Pressure ulcers

1. Pressure ulcers Key slides

2. Pressure Ulcers • What are we worried about? • Costs (not just £, but also QoL) to patients and the NHS • Ensuring pressure ulcers are prevented 2. What management options do we have? • Assessing risk and preventing ulcers from occurring • Managing pressure and ulcers according to guidance • Preventing infection Useful reviews and reading: • NICE Clinical Guideline 29 :Pressure ulcers: The management of pressure ulcers in primary and secondary care September 2005

3. Pressure ulcer DefinitionEuropean Pressure Ulcer Advisory Panel 2003NICE Pressure ulcer management CG29 September 2006 • An area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and/or a combination of these • Damage is believed to be caused by a combination of factors including pressure, shear forces, friction and moisture • Pressure ulcers can develop in any area of the body. In adults damage usually occurs over bony areas, such as the sacrum. Presentation in infants and children is more likely to occur, for example, on the occipital area or ears

4. Prevention and treatment of pressure ulcers NICE Clinical Guideline 29 September 2005 Assess and record risk Patient with pressure ulcer People vulnerable to pressure ulcers Assess pressure ulcer Re-ssess Re-assess Prevent pressure ulcer Treat pressure ulcer and prevent new ulcers

5. Classification of pressure ulcer severityNICE Clinical Guideline No29 September 2005Reproduced by kind permission of EPUAP (2003) • Grade 1- non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness can also be used as indicators, particularly on individuals with darker skin • Grade 2 - partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister

6. Classification of pressure ulcer severityNICE Clinical Guideline No29 September 2005Reproduced by kind permission of EPUAP (2003) • Grade 3 - full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia • Grade 4 - extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with/without full thickness skin loss

7. Pressure Shearing Friction Level of mobility Sensory impairment Continence Level of consciousness Acute, chronic and terminal illness Co morbidity Posture Cognition, psychological status Previous pressure damage Extremes of age Nutrition and hydration status Moisture to the skin Risk factors for pressure ulcer developmentNICE Clinical Guideline 29 September 2005

8. Persistent erythema Non-blanching hyperaemia Blisters Localised heat Localised oedema Localised induration Purplish/bluish localised areas Localised coolness if tissue death occurs Pressure ulcer prevention:Skin assessmentNICE Clinical Guideline 29 September 2005 • Assess skin regularly - inspect most vulnerable areas • Frequency - based on vulnerability and condition of patient • Encourage individuals to inspect their skin • Look for:

9. Assess: Cause Site/location Dimensions Stage or grade Exudate amount and type Local signs of infection Pain Wound appearance Surrounding skin Undermining/tracking, sinus or fistula Odour Record Document: - Depth - Estimated surface area - Grade using EPUAP Support with photography and/ or tracings Document all pressure ulcers graded 2 and above as a clinical incident Pressure ulcers shouldnot be reverse graded Assessment of pressure ulcerNICE Clinical Guideline No 29, September 2005 Initial and ongoing ulcer assessment is the responsibility of a registered healthcare professional

10. Treatment of pressure ulcerNICE Clinical Guideline 29 September 2005 • Choose dressing/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/techniques • Manufacturer’s indications/contraindications for use • Risk of adverse events • Patient preference

11. What does NICE say about pressure ulcer wound dressings?NICE Clinical Guideline 29 September 2005 ‘There is insufficient evidence to indicate which dressings are the most effective in the treatment of pressure ulcers’ ‘However, professional consensus recommends the creation of the optimum wound healing environment by using modern dressings in preference to basic dressing types such as paraffin gauze’

12. Managing infected pressure ulcersNICE Clinical Guideline 29 September 2005 • Consider oral antimicrobial therapy in the presence of systemic and/or local clinical signs of infection • Do not routinely take a swab. If there are clinical signs of infection cultures may be taken • Reduce the risk of infection and enhance wound healing by hand washing, infection control, wound cleansing and debridement • If purulent material or foul odour is present, more frequent cleansing and possibly debridement are required • Protect wounds from exogenous sources of contamination (e.g. faeces) • Dressings need to be reapplied daily or on alternate days to allow assessment of the wound and infection

13. Treatment: Prevention NICE Clinical Guideline 29 September 2005 • Patients assessed as having a Grade 1 or 2 ulcer should, as a minimum, be placed on a high -specification mattress or cushion with pressure reducing properties combined with close observation of skin changes and a documented positioning and re-positioning regime • Patients with a Grade 3 or 4 ulcer should, as a minimum, be placed on an alternating pressure mattress (replacement or overlay) or sophisticated continuous low pressure system – for example low air loss, air fluidised, viscous fluid

14. Treatment: ReassessmentNICE Clinical Guideline 29 September 2005 • Reassessment of the ulcer should be performed at least weekly but may be required more frequently, depending on the condition of the wound and the result of holistic assessment of the patient • Treatment plan should be changed in line with reassessments • Refer to a surgeon if indicated e.g. failure of previous conservative management interventions

15. Prevention and treatment of pressure ulcers NICE Clinical Guideline 29 September 2005 • Record pressure ulcer grade using European Pressure Ulcer Advisory Panel Classification System • All pressure ulcers graded 2 and above should be documented as a local clinical incident • Patients with pressure ulcers should receive initial and ongoing ulcer assessments • Patients should have access to pressure relieving support surfaces and strategies • All patients with Grade 1 or 2 ulcers should have pressure relieving mattress or cushion, close observation of skin changes and documented repositioning regime. If any deterioration use an alternating pressure (AP) or continuous low pressure (CLP) system • Patients with Grade 3 or 4 ulcers should use an AP or CLP mattress. • Create the optimum wound healing environment