ent
and
Inte
rven
tion
Path
way
Un
ders
tan
din
g p
ati
en
t n
eed
s
ask p
atient if t
hey w
ish
8
to g
o t
o toile
t, r
equir
e a
drink,
req
uire
pain
relie
f
Y –
Yes n
eeds m
et
N –
No n
ee
ds n
ot
met
ple
ase e
xpa
nd in fF
alls
Assessm
ent
an
d
Inte
rve
ntio
n P
ath
way
Sen
so
r: I
f p
atient
has b
ed/c
hair
se
nsor
is it conn
ecte
d a
nd w
ork
ing.
9
Y –
Yes
N –
No
N/A
- N
o s
ensor
requir
ed
No
n c
om
pli
an
ce
(Ple
ase s
pecify w
hic
h a
sp
ect of ca
re / n
um
be
r)
Pa
tie
nt
no
t o
n W
ard
-
Ple
ase
Sta
te
Init
ials
00.__m__m____
01.__m__m____
02.__m__m____
03.__m__m____
04.__m__m____
05.__m__m____
06.__m__m____
07.__m__m____
08__m__m____
09__m__m____
10.__m__m____
11.__m__m____
12.__m__m____
13.__m__m____
14.__m__m____
15.__m__m____
16.__m__m____
17.__m__m____
18__m__m____
19__m__m____
20.__m__m____
21.__m__m____
22.__m__m____
WMF823 Version 2: Review April 2019 KEY- Specialist Nurse Only - SNO Tissue Viability / Vascular Nurse LP71875
If fluid chart is NOT needed RN to sign and print name:
Integrated Fluid Chart
Offer Oral intake or
Mouth care & record
IV Other
Peg / NG Running Total In
Offer toileting
and Record Urine
Record Bowel
Activity NG
Other (drains
etc)
Running Total out
Initial
00.00
01.00
02.00
03.00
04.00
05.00
06.00
07.00
08.00
09.00
10.00
11.00
12.00
Total in = Total out =
Patients with midday totals of Intake of less than 300mls and/or Output less than 300mls Must have: Tick and initial when in place
Accurate fluid balance recorded Daily target of fluid intake set
Red drinking glasses Red jug lids Information about importance of hydration
Identified on Handovers that patient requiring encouragement/assistance to drink
If safe to do so, relatives should be encouraged to give patient drinks.
If urine output drops to below 30 mls per hour for more than four hours then the patient should be escalated as though they are at medium risk as per NEWS
if catheterised, please check urinary catheter is patent,
if not catheterised already, consider if pt is in urinary retention and/ or need for catheter
Offer Oral intake or
Mouth care & record
IV Other
Peg / NG Running Total In
Offer toileting
and Record Urine
Record Bowel
Activity NG
Other (drains
etc)
Running Total out
Initial
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
Total in = Total out =
24 Hrs Balance =
Previous 24hr Balance =
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Any patient NBM must have a plan including reason and review date in medical notes
Food Chart Guidance Tick and initial when in place
Any patient in the red Any patient in the yellow
Must be offered alternative meal/Build Ups
at every meal that is missed
Must have a red placemat
Ensure likes and dislikes form is completed Re calculate NRS
Offer alternative meals
Ensure likes and dislikes form is completed
If in yellow for 3 days consider fortifying
food and giving ward snacks / Build Ups
Remember Nutrition & Hydration is as important as medication
Food Chart All ¾ ½ ¼ 0 record all dietary intake after every meal
Breakfast Record what has been refused by patient
Lunch Record what has been refused by patient
Supper Record what has been refused by patient
Snacks offered
WHAT assistance/support IS required to eat or drink?
If Food Chart is Not Applicable; a RN must tick box and Print Name:
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Wound Management Booklet
Mark location of wound with an X on the Body Images below:
FRONT
BACK
Type of Wound
Pressure Damage
Diabetic Ulcer
Leg ulcer
Surgical Wound
Cellulitis
Other (Please specify)
Please Tick
Pressure Damage
Diabetic Ulcer
Leg Ulcer
Surgical Wound
Cellulitis
Other (Please Specify)
Factors that could delay wound healing
(Please Circle)
Immobility Medication
Poor Nutrition Weight
Diabetes Wound Infection
Incontinence Other (Please specify)
Oedema
Referral date if appropriate:
Discipline Date
Tissue Viability Team
Vascular Nurse
Podiatrist
Orthotist
Physiotherapist
Dietician
Other ( Please Specify)
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Necrotic Wound Sloughy Wound Infected Wound Granulating
Wound
Epithelialising
Wound
Diabetic Foot
Ulcer
Lacerations/
Trauma
Fungating/
Malodorous
Over granulation Surgical Wounds
Appearance Appearance Appearance Appearance Appearance Appearance Appearance Appearance Appearance Appearance
Necrotic area of hard dead tissue
If diabetic – do not
hydrate
Dead cells accumulated in
exudate presents as
yellow tissue
Signs of inflammation /
redness /heat / odour
/Cellulitis
Granular appearance bright red and moist
Silvery pinky-white
Deep or superficial ulcer with or
without
necrotic/sloughy tissue
Superficial or deep skin loss
Cauliflower like appearance with
increase malodour
Granular appearance bright red and moist,
appears as tissue
raised above level of peri-wound
Superficial or deep incision
Management Management Management Management Management Management Management Management Management Management
Rehydrate, soften and remove necrotic
tissue if visible
signs of infection
Rehydrate and remove sloughy
tissue
Reduce levels of bacteria, eliminate
infection and
promote healing
Promote granulation and wound healing
Protect new tissue, maintain a
moist warm clean
wound
Prevent infection Remove
necrotic/sloughy
tissue / Promote
healing
Remove debris Prevent infection
Promote healing
Absorb excess exudate / Reduce
risks of infection
Reduce odour
Reduce level of over granulation tissue
Prevent Infection Promote healing
Treatment
Options
Treatment
Options
Treatment
Options
Treatment
Options
Treatment
Options
Treatment
Options
Treatment
Options
Treatment
Options
Treatment
Options
Treatment
Options
Primary Dressing
Activheal hydrogel
Flaminal Hydro
L Mesitran
Ointment (SNO)
Secondary
Dressing
Activheal non-
adhesive foam
Mepilex ST
Softban / comfifast to secure
Primary Dressing
Activheal hydrogel
Flaminal Hydro
L Mesitran
Ointment (SNO)
Iodoflex
Debrisoft (SNO)
Larvae Therapy (SNO)
Secondary
Dressing
Activheal non-
adhesive foam
Mepilex ST
Softban / comfifast
to secur
Primary Dressing
Iodoflex
Aquacel Ag
(SNO)
Povitulle
(A&E only)
L Mesitran
Ointment ( SNO)
Secondary
Dressing
Activheal non-adhesive foam
Mepilex ST
Softban / comfifast
to secure
Primary Dressing
Adaptic Touch
Zetuvit E
Activheal aquafiber
Secondary
Dressing
Activheal non-adhesive foam
Mepilex ST
Mepilex Border
Aquacel Adhesive (SNO)
Primary
Dressing
Adaptic Touch
NA Ultra
Atrauman
Secondary
Dressing
Activheal non-adhesive
Mepilex ST
Softban /
comfifast to secure
Complete an
urgent referral to
Podiatry
Keep the area dry
until Specialist
advice sought
Do not apply
adhesive dressings
to diabetic foot
ulcers
Secondary
Dressing
Activheal non adhesive foam
Mepilex ST
Softban / comfifast
to secure
Primary Dressing
Adaptic Touch
Activheal Aquafiber
Secondary
Dressing
Activheal non-
adhesive foam
Softban / comfifast
to secure
Mepilex boarder
Aquacel Adhesive (SNO)
Primary Dressing
Activheal aquafiber
Actisorb Silver 220
(SNO)
Zetuvit E
Secondary
Dressing
Activheal non-adhesive foam
Mepilex ST
Softban / comfifast
to secure
Primary Dressing
Apply double layer
Activheal foam
(2 week period)
If no improvements apply Ag foam
(2 week period)
If no improvements
apply
Hydrocortisone 1% (2 week period)
If still no
improvement
contact Tissue
Viability Nurse
Primary Dressing
Opsite post-op
Tegaderm + pad
Activheal Aquafiber
Activheal Alginate
Aquacel Ag (Specialist
Nurse Only)
Secondary
Dressing
Activheal non-
adhesive
Mepilex ST
Softban / comfifast to
secure
Mepilex boarder
Topical Negative
Therapy(SNO)
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Wound Management Assessment Chart
(Please complete each section when dressing is changed)
Date Date Date Date Date
Size of wound
Photograph (Yes / No)
Length (cm)
Width (cm)
Is wound tracking / undermining
Condition of Wound (Please Tick)
Necrotic (Black)
Sloughy (Yellow/Green)
Granulating (Red)
Epithelialising ( Pink)
Hypergranulating ( Red)
Haematoma
Bone/tendon exposed
Other:
Level and Type of Exudate (Please Tick)
None
Low
Moderate
High
Serous (Straw)
Haemoserous (Red/Straw)
Purulent (Green/Brown/Yellow)
Condition of Surrounding Skin (Please Tick)
Macerated (White)
Oedematous
Erythema (Red)
Excoriated (Red)
Fragile
Dry/scaly
Healthy/intact
Signs of a deteriorating wound bed (Please Tick)
Increasing pain
Increasing odour
Wound Swab sent for C & S
Assessors Initials
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Date Dressing Regime / additional comments If Pressure Ulcer
State Grade / Category
Review
Date
Signature/ Print
WMF823 Version 2: Review April 2019 KEY- Specialist Nurse Only - SNO Tissue Viability / Vascular Nurse LP71875
Gateshead Health NHS Foundation Trust Appendix 9
Orthotic Devices/Splint Guidance – Prevention of Pressure Ulcers
Patient name (Please place addressograph label if available)
D.O.B NHS Number Unit Number.
Ward Consultant
SECTION A
Name of orthotic device Date device first applied Fitted by Print Name: Signature:
Orthotics or prescriber to complete Designation/Grade: Contact Number:
SECTION B
Nursing staff / AHP to Complete Initial observation assessment
Print Name Signed Grade Date Time
Frequency of application of splint to be worn as discussed with ward Nurse
During day
Night use Remove splint at night.
Duration of wearing splint
Every- (e.g. 3 hours per day/all day) Other
Yes No
Observation Checklist Frequency of observation: Observations to look for on skin of Body part: Is there any
Orthotic indentation
Presence of blisters
Redness
Swelling
Skin integrity
Skin discolouration
Skin sweating
Other observations found
CHECKLIST TO BE COMPLETED ON INITIAL FITTING AND AT EACH OBSERVATION
1hr 2hr 3hr 4hr
Daily Complete chart overleaf and observe at least 3 times daily
Yes No
Yes No
Yes No
Yes No
Intact Broken
Yes No
Yes No
Yes No
If any of the above are yes document pressure prevention plan actions in nursing care plan
Has the patient any known allergies for example, nickel, plastic, latex etc Check relevant pulses in relation to splint / appliance. Is patient a Diabetic
Yes No Name any allergy
Yes No NA
Yes No
Body part to be applied to. Specify left/right! Other
Left Right
Other …………………... …………………………… …………………………….
Signs and symptoms that require referral to a Doctor
- Pain from body part supported - Skin temperature! or 1. - Check relevant pulses in relation to splint/appliance
Splint use for; Weight bearing Resting Sitting out Serial casting
Yes No
Yes No
Yes No
Yes No
Checklist before reapplying splint/orthotic device
Ensure splint is correctly fitted
Review and update pressure Area monitor plan
Orthotic padding/lining to be inserted
Straps and fastenings are secure
Rivets and screws are flush/ covered secure
There are no loose movements in any of the joints or spurs.
IF PATIENTS CONDITION CHANGES. I.E. SEPSIS. Immediately Review use of SPLINT/ORTHOTIC DEVICE. SEEK MEDICAL ADVICE IMMEDIATElY
Yes No
Yes No
Yes No NA
Yes No
Yes No
Yes No Review use of splint/orthotic device if there is any damage to the skin in the area being supported. Request an immediate Orthotic review.
Instruction leaflet supplied to ward Leaflet given to patient
Yes No Other
Yes No Other
Special instructions for application from Orthotist or prescriber
ie range of movement
Date of Orthotics review. If appropriate Any Comments ie if high risk of pressure damage
WMF823 Version 2: Review April 2019 KEY- Specialist Nurse Only - SNO Tissue Viability / Vascular Nurse LP71875
Orthotic Devices/Splint Monitor Plan
Monitor splint minimum three times a day following fitting or as instructed by the Orthotist
Date Time Observation
Checklist completed (Section B)
Document Problems identified
Plan and Action Taken
Signature, Print Name and
Designation
WMF823 Version 2: Review April 2019 KEY- Specialist Nurse Only - SNO Tissue Viability / Vascular Nurse LP71875
Patients Name: Unit Number: Date of Birth: Age: Appendix 10
SITUATION
Datix ID Number:
Date / time of completion:
Grade/ Category:
Location:
Deterioration : Yes / No
Device related: Yes / No
Please specify if yes:
BACKGROUND
Date of Admission:
Source of Admission:
Reason for admission: Past medical history:
Is the patient currently prescribed long term steroids or
cytotoxic drugs?
Yes / No
ASSESSMENT
Is the patient compliant with nursing intervention?
Yes / No
Date / time of Validation by Tissue Viability:
Skin Assessment
Pressure Ulcer Risk Assessment Score( PURS):____
Has the PURS been calculated on admission / transfer /
weekly or if the patients condition has changed: Yes /
No
Preventative aids in situ: Yes / No
Please specify:
Mattress in situ:
Date / time of installation:
Manual Handing Risk Assessment:
Has a Manual Handing Risk Assessment been
completed on admission / weekly or if the patient’s
dependency has changed? Yes / No
Level of Mobility ( Please specify):
Manual handling aids used: Yes / No
Please specify:
Evidence of slidesheet at the bedside: Yes / No
Continence Assessment:
WMF823 Version 2: Review April 2019 KEY- Specialist Nurse Only - SNO Tissue Viability / Vascular Nurse LP71875
ASSESSMENT
Any delays identified in providing equipment?
Yes / No
Care Standard 15 initiated: Yes / No
Wound Management Plan in place: Yes / No
Intentional Rounding Chart or Care Monitoring Chart
initiated: Yes / No
Average number of positional changes recorded within
24 hour period: __________
Is the patient incontinent: Yes / No
Please specify:
Nutritional Risk Assessment Score (NRS ):______
Has the PURS been calculated on admission / transfer /
weekly or if the patients condition has changed: Yes /
No
Has the appropriate action been taken: Yes / No
Please specify:
RECOMMENDATIONS
Any contributing factors you would like to highlight?
Completed by:
Key themes identified:
Areas of good practice:
Areas for improvement:
Action to be taken at ward level:
WMF823 Version 2: Review April 2019 KEY- Specialist Nurse Only - SNO Tissue Viability / Vascular Nurse LP71875
Appendix 11
Pressure Ulcers Advice for patients and relatives
What is a pressure ulcer? A pressure ulcer is caused when someone sits or lies in the same position for too long. The pressure cuts off the blood supply, damaging the skin What does a pressure ulcer look like? When a pressure ulcer first appears it can show as a change of colour, blister, swelling or patches of hot or cold skin Where could I develop a pressure ulcer? Pressure ulcers are more likely to appear on parts of the body which take weight and where the bones are close to the surface. Areas most at risk are heels, base of spine, elbows, bottom, shoulders and hips Who can develop a pressure ulcer? Anyone can develop a pressure ulcer. If you, your partner, your child or someone you are looking after has an illness that means they need to sit or lie in one position for any length of time you, or they, could be at risk of developing a pressure ulcer. What can be done to prevent pressure ulcers developing? To prevent pressure ulcers developing the following tips are recommended:
Check the skin at least once a day for signs of pressure damage. Keep your skin clean and dry, avoid heavily perfumed products or talcum powder as these can soak up the skin natural oils and dry it out
Make sure you turn and change your position regularly Eat a well balanced diet and drink plenty If you have to sit or lie for long periods of time make sure you have cushions or mattresses to reduce the risk of damage
WMF823 Version 2: Review April 2019 KEY- Specialist Nurse Only - SNO Tissue Viability / Vascular Nurse LP71875
If I develop a pressure ulcer what should I do? If you think someone you know is at risk of developing a pressure ulcer make sure you speak to a health professional immediately RM72 Pressure Ulcer Prevention and Management Policy – v1 2 Where can I obtain more information? If you require more information about how pressure ulcers develop and what you can do to prevent them, contact a member of the nursing staff within the hospital or community or access information by: Telephoning NHS Response Line on 0870 1555 455 and asking for a printed copy of Pressure Ulcers - Prevention and Treatment N0913 (Information for the public) or visit the website www.nice.org.uk where you can download a copy. Also information can be found if you log onto Your-Turn website www.your-turn.org.uk References National Pressure Ulcer Advisory Panel (2016) National Institute for Health and Clinical Excellence (2005) The Prevention and Treatment of Pressure Ulcer
Information Leaflet: NoIL207 Version: 1 Title: Pressure Ulcers First Published: March 2019 Review Date: March 2021 Author: Tissue Viability Service
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