Prevention and Management of Pressure Ulcers - Black ...

Version 1.4 January 2020

Prevention and Management of Pressure Ulcers

Target Audience

Who Should Read This Policy

All Clinical Staff

Prevention & management of pressure ulcers Policy


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Ref. CONTENTS Page No.

1.0 Introduction 4

2.0 Purpose 4

3.0 Objectives 4

4.0 Process 4-20

5.0 Procedures connected to this policy 20

6.0 Links to relevant Legislation

6.1 Links to relevant National Standards

6.2 Links to other key Policies

6.3 References

20 20 21

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7.0 Roles and responsibilities for this policy 23

8.0 Training 25

9.0 Equality Impact Assessment 26

10.0 Data Protection and Freedom of Information 26

11.0 Monitoring this Policy is Working in Practice 27

APPENDICES

1 Guidelines for completion of a body map 29

2 Adult Body map chart & skin integrity assessment sheet 30-31

3 Paediatric skin integrity & tissue viability risk assessment tool 32-34

4 Flow chart for prevention & treatment of Pressure Ulcers 35

5 Guide to reporting pressure ulcers - DATIX 36

6 Areas of the body at risk of Pressure Ulcers 37

7 Pressure Ulcer Grading Chart (Categories 1-4 etc.) 38

8 Grade 3 & 4 Pressure Ulcer Review Panel – Terms of Reference 39-40

9 Root Cause Analysis (RCA) for Pressure Ulcer Grades 2, 3 & 4 41-44

10 Wound care and treatment – care plan template 45-46

11 Management & Prevention of Nappy Rash & Moisture Lesions 47

12 Waterlow risk assessment tool 48-49

13 Malnutrtion Universal Screening Tool (MUST) 50-52

14 Pain assessment for people with dementia 53-56

15 Pain assessment for children 57

16 Simple, safe & effective 30° tilt 58

17 Pressure relieving equipment selection flow chart 59



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Explanation of terms used in this policy

Child and Parent Within this guideline, the term “Child” refers to infants, children and young people. The term “parent” refers to legal carers and any family member who provides care to the child.

Deep Tissue Injury (DTI) Are purple or maroon areas of intact skin or blood-filled blisters caused by damage to the underlying soft tissues and are known to deteriorate quickly even under optimal care.

Eschar Is a slough or piece of dead tissue that sheds or falls off from the surface of the skin. It is typically tan, brown or black and may be crusty.

Exudate Any fluid that filters from the circulatory system into lesions or areas of inflammation. It can be pus-like or clear fluid.

Device related pressure ulcer (DRPU)

A pressure ulcer that has developed due to the presence of a medical device (NHSI June 2018)

Moisture Associated Skin Damage (MASD)

Skin damage caused by excessive moisture e.g. perineal dermatitis, diaper dermatitis & incontinence associated dermatitis.

New Pressure Ulcer A “new” pressure ulcer is one that is first observed with the current episode of care

Pressure Ulcer Category 1-4

A pressure ulcer is localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful. (NHSI June 2018). Pressure ulcers are categorised from 1 to 4 depending on the severity.

Pressure Ulcer on admission (POA)

A pressure ulcer present when undertaking a skin inspection as part of the admission to the service/caseload/in-patient setting.

Slough The yellow/white material in the wound bed, it is usually wet but can be dry and generally has a soft texture. It can be thick and adhered to the wound bed, present as a thin coating or patchy over the surface of the wound. It consists of dead cells that accumulate in the wound exudate.

Skin tear A wound caused by shear, friction, and/or blunt force resulting in separation of skin layers. A skin tear can be partial-thickness (separation of the epidermis from the dermis) or full-thickness (separation of both the epidermis and dermis from underlying structures).

SSKIN A detailed skin assessment tool to be used for any patient with a Waterlow score of 10+ (At risk), or has an existing pressure ulcer, or is unable to re-position themselves independently.

Tissue Viability Tissue Viability refers to the assessment, treatment and management of patients with a wide variety of tissue integrity problems.

Unstageable pressure ulcers

Are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Ulcers covered with slough or eschar are by definition unstageable.


Version 1.4 January 2020 4

1.0 Introduction Pressure Ulcers can affect anyone from new-borns to those at the end of life and can cause significant pain and distress for patients. The Black Country Partnership NHS Foundation Trust recognises the need to minimise the risks and avoid unnecessary pressure ulcers within all patients’ care settings. Pressure ulcers cause considerable harm to patients and may lead to increased hospital costs and length of stay. Pressure ulcers may predispose the patient to infection, sepsis and treatment that may require surgical intervention. Occipital pressure ulcers may cause permanent alopecia, embarrassment and body image disturbances. (McCord et al 2004). Very young children (i.e. younger than 5 years of age) are at risk of pressure ulcer development, with the head (occiput) being the most common site of pressure ulcer occurrence (Quigley & Curley 1996).

2.0 Purpose To provide direction and standardise practice for staff on the prevention and management of pressure ulcers in a secondary care setting. 3.0 Objectives – delivering safe, high quality care

To identify those who are at risk of developing skin damage and pressure ulcers to ensure appropriate preventative interventions.

To provide guidance to all clinical staff on the key elements & requirements of practice when undertaking pressure ulcer preventative care and treatment which reflects National standards.

To ensure that patients receive timely, individualised, appropriate, safe, evidence-based pressure ulcer preventative care, to minimise the risk of complications.

To ensure that all patients receive on-going SSKIN skin assessment according to their individual clinical condition, age and specific needs.

To ensure National and Local requirements regarding reporting and investigating incidents relating to pressure ulcer prevention and management are followed.

4.0 Process 4.1 Assessment and Management of Skin from Admission/Initial Assessment through to Discharge. The skin of vulnerable adults and children can be compromised for various reasons including poor care and physical abuse. This can in the most severe cases, lead to the premature death of the vulnerable patient. It is essential that when a vulnerable patient moves into another environment i.e. hospital, ward, care home etc. that the condition of their skin is assessed using a body map to enable any further investigation to determine if abuse has occurred and if so where it occurred.



4.1.1 Adult Assessment On admission or first assessment the designated nurse will complete a

Waterlow risk assessment (Appendix 12) Body Map Chart & Skin integrity assessment sheet (Appendix 2) Also see Guidelines for completion of a Body Map Chart (Appendix 1)

4.1.2 Paediatric Assessment On admission or first assessment the designated nurse will complete the

Paediatric Skin Integrity & Tissue Viability Risk Assessment (Appendix 3) and record the score and any evidence of tissue vulnerability and act accordingly. The frequency of further re-assessments will be documented in the individuals care plan.

Other Useful tools (adults & children):

Flowchart for the prevention and treatment of pressure ulcers (Appendix 4), Areas of the body at risk of pressure ulcers? (Appendix 6)

In the community setting, staff must monitor skin integrity at each clinical opportunity, either in the form of a full skin inspection or by verbal questioning regarding possible pressure damage. A documented skin inspection must be reviewed as a minimum every 3 months for at-risk patients or as / when the clinical condition changes – the frequency will be determined by the Registered Nurse/Team Leader. For in-patients identified as being at-risk of developing pressure ulcers by the appropriate an screening tool, daily skin inspections must be undertaken and documented using appropriate clinical opportunities to check skin integrity. For in-patients who are fully self-caring, staff must monitor and document skin integrity daily, using appropriate clinical opportunities, either in the form of a skin inspection or by verbal questioning regarding possible pressure damage. A skin assessment includes all skin surfaces from head to toe. Special attention should be given to areas at high risk for pressure ulcer development. Particular attention should be given to the occipital area (back of head), sacrum, back, buttocks, heels and elbows. 4.2 Reporting of Pressure Ulcers All pressure ulcers Category 2 or above must be reported to the Trust through the Clinical Incident Reporting System (DATIX). If the pressure ulcer is a Category 3 or 4 this must be reported through the Trust Governance Team as a Serious Incident and reported on STEIS. See the Guide for reporting Pressure Ulcers - DATIX in (Appendix 5) A ‘round table’ approach is recommended when completing the RCA and should include all members of the multidisciplinary team involved in the patients care up until they developed the pressure ulcer. This will involve the Divisional Lead Nurse and other key individuals from the service.

Category 3 & 4 Pressure Ulcer Review panel -Terms of Reference (Appendix 8)



Root Cause Analysis Tool for Pressure Ulcers Category 2, 3 & 4 (Appendix 9) In-patients who have a pressure ulcer/moisture lesion etc. or who are identified as at high-risk of developing pressure ulcers on the Waterlow screening tool, must have skin inspections carried out and documented at every shift, one of these inspections should be undertaken by a Registered Nurse. When undertaking a skin inspection during admission to the service (caseload or in-patient setting), if the patient is observed to have a pressure ulcer, it will be referred to as a “pressure ulcer on admission” (POA). This must be documented in the patient’s notes and reported accordingly, (see Appendix 5)

A “new” pressure ulcer is one that is first observed with the current episode of care and must be reported accordingly. 4.2.1 Process for assessing Pressure Ulcers

1. Measure and trace the wound using a disposable tape measure and an aseptic technique (including depth) and document findings in the patient’s notes.

2. Take a digital photo and keep a copy in the patients notes (NB - must have patient consent – applies to adult patients only or parental consent for paediatrics

3. Report the pressure ulcer/moisture lesion including category on DATIX ensuring the Ward Manager & Nurse-in-Charge are notified (see Appendix 5 & 7

Most pressure damage can be prevented, and it can be argued that not to prevent the preventable constitutes neglect. (EPUAP 2001) A safeguarding alert must be considered for all Category 3 and 4 pressure ulcers. 4.3 Care and Treatment Planning 1. Implement appropriate plan of care in accordance with Policy and Treatment

Plan. (See the Flow chart for the prevention & treatment of pressure ulcers Appendix 4, and Wound Care and Treatment Care Plan Template Appendix 10)

2. Review treatment via Team/Multidisciplinary meetings.

3. Must have all relevant risk factors recorded on their risk assessment, including special considerations (additional risk factors such as anaemia, neutropenia, plaster casts etc.).

4. Must have their parent and carer involved in the assessment process and care planning process and be advised regarding their roles in identifying early signs of skin damage.

5. Must have an individualised documented plan of care, which includes the management of skin integrity and the risks identified. All care plans will identify repositioning regimes, appropriate support surfaces, appropriate equipment, and skin care to meet the individual needs and comfort of patient (including children).



6. Patients must be assessed for a high specification pressure-relieving mattress if identified as high-risk, the Tissue Viability Nurse may be able to advice.

7. Patients will be prescribed appropriate dressings as advised by the Tissue Viability Nurse, including alginates, soft silicones, films, hydrogels, and foams.

8. Patients will be given access to an interpreter if English is not the family’s first language, to help with pressure ulcer management.

9. If there is evidence of improvement, continue with current plan of care and review accordingly.

10. If there is no improvement and there is evidence of deterioration the treatment plan must be reviewed with the local Tissue Viability Link Nurse. If the pressure ulcer deteriorates, a new DATIX must be submitted within 24 hours. Appendix

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4.3.1 Non-compliance with Treatment Plans

Where there is an issue of non-compliance with recommended treatment plans, it is essential to ensure that the choice made is an informed one. Therefore, the patient’s capacity should always be considered and recorded in their records. If necessary, a best interest assessment should be completed and a safeguarding referral should be considered.

Please discuss the case with the relevant Line Manager and a Named Safeguarding Professional, as non-compliance may need to be considered.

In the case of children, the same process should be followed in as much as ensuring that the child is of an age to be deemed Gillick Competent. If the carers are seen as not adhering to any aspect of the care plan then again a safeguarding referral should be considered.

Not all pressure ulcers in an adult or child are the result of neglect or self-neglect but they may be an indication of lack of resources, lack of clinical skill or poor practice. As a result, consideration at each assessment should be given as to whether a Safeguarding Adults or Children’s referral should be made.

4.4 Who is at Risk? Deep tissue damage leading to pressure ulceration often occurs before outward signs are visible. Identifying individuals ‘at risk’ is essential in reducing the incidence of pressure ulceration. See Areas of the body at Risk of pressure ulcer areas diagram (Appendix 6) Although potentially all patients are at risk, some groups have an enhanced risk status these include;

Those with impaired mobility or who are immobile (including a recent fracture/ cast, prosthesis, splints, cardio vascular accident CVA)

Those with physical ill health e.g. chest infection, flu, winter vomiting disease

Those with severe depression leading to lack of motivation to mobilise

Those with anorexia nervosa

Those with impaired/compromised nutrition and/or dehydration

Those with a neurological or sensory deficit; dementia, CVA, MS, diabetes, spinal injuries, epilepsy, motor neurone disease

Those who are obese

Those with poorly controlled pain



The terminally ill

Those who are incontinent

Wheelchair users

Patients with chronic skin conditions such as eczema/psoriasis etc. should have specialist advice sought from a Dermatology specialist.

Assessment of the persons who have darker skin should have careful attention paid to any purplish/bluish looking areas of skin, localised heat or coolness and oedema

Health professionals also need to be aware that anxiety, a frequent feature of dementia and depression reduces the efficiency of the immune system. This has implications for existing ulceration and increases the risk of wound infection. 4.4.1 General Health When assessing the patient’s risk of pressure ulceration it is imperative that a holistic assessment is performed, as there are many predisposing factors such as:

Age - With increased age there is thinning of the dermis, which leads to decreased elasticity. The collagen in the dermis provides a buffer which helps to prevent disruption of the micro circulation. Also, it takes longer for an ulcer to heal in the older person when compared to a younger person. As age increases so does the likelihood of chronic illness which also predisposes to development of pressure ulcers.

Reduced Mobility - There may be numerous reasons why a patient (including children) has decreased mobility, neurological deficit such as paraplegia, multiple sclerosis, pain, diabetes and spinal injury or degeneration and patients undergoing major surgery. Reduced mobility increases the likelihood of pressure ulcer development.

Decreased Consciousness - There is a strong relationship between reduced movements and the development of pressure ulcers. Therefore, increased risk may be evident in those patients (including children) who are confused or patients on antidepressants or opioids because they may not move of their own accord in order to relieve their pressure areas.

Incontinence / Moisture Associated Skin Damage / Nappy Rash Moisture lesions, moisture ulcers, perineal dermatitis, diaper dermatitis and incontinence associated dermatitis (IAD) all refer to skin damage caused by excessive moisture. Yet there is often confusion between pressure ulcers and this kind of lesion. Due to the location of moisture lesions, they are often mistaken for pressure ulcers however, skin damage as a result of excessive moisture is defined as being associated with incontinence and not pressure or shear although moisture can contribute to the formation of pressure ulcers.

The risks of developing pressure ulcers or other problems with the skin increase where there is faecal and/or urinary incontinence, often resulting in maceration of the skin and friction This leads to the protective barrier of the skin being breached, allowing enzymatic attack. It is of paramount importance that clinicians are able to correctly identify this and implement strategies for the prevention and/or treatment of these lesions The significance of correct identification and classification has



never been more central, with many trusts identifying that Moisture Associated Skin Damage are often incorrectly categorised as category 2 pressure ulcers. Constant washing removes the body’s natural oils by drying the skin; however, dry skin can also cause problems. (See Management and prevention of nappy rash//Moisture Associated Skin Damage (Appendix 11)

Moisture Associated Skin Damage

Nutrition - Malnutrition is frequently cited as a risk factor for the development and non-healing of pressure ulcers. Malnutrition and specific nutrient deficiencies compromise the body’s ability to heal wounds and make the individual more susceptible to pressure damage. Nutrition plays a vital role in the prevention and treatment of wounds and pressure ulcers. Nutritional status has a direct influence on the health of the body’s tissue and its repair in the event of damage. Wound healing is a complex process which can be further complicated by chronic illness.

The nutrition of the patient (including children) with a pressure ulcer requires a multidisciplinary approach and effective communication between all health care workers. Improving nutrition can improve the quality of life by reducing the risk of infection, increasing the strength of the skin and improving the appearance of the patient’s pressure ulcer.

Many people admitted to hospital have an impaired nutritional intake due to functional or psychological issues, for example, arthritic fingers and self-neglect. Research has shown that nutritional status deteriorates in hospital, particularly in older people.

Malnutrition has direct influence on the development and severity of pressure ulcer (NICE 2005). Skin tolerance is also reduced by dehydration, decreased calorie intake and a fall in serum albumin; this increases the risk of skin breakdown and delays wound healing (NICE 2005). Utilise a dietary intake chart to identify the adequacy of total nutrient intake in in-patient units. The European Pressure Ulcer Advisory Panel (EPUAP) 2009, suggests that every individual with nutritional risk and pressure ulcer risk should be routinely referred to a dietician.

All patients should, be screened on admission/initial assessment for malnutrition using a recognised screening tool. Please see The Waterlow Risk Assessment Tool (Appendix 12), The Malnutrition Universal Screening Tool (MUST) in adults (Appendix 13), and the Paediatric Skin Integrity & Tissue Viability Risk Assessment Tool (Appendix 3).



Body weight - Emaciated patients have no subcutaneous fat particularly over the bony prominences and so have less protection against pressure ulcers. However, obese patients are also at high risk of pressure damage due to immobility and excess moisture in skin folds causing maceration. Both extremes of patient bodyweight may have poor nutritional status (Dealey 1994(a)). Factors affecting perfusion and oxygenation, diabetes, cardiovascular instability, hypotension, peripheral vascular disease and those with low oxygen saturations have reduced tissue perfusion and risk of pressure ulceration.

Holistic assessment - The potential to develop pressure damage may be influenced by both individual intrinsic factors and external or extrinsic risk factors, all of which need to be considered when performing a risk assessment. (including children). Individual or intrinsic factors relate to the patients tolerance to pressure, whereas external or extrinsic factors concern the intensity and duration of external pressures/ moisture.

Individual or Intrinsic risk factors to consider

Decreased mobility Can the patient relieve pressure from a particular area by repositioning themselves or do they need assistance to stand or walk?

Are verbal prompts needed for them to move?

Are they alert and orientated to their surroundings?

Does the patient have functional awareness of the need to reposition?

Is weight bearing not possible?

Is the patient in pain? Uncontrolled pain can affect mood and mobility

Positioning Does the patient need repositioning during the day and night? (Patients should be repositioned according to their individual schedule; if this does not happen then prolonged pressure on bony prominences may lead to the formation of pressure ulcers.)

Problems may also occur if the patient has a medical condition that makes repositioning difficult (e.g. cerebral palsy) or if the patient has had previous pressure damage. One year post healing the skin still has only 80% of its original strength so will still be vulnerable.

Age Older patients are more likely to develop pressure ulcers due to alterations in sebum levels and retraction at the epidermal junction; dry skin and erythema (redness) are alterations to the skins natural state and indicate an increased risk of pressure ulceration.

Neurological/ Sensory Impairment/ Psychological / Learning disability

The patient might not be aware of pressure in a particular area of the body and will therefore not reposition themselves to avoid discomfort.

Mood factors can also influence other risk factors such as mobility and nutritional status

Concordance with treatment is also required by the patient. Consider if they have the ability and motivation to do this?

Does the patient or Carer have the insight into the risks and care interventions associated with pressure damage.

Some learning disabilities and children will impact on capacity to understand the need for pressure prevention strategies

Disease pathologies

Acute, chronic, terminal illness and certain pathologies increase the risk of developing pressure ulcers.

The risk for diabetic patients, for example, is approximately three



Individual or Intrinsic risk factors to consider times higher than that for non – diabetic patient.

Heart failure patients may have oedematous / pitting oedema and the skin is more prone to breaking down. They may also become breathless on movement and so avoid doing so.

Impaired breathing /COPD patients have very poorly perfused tissues due to lack of oxygen. They may also be very limited in mobility due to breathlessness.

Some medications can also increase the risk of pressure ulcer development. Some drugs work on the central nervous system (as depressants) others, such as steroids taken either orally, topically or inhaled can affect the thickness of the skin.

Temperature Skin cell function is impaired if the skin becomes too hot or cold.

Decreased nutrition and circulation

Low body fat and low muscle bulk reduce padding on bony prominences.

High body fat patients have a thicker layer or adipose tissue but this tissue is poorly vascularised and there is greater bulk compressing the tissues

Dehydration is a major risk factor.

Contact the dietician for patients with heavy exuding wounds/ ulcers as these wounds lose protein and vitamins, which are needed with zinc, and some trace elements for effective wound healing. For adults see MUST tool (Appendix 13).

External or Extrinsic factors

Pressure The intensity and duration of pressure, particularly over bony prominences, is a major risk factor.

Friction When two surfaces move across one another, friction coefficient increases with moisture thus increasing associated shear effects. Often seen as a blister.

Shear

When underlying body structures try to move but the surface of the skin remains attached to the support surface (heels pushing up in bed)

Moist skin Moist skin (possibly due to incontinence or sweating) is more susceptible to damage.

A continence assessment should be completed and appropriate action undertaken to prevent excoriation of the skin and further damage.

A urethral catheter should be considered for patients with a Category 3-4 pressure damage whose wound is constantly wet due to incontinence of urine (with the patients consent) in order to promote wound healing and prevent further damage.

Time Pressure ulcers can develop quickly, sometimes in less than 1 hour and are associated with prolonged lying in the same position without adequate provision of a pressure relieving/ redistributing surface.

SSKIN Assessment

Surface: Make sure your patients have the right support.

Skin Inspection: Early inspection means early detection. Show patients and carers what to look for.

Keep your patients moving.

Incontinence/Moisture: Your patients need to be clean and dry.

Nutrition/Hydration: Help patients have the right diet and plenty of fluids.



(See Standard Operating Procedure 1 SSKIN Assessment & Appendix 3 for Paeds) Skin inspection Skin inspection provides essential information for pressure ulcer prevention. Regular inspection of vulnerable parts of the body will enable early detection of pressure damage. Skin should be inspected for any ulceration, redness, erythema, non-blanching erythema. It should include inspection of the most vulnerable areas of risk for each patient including children are typically:- occipital areas and ears back of head Temporal regions of the skull Shoulders Spine Scapular Elbows Hips Sacrum Ischial tuberosities Knees Ankles Heels Toes Parts of the body that are affected by the wearing of anti-embolic stockings Parts of the body where pressure, friction or shear is exerted in the course of

an individual’s daily living activities e.g. on the hands of wheelchair users Parts of the body where there are external forces exerted by equipment and

clothing e.g. endotracheal tubes, intravenous lines, catheters, shoes, elastic clothing

Blanch testing of intact skin aids the identification of potential damage. Pressure is applied to the ‘red’ area, healthy microcirculation will cause the skin to turn white, and on removal of pressure, the capillaries will refill and turn the skin back to red. This indicates the skin is healthy and there is no pressure damage. If the skin does not turn white on the application of pressure the microcirculation is already damaged and the patient has a Category 1 pressure ulcer. Sometimes the skin will be slow to turn back to red, this is known as ‘sluggish hyperaemia’ and indicates the need to start or increase repositioning – if this is not done pressure damage will occur.

The assessment of darkly pigmented skin is different. Clinical signs to consider

during skin inspection are; localised heat and purplish/bluish skin hue. If pressure damage has already occurred the area may feel cool, harder, have increased pain and localised oedema. Pressure ulcers are under detected in darkly pigmented skin as early damage is harder to see. (See Appendices for Body maps, guidelines and assessments)

Should patients be using a medical device i.e. callipers, plaster cast or naso-gastric

tube fixers the risk of pressure ulcers should be considered.



Children with chronic skin conditions such as eczema/psoriasis etc. should have specialist advice sought from a Dermatology specialist if deemed necessary. Pain

Assess for pressure ulcer related pain using a validated pain tool; include non-verbal cues and body language - see Pain Assessment of People with Dementia (Appendix 14) and for Pain Assessment in Children (Appendix 15)

Use appropriate equipment to minimise friction/shear when repositioning, keep sheet smooth and wrinkle free.

Position off the pressure ulcer whenever possible.

Avoid postures that increase pressure i.e. 90-degree side lying or semi recumbent (30 degree lateral tilt) see Appendix 16.

Handle all wounds gently, irrigate carefully, protect surrounding skin, remove dressings correctly, choose appropriate dressings.

Organise care delivery in co-ordination with pain relief.

Where possible provide pain relief 20-30 minutes prior to intervention.

Encourage the patient/ child to request ‘time out’ if the procedure causes pain.

Re-Positioning Relieving pressure especially over bony prominences is of primary concern. Patients with limited mobility are especially at risk for the development of pressure ulcers. Every effort should be made to redistribute the pressure on the skin, either by repositioning or utilising pressure relieving surfaces. Pressure redistribution can be achieved through repositioning and use of pressure redistribution surfaces & Physiotherapist’s input to the patients care is valued.

Consider mobilising, positioning and repositioning interventions for all patients (including those in beds, chairs and wheelchair users) (NICE, 2005). Frequency of repositioning will be determined by an individual assessment and daily skin inspections. In the community setting the patient’s carer’s may be involved and should have adequate instruction to ensure no further skin damage e.g. due to shearing.

Frequency must be adjusted according to the response of the patients’ skin to pressure/ tissue tolerance, as indicated by changes in skin colour/ texture/ temperature etc. (i.e. if the skin reddens after two hours, reduce the time interval and reassess. If there is no evidence of persistent erythema or any other indication of early tissue damage, then the frequency of repositioning may then be reduced). The acutely at risk patient should still be assessed every two hours (NICE 2005; European Pressure Ulcer Advisory Panel, 1999).

All patients with pressure ulcers should actively mobilize or change their position or be repositioned frequently.

Minimise pressure on bony prominences and avoid positioning on pressure ulcer if present.



Frequency of repositioning may be restricted by the patients’ medical condition, level of comfort and attached medical devices e.g. IV cannulae, external fixators, urinary catheters. In cases where patients cannot be adequately repositioned suitable support surfaces must be used and regular repositioning introduced as soon as possible.

If unable to turn the patient’s position then a 30° lateral tilt can be achieved to minimise pressure on bony prominences. See Simple Safe Effective 30° Tilt (Appendix 16)

It is important to recognise and prevent the effects on the skin caused by poor

manual handling techniques. A documented care plan to minimise friction, shear, rubbing or dragging on the patients skin should be documented, implemented, and evaluated.

Devices to assist manual handling such as slide sheets and hoists should be used to reduce the potential skin damage to the patient or injury to carers.

Older children/young people at risk of developing pressure ulcers should be discouraged from sitting in chairs for prolonged periods.

Patients who use wheelchairs should be assisted to regularly redistribute their weight. An agreed period of time should be negotiated with the patient and carer and should be recorded in the care plan and should be no longer than two hours. Use of pressure relieving cushions should be based on risk assessment. Specialist advice and expertise on repositioning patients with restricted mobility should be obtained from the Moving & Handling Advisor for the division/Tissue Viability Specialist Nurses and the Physiotherapist.

4.5 Mattresses, Support Surfaces and Equipment

Consideration will need to be given to the utilisation of specialist pressure, redistribution or pressure relieving equipment by the multi-disciplinary team. (See Pressure relieving equipment selection flow chart (Appendix 17)

It is important that the following factors be taken into account: Individual clinical need and general comfort of the patient

Acceptability of the equipment to the patient and carer

Compatibility of the equipment for use with the patient

Ease of use

Impact on care procedures

Cost

All equipment must be used in accordance with the manufacturer’s instructions, and equipment provided must not put the patient at any additional risk to their health and safety.

Staff must not use equipment for which they have not received training; it is their

responsibility to identify and rectify deficits in training needs according to local guidelines.



The provision of specialist mattresses does not replace the need for repositioning/redistributing the patient’s weight.

Unless there is a clinical contra-indication patients on pressure redistributing/

relieving surfaces still need to be re-positioned as directed by their individual risk assessment.

If additional equipment i.e. pillows, gel pads are used to prevent pressure between knees and ankles, their use must not compromise the pressure redistribution / relief of the support surface the patient is being nursed on.

Patients who have specific moving and handling requirements may also require additional equipment such as:

A hoist

Low friction slide sheets, or handling belts to assist with patient movement that will reduce the risk of problems associated with shear or friction.

N.B. The use of water filled gloves or sheepskins, Doughnut type devices, i.e. ring cushions is no longer acceptable under any circumstances (NICE, 2003). Guidance is given in the selection of the correct pressure relieving equipment on the Pressure relieving Equipment Selection Chart (Appendix 17). Allocation of specialist mattresses should be considered in accordance with an overall assessment and not based solely on the basis of risk assessment scores (EPUAP/NPUAP 2009).

The health professional’s judgement is key here.

Check that the base on which they are placed provides adequate support for the device, as per the manufacturer’s instructions.

Provide information for carers/family/friends, when caring for someone on pressure relieving equipment.

4.5.1 Seated Assessments and Posture A good, stable posture is central to pressure reduction, however poor posture can predispose pressure ulcers and can render ineffective any pressure-reducing cushion. Remember that in any seated position, the body weight is being taken over a much smaller surface area, possibly even smaller if posture is affected, therefore the risk is increased. The physiotherapy & occupational therapist input should be included in the assessment and patient care. A good posture may be described as-

Upright

No gap between pelvis and chair back

Spine supported upright in natural curvature (back supported at a slope will increase shear forces to buttocks)



Weight distributed through ischial tuberosities (not sacrum) and thighs. This is achieved by maintaining the hollow of the back and correct chair height allowing the thighs to lie level on the seat

The seat should be the correct dimensions for an individual i.e. feet should be flat on the floor (up to 25% of the body weight is transmitted through the feet if they are flat); arms supported on the armrests with shoulders in neutral position and correct width, depth dimensions.

Good Posture

Poor Posture

Backwards Slump Sideways slump



4.5.2 Cushions The cushion should provide the optimum postural support and maximum contouring with the patient’s body shape in order to distribute pressure as evenly as possible. Any contouring provided by the cushion will allow the ischial tuberosities to sit lower than the thighs; increasing stability this reduces the slide forward, which reduces both friction and shearing. In children the cushion/contouring is usually built into their seating systems. 4.5.3 Factors to consider for cushions - Cautions:

Placing any cushion on top of a chair will impact on its dimensions/height and in turn its support and stability for the individual. This may affect transfers/posture/functional ability.

User Weight. Please remember all equipment has a user weight.

Alternating Pressure Cushions and Riser-recliners. There are contraindications for use with this type of equipment e.g. alternating cushions that are electric and need to be plugged in can pose a different risk on recliner chairs so risk assessment should be carried out prior to issue. The wires could become trapped in the chair mechanism and the cushion is likely to be less effective, if at all due to changes in position and weight distribution during reclining. These cushions also pose a risk with posture as they can be unstable and increase postural instability and shear. Please seek further advice regarding this option. There are certain types of cushion which require the patient to be positioned correctly on them to be effective e.g. Contoured cushions. If used incorrectly, they may cause further damage. Please seek further advice if unsure.

4.5.4 Reassessment It is important to reassess the patient’s equipment needs regularly, at least weekly or as documented in the individuals care plans. It is important to utilise the equipment as per the patient’s needs this may mean upgrading or down grading equipment. 4.5.5 Continence Management It is generally recognised that incontinence is one of the major causative factors in the development of pressure ulcers/ nappy rash and moisture associated skin damage. It increases the risk of friction and the chemical reaction of urine and faeces on the skin causes further tissue breakdown with ammonia being produced leading to excoriation. This increase in moisture combined with bacterial and enzymatic activity can result in the breakdown of vulnerable skin. Therefore, the treatment of any incontinence needs to be addressed. In incontinence related moisture lesions the skin should be cleansed with cleansing foam and a barrier film is recommended. They must be labelled for individual single patient use.



The patients’ skin should be kept clean and dry. The use of soap can destroy the natural oils produced in the sebaceous glands of the skin and it is advisable not to use soap for skin cleansing. Specialist expertise and advice about the care of children with chronic or unusual skin problems should be obtained from the Multidisciplinary Team or via referral to a specialist if deemed necessary. 4.6 Heel Pressure Ulcers Pressure ulcers on the heel can develop as a result of both intrinsic and extrinsic factors, They are the second most common site for the development of pressure ulcers (Cheneworth, 1994). The heel has a relatively low resting blood perfusion level and ulceration can occur if subjected to pressure lower than 32mmHg, friction and shearing forces can reduce the tissue tolerance even further (Cheneworth, 1994). A vascular assessment should be undertaken if ischaemia is suspected. The most effective way of relieving pressure is to totally offload the pressure on the heel. Prevention can be achieved with the following:

Pillows – Carefully placed will relieve pressure but a higher amount of pressure may then be borne by the rest of the limb

The use of the 30° lateral tilt where a pillow is placed to act as a ‘space filler’ (Appendix 16)

Where relevant

The use of a bed cradle to take away the weight of the bedclothes

Foam leg troughs and foam heel suspension boots

Air filled heel protectors i.e. waffle and repose boots.

Gel heel pads

Fibre filled heel pads can be used to protect from friction and shearing but do not offload pressure.

Foam dressing products do not offer any offloading or pressure relief and should not be used for treatment or prevention purposes.

Heel protection devices should elevate the heel completely (offloading) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. The heel should be in a slight flexion. Pressure reducing mattresses do not appear to be effective in preventing heel ulcers as, mechanisms, which offload pressure. Therefore, their use is questionable for the treatment and prevention of heel ulcers alone (Dinsdale, 1974). Identified patients in inpatient areas who wear compression hosiery or anti-embolism stockings need to be able to have their heels checked daily for any pressure damage (Donnelly, 2001).



4.7 Infection Prevention High standards of infection prevention must be maintained, using standard precautions, maintaining asepsis and appropriate hand decontamination. Wherever possible the pressure ulcer must be covered. Further advice must be obtained from local Trust guidelines and the Infection Prevention & Control Team. Adults, children /young people who are transferred from other hospitals or community homes should be screened in accordance with the local Infection Prevention & Control Policy. When screening swabs are obtained, they should include swabs of any wounds, lesions or pressure ulcers.

Any patient who has an interruption in the continuity or integrity of their skin is at risk of developing a local or systemic infection and may also pose a risk to other patients. Individual advice should be sought from the Infection Prevention & Control Team. Signs of infection include-

pyrexia

increased pain at the site

cellulitis

malodour

increasing size of ulcer

purulent discharge

tachycardia / tachypnoea Sepsis should be considered as a possibility if the patient becomes unwell. 4.8 Patient / Parent / Carer Information Adults, children, young people referred to BCPFT clinical services (including their parents and carers), will be provided with written peer and patient reviewed information identified on the care plan to include:

A patients risk of pressure ulcers

Pressure ulcer prevention strategies (repositioning, nutrition, equipment, skin inspection, skin care etc.)

Safe use of specialist equipment

Useful contact details see SSKIN patient leaflet found in SOP 1: SSKIN Assessment

The patients and family will be given the opportunity to ask questions and share their views. They will be encouraged to actively participate in care planning and care interventions to maintain or improve their tissue viability. 4.9 Discharge or transfer of patients All patients should be reassessed, including skin assessment, prior to discharge or transfer from BCPFT services. This should be documented accurately and should include a description of the patient’s pressure areas. If any pressure ulcers are present, there should be a wound assessment and details of the treatment plan. When discharging or transferring a patient from hospital it is essential that all the relevant people are informed. This includes District Nurses, Community Paediatric



Services, General Practitioners, Carers and Nursing Homes. This contact should be timely in order to ensure relevant resources are in place prior to discharge. 4.10 Compliance/Capacity Compliance/capacity refers to patient’s ability to follow a treatment plan that has been agreed between the patient and health care professionals. The nurse should not only assess compliance/capacity but also identify potential reasons for non- compliance. Pressure ulcer treatment and palliative/end of life care

Set treatment goals consistent with the values and goals of the patient whilst considering family input

Set goals to enhance quality of life; healing may not be achievable but reducing pain/odour/exudate

Assess the pressure ulcer at least every two days unless the patient is end of life and document findings

Monitor to ensure the aims of comfort and reduction in wound pain/symptoms are met

Debride the ulcer of devitalised tissue to control infection and odour only if healing can be achieved

Consider charcoal dressings to help control odour

Utilise dressings that do not require frequent changing but manage the wound Symptoms

Utilise a dressing that maintains a moist healing environment and is comfortable for the patient if healing can be achieved. If not and necrosis is dry maintain a desiccated state.

For children who are end of life – liaise with tissue viability and all healthcare professionals involved to plan the appropriate course of action.

5.0 Procedures connected to this Policy Prevention & Management of Pressure Ulcers SOP 1 – SSKIN Assessment.

6.0 Links to Relevant Legislation

Department of Health (2010a) Equity and Excellence Liberating the NHS London:

Department of Health (2010b) The NHS Quality, Innovation, Productivity and Prevention Challenge: An Introduction for Clinicians. London: DH.

Department of Health (2009a) NHS 2010–2015: From Good to Great. Preventative, Peopled-centred, Productive. London: DH.

Department of Health (2009b) The Framework for Quality Accounts: A Consultation on the Proposals. London: DH.

Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report.London: DH.

Department of Health 1999. Making a difference: strengthening the nursing

and health visiting contribution to health and healthcare

Department of Health 2001 Essence of care Department of Health London

http://luna.smhsct.local/documents/policies-a-z/p/4214-pressure-ulcers-prevention-and-management-sop-1-sskin-assessment/file

http://www.tinyurl.com/equality-and-excellence

http://www.tinyurl.com/nhs-quality



http://www.tinyurl.com/good-productive

http://www.tinyurl.com/good-productive

http://www.tinyurl.com/account-framework

http://www.tinyurl.com/account-framework

http://www.tinyurl.com/high-quality-care

http://www.tinyurl.com/high-quality-care



Department of Health 1999 Making a difference: strengthening the nursing and health visiting contribution to health and healthcare

6.1 Links to Relevant National Standards

Care Quality Commission(CQC)

NHS Litigation Authority (NHSLA)

National Institute for Health & Clinical Excellence (NICE)

NICE Clinical Guideline CG179

Pressure Ulcers published April 2014

6.2 Links to other Key Policies

Care Record Keeping

Risk Management Strategy Policy and Process

Infection Prevention and Control Standards and procedures 6.3 References

Bale, S (2005) Chapter 6, Incontinence Care In: Skin Care In Wound Management Assessment Prevention and Treatment, Wounds UK Ltd, Aberdeen.

Cheneworth CC et al. (1994). Portrait of practice: healing heel ulcers. Advances in Wound Care. 7,2, 44-48

Collins, F (2001) How to assess a patient seating needs, some basic principles. Journal of wound care 10(9) 383-386

Cooper P. Gray D. (2001) Comparison of two skin care regimes for incontinence, British Journal of Nursing Tissue Viability Supplement Vol 10 No 6 pS6-S20.

Dealey C. (1994) (a) The Care of Wounds. Blackwell Scientific Publications. Chapter 5 P83.

Department of Health – (1995) Pressure ulcers: A Key Quality indicator. HMSO London.

Defloor, M, (1999). The risk of pressure sores- a conceptual scheme. Journal of clinical nursing, 8 (2) pp63-64

Dinsdale. S.M. (1974). Decubitus ulcers: role of pressure and friction in causation. Arch Phys Med Rehab. 55:4 pp147-152

European Pressure Ulcer Advisory Panel (2001) Pressure Ulcer Prevention Guidelines, EPUAP Business Office. Churchill Hospital Old Road Headington, Oxford

European Pressure Ulcer Advisory Panel (2003) Pressure Ulcer Prevention Guidelines, EPUAP Business Office. Churchill Hospital Old Road Headington, Oxford

European Pressure Ulcer Advisory Panel (1999) Pressure Ulcer Prevention Guidelines, EPUAP Business Office. Wound Healing Unit Department of Dermatology. Churchill Hospital Old Road Headington, Oxford

National Institute for Clinical Excellence (2003), CG29. Pressure ulcers: prevention and pressure relieving devices. NICE. London



National Statistics online (31st January 2006) Preston K. N. (1988) Position for comfort and pressure relief: the 30 degree alternative. Care Science and Practice 6. 4. 116-9.

Nursing and Midwifery council (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. NMC. London

Torra I, Bou J, Garcia-fernandez FP, Pancorbo-Hidalgo PL, Furtado K. Risk assessment scales for predicting the risk of developing pressure ulcers. In: Romanelli M, Clark M, Cherry G, et al (eds). Science and practice of pressure Ulcer Management. London: Springer-Verlag, (2006).

Tissue viability society 2009 Seating and Pressure ulcers Clinical Practice Guideline

Waterlow J. (1988) Prevention is cheaper than cure. Nursing Times 84 25 p69-70

Paediatric pressure ulcer guidelines developed by: The West Midlands Paediatric Tissue Viability Regional group (Adapted from Birmingham Children’s Hospital guidelines March 2012)

Buckingham KW and Berg RW. (1986) Etiological factors in diaper dermatitis: The role of faeces. Paediatric Dermatology 3(2) pp.107-12.

Gray M (2004) Which pressure ulcer scales are valid and reliable in the paediatric population? Journal of Wound Ostomy and Continence Nursing 31, pp.157-160.

Bethell E (2005) Wound care for patients with darkly pigmented skin. Nursing Standard 20 (4) pp.41-49.

McGurk V, Holloway B, Crutchley A and Izzard H. (2004) Skin integrity assessment in neonates and children. Paediatric Nursing 16 (3) pp.15-18.

Sims A and McDonald R. (2003) An overview of paediatric pressure care Journal of Tissue Viability 13 (4) pp.144-148.



7.0 Roles and Responsibilities for this Policy

Title Role Key Responsibilities

Trust Board Strategic Trust Board is responsible for:-

- Setting policy for the organisation through powers delegated to relevant committees;

- Ensuring policy is implemented through agreed management arrangements;

- Ensuring they are alerted to relevant issues arising that may affect policy

Chief Executive

Accountable The Chief Executive is responsible for:

- Agreeing annual policy objectives with Executive Directors who will ensure appropriate cascading of objectives throughout the area of their responsibility;

- The provision of sufficient resources to implement policy;

- Ensuring that arrangements are in place so that all employees are fully aware of their statutory responsibilities and that those responsibilities are fulfilled;

- Ensuring that the organisation complies with its statutory requirements;

- Ensuring that the arrangements in support of policy are fully implemented by Divisions.

In order for this responsibility to be effectively discharged, other senior colleagues will have specific delegated responsibility

to support the Chief Executive in this process.

Director of Nursing and

Professional Practice Executive Lead Responsibility for this policy has been delegated by the Chief Executive to the Director of Nursing and Professional Practice

who:-

- is responsible for ensuring the Trust’s prevention and management of pressure ulcers is discharged appropriately and has lead responsibility for the implementation of this policy

- Identifying and implementing strategies to minimise any risks in relation to the standards for pressure ulcers

- and that any serious concerns regarding the implementation of this policy are brought to the attention of the Board

Divisional Managers

and Lead Nurses

Operational

Supervision

- Ensure Pressure Ulcer assessment and management system is implemented and monitored within the Division

- Ensure any shortfalls, gaps or concerns with regard to pressure ulcers are investigated with the Clinical Teams to ensure

remedial action is taken.

Title Role Key Responsibilities

Service Managers and

Deputy Modern

Matrons

Operational

Supervision

- To ensure appropriate staff undertake risk assessments for the prevention and management of pressure ulcers.

- Ensure that staff are skilled and adequately supervised to allow them to perform their work safely

- Ensure all pressure ulcers are graded, reported, investigated and appropriate measures taken to prevent recurrence

- Ensure staff are familiar with the pressure ulcer risk assessment process



- Where pressure ulcers identify a need for additional resources, ensure that the situation is analysed, actions agreed and

implemented.

- Audit of clinical practice as part of documentation audits to ensure this policy is implemented in practice

Ward or Team

Managers

Operational

Supervision

- Ensure staffs understand their responsibilities with regard to the pressure ulcers prevention policy, guidelines and annual audit.

- Ensure staff attend appropriate training and are competent to carry out a Waterlow risk assessment, grading of pressure ulcers where applicable, report accordingly and implement appropriate management plans.

- Ensure staffs talk to service users, carer and family about pressure ulcer prevention and management plans.

- Monitor the implementation of the Pressure Ulcer Prevention policy through line management supervision.

- Support Tissue Viability Link Nurses in their role

- Ensure all pressure ulcers are reported through the Trust incident Reporting system DATIX

- Ensure case note audits undertaken include the compliance monitoring in relation to this policy

Trust Tissue Viability

Nurses/ Link Nurses

(including paediatrics)

Health Care

Professionals

Adherence All Health Care Professionals must:

- Familiarise themselves with this Policy and NICE Prevention and Treatment of Pressure Ulcers Quick Reference Guide. (NICE 2005)

- Ensure the Waterlow Pressure Ulcer risk assessment is completed on all service users admitted to an inpatient setting and a pressure ulcer management plan is formulated where appropriate.

- Assess and manage skin from admission to discharge as per Trust Flowchart for Prevention and Treatment of Pressure Ulcers. (Appendix 1a)

- Ensure any evidence of a pressure area is graded in accordance with the Pressure Ulcer Grading Chart NHS Midlands and East adapted from EPUAP/NPUAP 2009 (Appendix 2a & 2b)

- Ensure continuity of care between shifts via handover

- Ensure service users and carers are involved in treatment and care planning

NB NICE guidance does not override the individual responsibility of health professionals to make decisions appropriate to the

needs of the individual service users.



8.0 Training Please refer to the Trust’s Mandatory and Risk Management Training Needs Analysis for further details on training requirements, target audiences, and update frequencies.

What aspect(s)

of this

policy will require

staff training?

Which staff groups

require this

training?

Is this training

covered in the Trust’s

Mandatory

and Risk Management

Training Needs

Analysis

document?

If no, how will the training be delivered? Who will deliver the training?

How

often will

staff

require training

Who will

ensure and

monitor

that staff

have this

training?

All aspects

needs specialist

training

including assessment

& treatment

of pressure

ulcers

Registered

Nurses/ Health Care

Professionals/

Health Care Support

Workers

No External study days

Liaison with wound dressing providers e.g.3M https://www.3mlearning.co.uk/courses/skin-care-

pressure-ulcers#courseSubMenu

https://www.3mlearning.co.uk/courses/wound-

care#courseSubMenu

E-learning

Stop the pressure workbook

https://nhs.stopthepressure.co.uk/docs/Workbook%20(1

).pdf

Tissue Viability trained nurses external to BCPFT via one off

arrangements or SLAs

On-line e-learning

As

directed by Line

Managers

or

Matrons

Physical

Health Steering

Group

https://www.3mlearning.co.uk/courses/skin-care-pressure-ulcers#courseSubMenu

https://www.3mlearning.co.uk/courses/skin-care-pressure-ulcers#courseSubMenu

https://www.3mlearning.co.uk/courses/wound-care#courseSubMenu

https://www.3mlearning.co.uk/courses/wound-care#courseSubMenu

https://nhs.stopthepressure.co.uk/docs/Workbook%20(1).pdf

https://nhs.stopthepressure.co.uk/docs/Workbook%20(1).pdf



9.0 Equality Impact Assessment

Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected]

10.0 Data Protection and Freedom of Information

Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act. All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.

mailto:[email protected]

http://simple.wikipedia.org/wiki/Information

http://simple.wiktionary.org/wiki/right



11.0 Monitoring this Policy is Working in Practice

What key elements will be monitored?

(measurable policy objectives)

Where described in

policy?

How will they be monitored?

(method + sample size)

Who will undertake this monitoring?

How Frequently?

Group/Committee that will receive

and review results

Group/Committee to ensure actions

are completed

Evidence this has

happened

Pressure Ulcer 4.0 Process Individual Care Plans and healing processes

Safety thermometer

Ward Managers,

Service Managers

Matrons

Determined by GAU

Divisions

Governance Assurance Unit

Physical Health Steering Group

Physical Health Steering Group

n/a



APPENDICES TO SUPPORT THIS POLICY



GUIDELINES FOR COMPLETION OF BODY CHART

1. Complete body chart on admission or following a significant event.

2. Using the key below, shade onto the body chart the affected area, from the site draw an arrow and put the key next to it. Any characteristics i.e. colour of bruise, length of scar, MUST be added.

3. Sign and date the form.

4. Repeat as advised, remembering to file previous forms in the patients notes.

5. If a DATIX form is used please enter number here:

KEY

1. Bruise 2. Abrasion 3. Skin tear

4. Laceration 5. Haematoma 6. Operation scar

7. Swelling 8. Tattoo 9. Self-harm wound

Please Note See Appendix 4 regarding mandatory reporting of pressure ulcers Different skin shades and types present in different ways. If you are unfamiliar with any discolouration or injuries to a patient, always report it to the nurse in charge, advice can also be sort from the Tissue Viability Lead / link nurses

Appendix 1

DATIX NO:



ADULT Body Map Chart & Skin Integrity Assessment Sheet

Patient Name: NHS Number:

Completed by Name: Designation:

DATIX No. (if applicable) Date Completed:

Section 1: Body Map

Appendix 2



Section 2: Skin Integrity Assessment Sheet

Please see diagram to illustrate location of any skin damage including abrasions, rashes, wounds, red/darkened areas and size of wound.

Pressure ulcers are avoidable if regular assessment is undertaken and preventative care interventions are implemented and documented on the individualised care plan.

European Pressure Ulcer Grading System

Grade 1 Non-blanchable erythema of intact skin

Grade 2 Partial thickness skin loss involving epidermis or dermis or both

Grade 3 Full thickness skin loss or necrotic tissue

Grade 4 Extensive destruction tissue necrosis damage to muscle bone or supporting structures.

Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough

Deep Tissue Injury

Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying tissue from pressure and/or shear.

Action taken Date Details Sign

Pressure Ulcer measured

Wound Swabs taken

Photographs taken

Referrals to



Paediatric Skin Integrity/Tissue Viability Risk Assessment Tool

Please affix patient label here to include Name, DOB & NHS Number

All patients must be assessed within 6 hours of admission and reassessed according to risk score.

Note: For Community nurses completing this assessment tool. Where a high score is indicated, please use professional judgement to review patient presentation and condition alongside the score to determine the appropriate actions.

Ensure that parents/carers are fully informed of the outcome, and any actions they need to take are clearly explained and understood, and that they have a full understanding of when to seek advice. All information should be clearly documented in patient records.

Please continue overleaf

Risk Factors

Green = 0 Amber = 1 Red = 2 1 2 3 4 5 6 7

Weight Average weight 2 centiles over or underweight

More than 2 centiles over or under weight

Respiratory Self- ventilating Oxygen therapy Ventilated non-invasive respiratory support

Neurological Conscious and alert (GCS 10-15)

Neurological deficit (GCS-9)

Unconscious (GCS -5)

Sedation Not sedated Intermittently sedated Continually sedated and paralysed

Sensory No sensory loss Some sensory loss Cannot perceive sensation or paralysed

Mobility/ Posture

Mobile Mobility limited Restricted/or minimal handling Restless/fidgety

Immobile/paralysed Spinal injury/head injury Theatre > 4 hours Wheelchair user

Mobility / Handling

Moves without assistance

Needs assistance to move

Consistently difficult to reposition

Nutrition Normal diet or NBM < 4 hours

Enteral or parental feeds

NBM > 4 hours IV fluids or parental nutrition

Continence Continent Occasional incontinence or nappies < 5 years old

Incontinent nappies > 5 years

Skin Condition Intact / healthy Surgical wound or abrasions or stoma

Skin oedematous broken, excoriated or burnt

Tissue perfusion No problem capillary refill <2 seconds

Poor perfusion capillary refill <3 seconds

Prolonged capillary refill >3 seconds

Pain Pain free Intermittent/pain on movement PCA or NCA

Continuous pain or discomfort, Epidural.

NB: Special Considerations

Date & Time Assessed by Score Comments

Action to be taken – see score below 0 CAMHS Patients only Reassess monthly

0-5 Low Risk Reassess weekly

6-10 Medium Risk Review daily

11-20 High Risk Review 8 hourly

Over 20 Very High Risk Review 6 hourly

Appendix 3



KEY CODE N.B. All patients at risk require a preventative care plan Skin intact (no pressure ulcers or moisture

associated skin damage) B Blanching erythema i.e. skin is red, but

blanches (turns white) under light finger pressure

1 Category one pressure ulcer – skin red but does not blanch under light finger pressure. If skin is darkly pigmented, observe/palpate for changes in colour, oedema and pain.

2 Category two pressure ulcer - affecting epidermis/dermis only or blister (complete wound care plan)

3 Category three pressure ulcer – full thickness skin loss (including subcutaneous layer) (complete wound care plan)

4 Grade four pressure ulcer – full thickness plus visible muscle/bone (complete wound care plan)

U Unstageable due to pressure or shear (not able to grade accurately)

SDTI Suspected Deep Tissue injury due to pressure or shear (not able to grade accurately)

MASD Moisture associated Skin damage – do not grade as a pressure ulcer

MDRPU Medical Device related pressure ulcer. Device related pressure ulcers should be reported and identified by the notation od (d) e.g. Category 2 (d)

VO View obscured i.e. POP insitu D Declined full inspection – this only applies to young people who have mental capacity to make this decision and is deemed to be clinically right

Skin Inspection records: Name/NHS No:

Date:

Time:

Location:

Frequency of

skin inspection:

Head (front)

Head (back)

Nose

Left Ear

Right Ear

Left Elbow

Right Elbow

Sacrum

Left Buttock

Right Buttock

Natal Cleft

Left Hip

Right Hip

Left Knee

Right Knee

Left Heel

Right Heel

Left Ankle

Right Ankle

Other please

state:

Registered Nurse

initials:

HCA/Student Nurse:



ACTION TO BE TAKEN IN THE COMMUNITY *Children’s Services Score Outcome Repeat risk

assessment and Skin

inspection

Care Plan

Patient Parent advice (SKIN)

Surface Skin Inspection

Keep Moving (Repositioning

tool)

Incontinence Nutrition Referral to TV Nurse

0-5

Low risk

On first visit reassess on change of condition or environment

Parents / carers to review with cares

Encourage a well-balanced healthy diet and plenty of fluids

6-10

At risk

3 monthly if skin intact. Or change of condition or environment

Consider appropriate equipment provision


Encourage / assist with repositioning min 4 hourly Ensure parents/carers are aware

Consider skin care and continence products if appropriate

Encourage a well-balanced healthy diet and plenty of fluids Liaise with dietitian if on enteral feeding as feed may potentially may need to be to altered

11-20

High risk

3 Monthly if skin intact or on change of condition or environment



Encourage / assist with repositioning min 4 hourly. Ensure parents/carers are aware


Encourage a well-balanced healthy diet and plenty of fluids. Liaise with dietitian if on enteral feeding as feed may potentially may need to be to altered

Seek advice from Link nurse / TV Specialist as clinically indicated. 'please refer to grading chart if area broken'

Over 20

Very high risk

Monthly if skin intact Discuss with tissue viability if skin is not intact and review weekly



Encourage / assist with repositioning min 4 hourly. Ensure parents/carers are aware


Encourage a well-balanced healthy diet and plenty of fluids Liaise with dietitian if on enteral feeding as feed may potentially may need to be to altered

Seek advice from Link nurse / TV Specialist as clinically indicated 'please refer to grading chart if area broken'

Action to be taken – see score below

0 CAMHS Patients only Reassess monthly

0-5 Low Risk

6-10 Medium Risk

11-20 High Risk

Over 20 Very High Risk Review 6 hourly



Community and Day Care Flow Chart

Appendix 4

Appendix 5

Flow chart for the prevention & treatment of Pressure Ulcers

Within 24 hours perform initial risk assessment in first episode of care

Assess risk. WATERLOW Risk factors include: pressure - posture - shearing – friction cognition, psychosocial status previous pressure damage extremes of age nutrition and hydration status moisture to the skin

RECORD – Document the assessment or risk, noting all relevant factors

Patient with pressure ulcer/ management

No wound / Prevention

Preventative Measures Positioning Consider:

Mobilising, positioning and repositioning interventions for all patients (including those in beds, chairs and wheel-chair users). Acceptability to the patient and needs of the carer should be considered

All patients with pressure ulcers should actively mobilise, change their position or be re-positioned frequently

Minimise pressure on bony prominences and avoid positioning on pressure ulcer if present.

Consider whether sitting time should be restricted to less than 2 hours per session

Utilising turn chart and 30% tilt and the use of cushions Nutrition

Provide nutritional support to patients with an identified deficiency Decisions about nutritional support/ supplementation should be based

on: nutritional assessment using a recognised tool (for example Malnutrition Universal Screening Tool [MUST]) general health status patient preference expert input (dietician/specialists)

ASSESSMENT OF PRESSURE ULCER COMPLETE

Wound Assessment Sheet Document all pressure ulcers Criteria 2 and above locally as a clinical incident Pressure ulcers should not be reverse graded. Photography and /or tracings (calibrated with a ruler)

Reassessment Ensure initial and ongoing pressure ulcer assessment

Reassess frequently (at least weekly or as advised by TVN)

No improvement

or deterioration

Refer

to

TVN

Treatment of pressure ulcers * Choose dressings/topical agent or method of debridement or adjunct therapy based on:

ulcer assessment & general skin assessment

treatment objective

characteristic of dressing/technique - previous positive effect of dressing/technique

manufacturer’s indications for use and contraindications

risk of adverse events

patient preference

dressings as prescribed by Dr/TV/District Nurse

Consider preventative measures shown in prevention box

As a minimum provision, patients with a grade 3-4 pressure ulcer should have a high

specification foam mattress with an alternating pressure overlay or cushion

Create an optimum wound healing environment using modern dressings (for example hydrocollolids, hydrogels, foam films, alginates, soft silicones)

Consider antimicrobial therapy, the presence of systemic and/or local clinical signs of infection



Guide to Reporting Pressure Ulcers on DATIX – ALL Services Category DATIX Other Actions

1 No Report to Nurse-in-Charge/Team Leader

Review & update care plan

Review daily

2 Yes – complete DATIX incident report within 24hrs to include category & NHS Number

Report to Nurse-in-Charge/Team Leader


Review daily


Escalate as a Serious Incident if pressure ulcer developed whilst under the care of BCPFT

Conduct a Root Cause Analysis (RCA)



Refer to Tissue Viability Nurse

Review daily

Pressure Ulcer Review Panel

Safeguarding alert must be considered


Escalate as a Serious Incident if pressure ulcer developed whilst under the care of BCPFT

Conduct a Root Cause Analysis (RCA)



Refer to Tissue Viability Nurse

Review daily

Pressure Ulcer Review Panel

Safeguarding alert must be considered

Deep Tissue Injury (DTI)

Yes – complete DATIX incident report within 24hrs to include category & NHS Number



Review daily

Un-stageable Yes – complete DATIX incident report within 24hrs to include category & NHS Number



Review daily

Moisture associated skin damage (MASD)




Review daily

Combined pressure ulcer

and MASD




Review daily

Pressure Ulcer on Admission (POA)

Yes – complete DATIX incident report within 24hrs for category 2 and above & ensure detailed as a POA & include NHS Number



Review daily

Device Related Pressure Ulcer

Yes – complete DATIX incident report within 24hrs to include category & NHS Number record as device related



Review daily

Appendix 5



Areas of the Body at Risk of Developing Pressure Ulcers

1. Sitting 2. Lying

Appendix 6



Pressure Ulcer Grading Chart

Appendix 7



Category 3 and 4 Pressure Ulcer Review Panel TERMS OF REFERENCE & MEMBERSHIP

1. Objectives 1.1 The Category 3 & 4 Pressure Ulcer Review Panel’s purpose is to review the Determination

of Causative Factors in the development of Category 3 and 4 Pressure Ulcers for those ulcers acquired in Black Country Partnership NHS Trust care.

The Panel’s core functions:

To ensure that all Category 3 & 4 pressure ulcers are investigated appropriately.

To monitor the quality and content of the notes and reviews submitted.

To ensure that lessons learnt are acted upon following review.

To ensure that all pressure injuries (Category 3+) that are identified as being acquired in BCPFT are recorded as a Serious Incident (SI) as per the Trust’s Risk Policy.

To ensure that any pressure injury acquired while under the care of BCPFT will be escalated and a Root Cause Analysis report delivered to SI panel in the required format and within agreed timescales.

2. Authority The Category 3 & 4 Pressure Ulcer Review Panel is authorised to carry out the activities specified within these Terms of Reference.

3. Review Panel Membership

The membership of the Category 3 & 4 Pressure Ulcer Review Panel includes: Core Panel Members

Chair -

Director/Deputy Director of Nursing

Service Director representation

Older Person’s Mental Health representation

Tissue Viability Specialist Nurse

Infection Prevention & Control Specialist

Clinical Risk Manager

Safeguard Lead

Community Nursing/Paediatric representation/designate as appropriate (if community paediatric involvement in patient care)

Associate Panel Members

Physiotherapy /Occupational Therapy Lead

Safeguarding Adults Lead / Designate

Safeguarding children’s lead / Designate other specialist co-opted as necessary 4. Terms of Reference Specific duties for the Category 3 & 4 Pressure Ulcer Review Panel include:

Appendix 8



Review of the 72-hour report and chronological notes review and Waterlow tool assessment of pressure ulcers acquired in BCPFT care at Category at 3 & 4 in a timely manner.

Monitoring compliance with BCPFT policies at locality level, consistent with efficient and economic use of resources throughout the Trust.

Review clinical activity related to Category 3 & 4 pressure injuries on an ongoing basis.

Discussion of any identified issues specifically related Category 3 & 4 pressure ulcers acquired in BCPFT.

The 72 hour report and notes review will be submitted to the Risk Management Team by the service completing the Determination of Causative Factors in the development of Category 3 & 4 Root Cause Analysis Pressure Ulcers Risk Assessment Tool (Appendix 9)

5. Frequency of panel meetings

The Panel will ‘meet’ in response to the submission of a Datix Report and 72 hours Report Review to the Risk Management Team, identifying a pressure ulcer acquired in Black Country Partnership NHS Foundation Trust. 6. Timescale All requests for review will be circulated within 2 working days of receipt to the Risk Management Team. 7. Decision Making

Panel members will discuss the Route Cause Analysis findings and any associated evidence that has been collated, as a result of the review of the Pressure Ulcer.

The Risk Management Team will collate responses and action appropriately given the panel decision.

8. Quorum No business shall be transacted at the panel unless the following are present:

Chairperson or Chair’s Designate

With a minimum of five of the membership three of whom will be core panel members.



Root Cause Analysis (RCA) tool for Pressure Ulcers Category 2, 3 and 4

Safeguard Number:

Datix Number:

STEIS Number: (only requred for 3&4):

Please fully complete all sections

PATIENT NAME:

DOB:

Name and designation of individual completing RCA:

Locality: Team or Ward Manager: DN Lead:

Date of referral to ward or caseload:

Date pressure(s) ulcer identified:

Where was patient from? Please name the residential or nursing home/ward/hospital

Own Home ☐

Paediatric ☐

Residential Home ☐

Name:

Nursing Home ☐

Name:

Hospital ☐

Name:

Other ☐

Does the patient have formal carers? Yes ☐ No ☐ Informal carers e.g. family? Yes ☐ No ☐

Site (e.g. Sacrum)

Wound Size please

state

Ulcer category

1 2 3 4

1.

2.

3.

4.

5.

6.

Has a photograph been taken? Yes ☐ No ☐

Date of 1st Waterlow score when patient was admitted to ward or on the caseload

1st Waterlow Score:

Where was this carried out? (give

details)

Date of most recent Waterlow:

Most recent Waterlow Score:

Where was this carried out? (give

details)

Right Left Right

Appendix 9

Please number each site



How often was the Waterlow score carried out before the incident was reported (circle one below) and by whom?

Daily Alternate days every 72

hours

weekly monthly other

If other please give details:

Person completing Waterlow (Name & designation):

How often is Waterlow score carried out now (circle one below) and by whom?

Daily Alternate days every 72

hours

weekly monthly other

If other please give details:

Person completing Waterlow (Name & designation):

Was a holistic assessment completed on admission to ward or to caseload?

Yes No

If no please give details or rationale for not completing:

Was an appropriate pressure prevention plan commenced? Yes No

Was a skin inspection carried out on admission on ward or to caseload Yes No

Was SSKIN completed as prescribed in care plan? Frequency Yes No

Elimination circle as required

Continent Catheter Incontinent of: urine

Incontinent of: faeces

Incontinent of: both

Is there any moisture-associated damage? Yes No

Continence aids are used? Yes No

Continence aids – detail all products used:

Patient information: Relevant medical history, including medication:

Nutrition and Hydration:

MUST / nutrition assessment completed and documented? Yes No

MUST nutrition score: Date MUST assessment completed:

Advice given:

Enteral feeding i.e. Peg Feeding Yes ☐ No ☐ Dietician referral Yes ☐ No ☐ Referral date: Has an appropriate pressure prevention care plan been completed? Yes No

Is there compliance with care plan / advice?

Yes No

Give details of planned review date:

Is pressure-relieving equipment required? Yes No

Detail all pressure relieving equipment required:

Has there been a delay in obtaining equipment? Yes No



If delay please give reasons:

Patient Compliance to using equipment? Yes No

If non-compliant, was a non-compliance form completed? Yes No

Level of Mobility (circle one):

Independent Assistance of 1 person

Assistance of 2 persons

Bedbound Chair bound

Approximate daily length of time in bed: Approximate daily length of time in chair:

Advice given (e.g. Turning regime, pressure relief care) details:

Patient Information Leaflet given: Yes No

Does the Patient have capacity to consent to preventative measures? Yes No

Was the delegation of care appropriate? Yes No

Was appropriate referral made to other services? Yes No Not required

Who was providing the care? (for completion by Community Services only)

Registered Nurse HCA Other

Was the patient referred to the TVN ? Yes No If yes date of referral:

Date of TVN assessment:

Please explain the causes of the pressure ulcer e.g. discharge planning, staff knowledge and training, communication, equipment, change in patient’s medical condition, end of life

Lessons learnt



Actions taken

Patient outcome at time of RCA e.g. transferred, stayed at home, died

TVN to complete if involved with patient. Team Leader / Lead Nurse to complete if no TVN involvement

Does the pressure ulcer need to be reported as a Safeguarding alert?

YES NO

Confirmed at Panel Review Meeting Date:

Date: PRINT name/designation:



Wound Treatment Care Plan

Patients Name: NHS Number:

SITE OF WOUND(s): Named Nurse:

Plan implementation date: Completed by:

CLEANSING REGIME REQUIRED : YES NO Product: Method:

DEBRIDEMENT PROCEDURE REQUIRED : YES NO Product:

PRIMARY WOUND DRESSING

Size Required: Quantity Used:

SECONDARY DRESSING

Product: Application Details:

DRESSING CHANGE FREQUENCY specific details:

OBSERVE FOR AND REPORT ANY SIGNS OF INFECTION e.g.: heat, redness, swelling, odour, increased

pain, increased exudate

OTHER ACTIONS REQUIRED e.g.: pressure sore prevention aids, consider behaviour needs

Nurse Signature:

Print name: Date:

I confirm a discussion of this care plan with the patient occurred

Discussion date:

Patient Signature:

If patient lacks capacity please discuss with family or carer and tick here:

Discussion of care plan with family or carer occurred on:

Family or carer Signature:

(print name and relationship)

Evaluations continued on the next page

Appendix 10



DATE & TIME

Insert Patients Name & DOB

WOUND CARE EVALUATION

SIGNATURE



Management and Prevention of Nappy Rash & Moisture Lesions

Atypical presentation Normal bowel

habit

Prophylaxis

For intact skin prior to therapy that may

alter bowel habit

Excoriation

Superficial epidermal

erosion and surrounding erythema

Ulceration

Damage extending to the

dermis

Bright red rash, satellite lesions,

pustules at margins. Rash

extends to areas not in contact with faeces e.g. groin

Other skin conditions such as eczema, psoriasis or ringworm can also be present in the perineal area. If you are unsure about the appearance of a presenting lesion then please contact your medical team, tissue viability or dermatology

3MTMCavilon TM No Sting Barrier

(NSBF) Every 48 -72 hrs

Continue with Cavilon while bowel

habit persists. (Cavilon NSBF not

to be used on babies less than 4

weeks old use Cavilon DBC)

3MTMCavilonT

M

No Sting Barrier (NSBF)

Every 48-72 hours. (Cavilon NSBF not to be used on babies

less than 4 weeks old, use Cavilon DBC)

Classic nappy rash

Mild to moderate

perineal erythema

Follow good nappy

care Clotrimazole 1%

TDS. Continue until rash clears plus 2 weeks Do not use any other

preparations at the same time e.g. Cavilon. This will reduce the effect of the Clotrimazole cream.

Altered bowel habit (or expectation of altered bowel habit due to intervention

e.g. antibiotic therapy

Candidiasis

3MTM Cavilon TM

Durable Barrier Cream (DBC) Re-apply every 3rd nappy change until bowel altering therapy stopped. (Highly concentrated. Only small amount req’d)

Healed No improvement/not healed after 7 days refer to Tissue Viability

Barrier

Prevention

GOOD NAPPY CARE

Frequent changing of gel core nappy

Nappy changes MUST take place as soon as possible after soiling

Use an emollient to clean the skin such as Dermol 500 (Named patient use only – remember to label the container) DO NOT USE SOAP

Apply barrier agents sparingly

Expose skin where possible N.B. ALL treatments MUST be prescribed

Appendix 11



Water Low Risk Assessment

Patients Name: DOB: NHS Number:

BUILD / WEIGHT FOR HEIGHT

RISK AREAS VISUAL SKIN TYPE

SEX/AGE Malnutrition Screening Tool (MST) Nutrition Vol 15, No. 6 1999 - Australia

Average BMI = 20 – 24.9 Above average BMI = 25-29.9 Obese BMI > 30 Below average BMI < 20 BMI= Wt (Kg) / Ht (m)2

0 1 2 3

Healthy Tissue Paper Dry Oedematous Clammy, Pyrexia Discoloured Grade 1 Broken / Spot Grade 2-4

0 1 1 1 1 2 3

MALE FEMALE 14 – 49 50 – 64 65 – 74 75 - 80 81+

1 2 1 2 3 4 5

A Has patient lost weight recently? Yes - Go to B No - Go to C Unsure - Go to C and Score 2

B Weight loss score 0.5 – 5kg = 1 5 – 10kg = 2 10 – 15kg = 3 > 15kg = 4 unsure = 2

C Patient eating poorly or lack of appetite ‘NO’ = 0 ‘YES’ = 1

Nutrition Score If > 2 refer for nutrition assessment / intervention

CONTINENCE

MOBILITY

SPECIAL RISKS

Complete / Catheterised Urinary Incontinence Faecal Incontinence Urinary and Faecal Incontinence

0 1 2 3

Fully Restless / Fidgety Apathetic Restricted Bedbound E.g. Traction Chair bound E.g. Wheelchair

0 1 2 3 4 5

TISSUE MALNUTRITION

NEUROLOGICAL DEFICIT

Terminal Cachexia Multiple Organ Failure Single Organ Failure (Resp, Renal, Cardiac) Peripheral Vascular Disease Anaemia (Hb < 8) Smoking

8 8 5 5 2 1

Diabetes, MS, CVA Motor / Sensory Paraplegia (Max of 6)

4 – 6 4 – 6 4 - 6

MAJOR SURGERY OR TRAUMA

Orthopaedic / Spinal On table > 2 hrs * On table > 6 hrs *

5 5 8

SCORE

MEDICATION – CYTOTOXICS, LONG TERM HIGH DOSE STEROIDS, ANTI-INFLAMMATORY MAX OF 4

10 + AT RISK * Scores can be discounted after 48 hours provided patient is recovering normally. 15+ HIGH RISK

20+ VERY HIGH RISK

Appendix 12



WATER LOW RISK ASSESSMENT cont.

Patients Name: Date of Birth: NHS No:

DATE BUILD/

WEIGHT

SKIN

TYPE

SEX/

AGE

MST CONTINENCE MOBILITY SPECIAL

RISK

TOTAL

SCORE

ASSESSMENT

RATING

ASSESSOR SIGNATURE

NEXT REVIEW

DATE



Malnutrition Universal Screening Tool - ADULTS

SCORE 2

NO CARE PLAN REQUIRED

REFER

TO

DIETICIAN

CARE PLAN AS PER DIETICIAN

RECOMMENDATION

SCORE 0

WEEKLY

RE-SCREEN

NO CARE PLAN REQUIRED

SCORE 1

MONITOR DIET AND FLUIDS

DISCUSS WITH MEDICAL TEAM ABOUT NUTRITIONAL SUPPORT

ENCOURAGE HIGH CALORIE INTAKE AND SNACKS BETWEEN MEALS

RESCORE WEEKLY AND REVIEW IN

MDM MEETING

Appendix 13



Step 1 + Step2 + Step3 Step 5 Management guidelines

BMI Score Weight loss score Acute disease effect score

Step 4 – Overall risk of malnutrition

Malnutrition Universal Screening Tool Adults cont.

Patient name: DOB: NHS Number:

Date

Height

Weight STEP 1

BMI Score

STEP 2

Weight loss score

STEP 3

Acute Disease effect score

STEP 4

Total Score / Risk

STEP 5 Score = 0 Low Risk.

No further action

STEP 5 Score = 1 or more. Action to be taken

Signature

BMI kg/m2 Score

>20 (>30 Obese) = 0

If Service User is acutely ill and there has been no nutritional intake for >5 days, Score = 2

Unplanned weight loss in past 3-6 months

% Score

0 = Low Risk Routine clinical care.

Repeat screening weekly

1 = Medium Risk

Observe

Document dietary intake for 3 days If improved or adequate intake little clinical concern if no improvement, clinical concern – follow Trust Policy. Weigh weekly and recalculate % weight change over the most recent 3-6 months. Note any changes in scores

2 or more = High Risk

Treat** - Refer to dietician

- Improve and increase overall nutritional intake

- Monitor and review care

- Weigh weekly and recalculate % weight change of the most recent 3-6 months

- Note any changes in scores

- ** Unless detrimental benefit is expected from nutritional support e.g. imminent death

Add scores from Steps 1, 2 and 3 together to calculate overall risk of malnutrition.

Score 0 = Low risk Score 1 = Medium risk Score 2 or more – High risk

All risk categories: Treat underlying condition and provide help and advice on food

choices, eating and drinking when necessary

Record malnutrition risk category.

Record need for special diets and follow Trust policy.



Patient name: DOB: Hospital number:

Date

Height

Weight

STEP 1 BMI

Score

STEP 2 Weight

loss score

STEP 3 Acute Disease

effect score

STEP 4 Total Score /

Risk

STEP 5 Score = 0 Low Risk.

No further action

STEP 5 Score = 1 or more.

Action to be taken

Signature



Pain Assessment of People With Dementia - For measurement of pain in people with dementia who cannot verbalise

Patients Name: NHS No: Primary Nurse:

Ward: Consultant: Date of completion:

While observing the patient, score questions 1 to 8

Yes scores 1 and No scores 0 - Please tick the appropriate box and record the score in the score box

SCORE ACTIONS / INTERVENTIONS

Q1. Pre-existing physical health conditions that may be painful. One or more of the following: Arthritis, Muscular skeletal problems, limbs contractures, osteoporosis

YES 1 No 0

Q2. Vocalisation One or more of the following: Whimpering, groaning, moaning, shouting, crying.

YES 1 No 0

Q3. Facial Expression One or more of the following: Grimacing, looking tense, frowning, looking frightened, staring, looking blank, showing pain.

YES 1 No 0

Q4. Changes in Body Language One or more of the following: Fidgeting, rocking, guarding part of the body, withdrawn, assuming foetal position, negative reaction to touch.

YES 1 No 0

Q5.Behavioural Changes One or more of the following: Increased confusion, refusing to eat/drink, alteration in usual patterns e.g. sleep, increased agitation, repetitive behaviour, decreased in usual level of function.

YES 1 No 0

Appendix 14



Pain assessment for people with Dementia continued SCORE

ACTIONS / INTERVENTIONS

Q6. Physiological Changes One or more of the following: Change in temperature, pulse, BP, respirations, perspiration, flushing, pale.

YES 1 No 0

Q7. Physical Changes One or more of the following: Skin tears, pressure areas, arthritis, contractures, previous injuries, immobility, unable to weight bear, deterioration in mobility.

YES 1 No 0

Q8. Changes in Communication One or more of the following: Changes in level of communication, patient demands attention in an unusual manner, absence or refusal of any form of communication.

YES 1 No 0

Q9. Changes in Social Life One or more of the following: Refuses to participate in any activity, only participates when asked.

YES 1 No 0

TOTAL

Signature:

Print name: Carers Notified (if required) :

Date seen by Doctor(if required): Pain relief commenced (if required)::



Appendix 14 continued

Patients Name DOB: NHS No:

Date of Reviews

Pre

Ex

isti

ng

Healt

h n

eed

s

Vo

cali

sati

on

Facia

l

Exp

ressio

n

Ch

an

ges in

bo

dy

lan

gu

ag

e

Beh

avio

ura

l

Ch

an

ges

Ph

ysio

log

ical

Ch

an

ges

Ph

ysic

al

Ch

an

ges

Ch

an

ges in

c

om

mu

nic

ati

on

Ch

an

ges in

So

cia

l L

ife

Score

Reviewed by (print name)

Signature

Date

reviewed by doctor (if required)

Date pain

relief commenced

(if required)

Frequency of Evaluation:

Review Records:

If score is over 5 or more please ensure the patient is reviewed by doctor.



Pain / W Pain/Wound/Bruise continuation sheet

Patients name: DOB: NHS No:

PAIN SITES

Label each site with a letter

(disabling)

Date

Time

Pain at sites Analgesic prescribed Alternative methods of pain relief

Outcome/Resolved

Signature

A B C D E F G H Name Dose Frequency Route Moving Turning Other

Excruciating (no control)

Effects on Sleep / Mood / Appetite / Mobility

Site Patient’s own description of the pain

Date Site Patients own description of the pain

Date



Pain Assessment in Children

BAKER- WONG FACES Paint Rating Scale This tool is usually appropriate for use with children 3 years and older

.

Brief word instructions:

Point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes how he/she is feeling

Original instructions: Explain to the person that each face is for a person who feels happy because he has no paint (hurt) or sad because he has some or a lot of pain. Ask the person to choose the face that best describes how he/she is feeling

Face 0 is very happy because he doesn’t hurt at all

Face 2 hurts just a little bit

Face 4 hurts a little more

Face 6 hurts even more

Face 8 hurts a whole lot

Face 10 hurts as much as you can imagine, although you do not have to be crying to feel this bad.

Appendix 15



SIMPLE SAFE & EFFECTIVE 30° TILT

Appendix 16

Prevention and Management of Pressure Ulcers Policy


Pressure Relieving Equipment Selection Chart

Very High Risk Waterlow Score

20+

Mobile (Able to relieve own

pressure areas)

Immobile (Assisted to relieve

pressure areas)

No Pressure Ulcer

No Pressure

Ulcer

Pressure

Ulcer

Foam Mattress

Stage 1-2 = Overlay Stage 3-4 = MR

Overlay ** MR

Consider Gel Cushion

Consider Gel or Alternating air

cushion

Consider Gel Cushion Consider

Gel or Alternating air

cushion

Consider Air Cushion

High Risk Waterlow Score

15-19

Mobile (Able to relieve own

pressure areas)

Immobile (Assisted to relieve

pressure areas)

No Pressure Ulcer

Pressure Ulcer

No Pressure Ulcer

Pressure Ulcer

Foam Mattress

Stage 1-2 = Overlay Stage 3-4= MR

Foam Mattress *

Stage 1-2 = Overlay **

Stage 3-4= MR



cushion



cushion

At Risk Waterlow Score

10-14

Mobile (Able to relieve

own pressure

areas)

Immobile

(Assisted to relieve pressure areas)

No Pressure Ulcer

Pressure Ulcer

No Pressure Ulcer

Pressure Ulcer

Foam Mattress

Grade 1-2 = Overlay

Grade 3-4= MR

Foam * Mattress

Stage 1-2 =

Overlay** Stage 3-4= MR

Consider Gel or Alternating

air cushion


Consider Gel or Alternating

air cushion

MR = Mattress Replacement * Consider Overlay if unable to reposition at least two hourly. **Consider Mattress Replacement if unable to reposition at least two hourly NB

Gel cushions to be used for Pressure Ulcers Category 1-2

Alternating Air cushion for Pressure Ulcers Category 3-4.

Appendix 17



Policy Details

* For more information on the consultation process, implementation plan, equality impact assessment, or archiving

arrangements, please contact Corporate Governance

Review and Amendment History

Version Date Details of Change

1.4 Jan 2020

Reviewed to ensure this policy complies with National guidelines following a gap analysis comparison against existing policy.

Explanation of terms expanded as per revised guidelines (June 2018)

Objectives reviewed & updated

Update includes more detail on moisture lesions

Appendices re-ordered & re-formatted

Appendix 3 (Paediatric tool) updated

Appendix 4 added – Reporting pressure ulcers

Appendix 6 updated to mirror the one in the Trust’s SSKIN standard procedure

Title of Policy Prevention and Management of Pressure Ulcers Policy

Unique Identifier for this policy BCPFT-PH-POL-01

State if policy is New or Revised Revised

Previous Policy Title where applicable n/a

Policy Category Clinical, HR, H&S, Infection Control etc.

Physical Health

Executive Director whose portfolio this policy comes under

Director of Nursing

Policy Lead/Author Job titles only

Matron of OA supported by Head of Nursing (Physical Health)

Committee/Group responsible for the approval of this policy

Nursing Board

Month/year consultation process completed *

January 2020

Month/year policy approved February 2020

Month/year policy ratified and issued March 2020

Next review date January 2023

Implementation Plan completed * Yes

Equality Impact Assessment completed * Yes

Previous version(s) archived * Yes

Disclosure status ‘B’ can be disclosed to patients and the public

Key Words for this policy Policy, Pressure Ulcer, Tissue Viability, Tissue Injury, Treatment of Ulcers, Assessment of Ulcers, Management of patients with Ulcers, Moisture lesions



1.3 Nov 2019 Appendix 9 amended to include Community Nurses Processes

Version Date Details of Change continued

1.2 May 2018 Reviewed in new Trust Policy template with updates made to section 5.0, 7.0, 8.0 and 11.0.

1.1 Nov 2014 Policy reviewed following publication of NICE Clinical Guideline CG179 April 2014

1.0 Mar 2013 New policy for BCPFT- Policy for BCPFT newly established organisation.

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