Assessment, Prevention and Management of Pressure Ulcers Policy

Transcription

1 Clinical Assessment, Prevention and Management of Pressure Ulcers Policy Document Control Summary Status: Version: Author/Title: Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Contents Replacement. Replaces C/YEL/cm/17 (Pressure Ulcers Policy 2011) v1.0 Date: March 2016 Pat Wain Associate Director of Physical Health Kenny Laing Deputy Director of Nursing Policy and Procedures Committee Date: Awaiting Trust Board Date: Ratification Clinical Strategy March 2016 March 2019 Bed sore, nursing care, pressure sores 1. Introduction Purpose Scope Pressure Ulcers Assessment / Management Guidelines Key Priorities for Assessment Pressure Ulcer Prevention Skin Care Treatment of Existing Pressure Ulcers Removing Damaged Skin Education Process For Monitoring Compliance And Effectiveness References... 8

2 Change Control Amendment History Version Dates Amendments 1. Introduction This policy supports the national drive to improve the quality of care in relation to reducing harm to patients by pressure area damage, in collaboration with the national nursing strategy, Compassion in Practice and previous High Impact Actions for Nursing, which both set standards of no avoidable pressure ulcers within the care environment by providing guidance on the early identification of patients at risk of developing pressure ulcers. Recommendations apply equally across the primary and secondary care interface, including specialist units, for example older people and eating disorders services. Avoidable means that the person receiving care developed a pressure ulcer and the provider of care did not do one of the following: Evaluate the person s clinical condition and pressure ulcer risk factors. Plan and implement interventions that are consistent with the person s needs and goals and recognised standards of practice. Monitor and evaluate the impact of the interventions or revise the interventions as appropriate. 2. Purpose The Trust has a duty to ensure the protection and safety of service users in receipt of care, from avoidable pressure ulcers by the development and deployment of an evidence based policy and training. 3. Scope It is the responsibility of all divisional directors, service managers and ward managers to ensure that all staff are aware of the Trust policy for pressure ulcer prevention and management. Managers should also ensure that clinical staff follow the Authorised Documents Policy relating to receipt of policies. Page 2 of 8

3 Senior managers have a responsibility to identify any issues which mitigate against the implementation of this policy within clinical practice and identify any staff training deficits. All staff working in clinical areas are responsible for ensuring that patients physical healthcare is subject to assessment and necessary intervention. This policy provides the framework for ensuring that those most at risk of developing pressure area damage are identified and clinical interventions are undertaken in a timely way to prevent or improve them. 4. Pressure Ulcers Pressure ulcers, commonly referred to as pressure sores, bed sores, pressure damage, pressure injuries and decubitus ulcers, are areas of localised damage to the skin, which can extend to underlying structures such as a muscle and bone. Damage is believed to be caused by a combination of factors including pressure, shear forces, friction and moisture. They can develop in any area of the body and in adults damage usually occurs over bony prominences such as the sacrum. Pressure ulcers are more likely to occur in those who are seriously ill, neurologically compromised, have impaired mobility, suffer from impaired nutrition or do not avail of appropriate pressure relief. In addition a combination of poor mobility, particularly in the elderly and medication with sedative action, can contribute to the development of pressure ulceration. 5. Assessment / Management Guidelines The patient s risk of developing a pressure ulcer and the extent of any existing damage will be assessed at first contact, and reassessed throughout an individual s episode of care. A plan of care will be drawn up, carried out, and reviewed regularly. NICE recommends that healthcare professionals work together with patients so that patients can play where possible, an active part in making decision about their care. The treatment offered should therefore take into account patient s individual needs and preferences. Screening / Assessment should always be undertaken at initial contact and the need for reassessment of patients / clients should be continuously considered using a Waterlow pressure ulcer risk assessment tool. (see separate Associated documents). Adapted for service users with an eating disorder (see separate Associated documents). Risk assessment tools should only be used as an adjunct to clinical judgement and should not replace it. Examine all patients fully taking into account the presence of any of the risks described under the headings below: Mobility Patients with impaired consciousness, undergoing prolonged surgery / procedure (i.e. on table >2 hours) or who have paralysis, neuropathy or orthopaedic trauma (below waist / spinal) Patients who have impaired ability to reposition themselves or where activity is limited to bed or chair. Epidural anaesthesia may increase patient risk of developing pressure damage. Page 3 of 8

4 Skin Health & Nutrition Poor nutritional status. Previous history of pressure ulcers, inflammation, disease, oedema or thinning (tissue paper) of skin. Body parts affected by anti-embolic stockings. Tissue perfusion and oxygenation Very poor tissue oxygenation occurs in patients with severe illness. In the presence of shock, hypoxia, low blood pressure or when medicated with high dose of steroids, vasoconstrictors or inotropes; and in those with cardiac failure, vascular disease, anaemia, multiple chronic disorders. Neurological deficits e.g. diabetes, multiple sclerosis, cerebro-vascular accident, paraplegia; and in smokers. Incontinence Urine and faeces and other body fluids can rapidly cause maceration or excoriation damage to the skin. For all patients / clients identified at risk screening must progress to further assessment. 6. Key Priorities for Assessment An initial and on-going risk assessment in the first episode of care (within 6 hours) The pressure ulcer grade should be recorded using the European Pressure Ulcer Advisory Panel Classification system. (see separate Associated documents). An initial and on-going pressure ulcer assessment process should be in place supported by photography and/or tracings with measurements All those identified as vulnerable to pressure ulcers should as a minimum be placed on a high specification foam mattress. Patients with grade 1-2 as a minimum should be placed on a high specification foam mattress/cushion with pressure-reducing properties and be closely observed for skin changes Patients with grade 3-4 pressure ulcer should at a minimum be placed on high specification foam mattress with an alternating pressure overlay, or a sophisticated continuous low pressure system, air flotation. See mattress assessment (see separate Associated documents). The optimum wound healing environment should be created by using modern dressings e.g. hydrocolloids, hydrogels, hydrofibres, foams, films, alginates, soft silicones. Following further / comprehensive assessment of those at risk record the risk and record your assessment of the patients risk, e.g. LOW, MEDIUM or HIGH RISK Patients with acute illness who have many of the above factors present are likely to be at HIGH RISK of developing pressure ulcers, patients with fewer factors MEDIUM RISK, many self-caring patients with few of the above factors may be considered to be at LOW RISK. Examine your patient fully, especially vulnerable areas any bony prominence. Describe any existing pressure ulcers / tissue damage. Record comprehensively in the plan of care the location and history of the pressure ulcer when it appeared, what treatment has been given, the grade of the pressure ulcer (see below). Page 4 of 8

5 GRADE 1 Discolouration of intact skin, including non-blanching hyperaemia (i.e. redness that persists when fingertip pressure released). GRADE 2 Partial-thickness skin loss or damage involving epidermis and / or dermis. GRADE 3 Full thickness skin loss involving damage or necrosis of some subcutaneous tissues. GRADE 4 Full thickness skin loss with extensive destruction and tissue necrosis extending to the underlying bone tendon or joint capsule. BLACK NECROTIC Grade cannot be determined document, black necrotic tissue. Record the dimensions of the ulcer; length, width, and estimate of depth cm; presence of sinus tracts, tunnelling, and odour. Record the appearance of the ulcer on formal wound assessment chart (see separate Associated documents). and Wound Treatment Care Plan. Necrotic (black) Sloughy (Yellow/Green) Granulating(Red) Epithelialising(pink) Haematoma Bone/tendon visible Amount and description of any fluid exudates e.g. serous, pus or bloody) Record condition of surrounding skin e.g. dry, scaly, oedema, eczema, cellulitic, inflamed, discoloured or moist. Improve nutritional status malnutrition delays, inhibits and complicates the process of wound healing. Food nutrition facilitates the process. Neglecting nutrition can compromise all other wound management plans and have resource implications. The key nutrients involved in good wound healing are carbohydrate, fat, vitamins especially A and C, iron and zinc. The optimum way to meet the requirements for these nutrients is from normal food. Supplementation and excessive consumption may have a detrimental impact. Assessing nutritional status is essential to help recognise and limit malnutrition and dehydration and its effect on wound healing. Assessment will ensure the identification and correction of the underlying cause (s) AND address any shortfall. The Nutrition / Hydration guidelines should be used to assess and manage the diet and fluid needs of service users. Ready reckoners for weight loss management and acceptable fluid intake comparable to age and weight are available for use. (see separate Associated documents). All completed Waterlow assessments and subsequent required information must be recorded for each service user on the Trust Electronic Patient Record RiO. All pressure ulcers graded as 3 and above must also be reported through the incident reporting process and additionally reported to the Associate Director of Physical Healthcare through matrons. Any pressure ulcer graded as a 4 should be reported as a SERIOUS INCIDENT and the policy for serious incident reporting must be followed. Page 5 of 8

6 7. Pressure Ulcer Prevention The following steps should be considered in the prevention of pressure ulcers/ damage: Relieve pressure use correct handling techniques. Manual handling devices should be used correctly in order to minimise shear and friction damage. After manoeuvring, slings, sleeves or other parts of handling equipment should not be left underneath individuals. Avoid positioning on a pressure ulcer or on a vulnerable area. Patients who are at risk should be repositioned and the frequency of repositioning determined by the results of skin inspection and individual needs not by ritualistic schedule. Positioning of patients should ensure that; prolonged pressure on bony prominences is minimised and that bony prominences are kept from direct contact from one another to minimise friction and shear damage. A repositioning schedule, agreed with the individual, should be recorded and established for each person at risk. Individuals should when able, be encouraged to do circulation and stretching exercises. Physiotherapy advice should be sought for these movements. High risk individuals should restrict chair sitting to less than 2 hours until their general condition improves. Individuals / carers, who are willing and able, should be taught how to redistribute weight. Individuals identified as High Risk may require a pressure reducing foam mattress Med high risk or an upgrade to a dynamic pressure-relieving mattress. Use of aids: The following should not be used as pressure reducing / relieving aids: Water filled gloves Synthetic sheepskins Genuine sheepskins Doughnut type devices 8. Skin Care Skin inspection should be based on an assessment of the most vulnerable areas of risk for each patient. Older age adults and people with an eating disorder who have lost body mass are particularly at risk. These patients will have lost body mass, are not very mobile and are at risk from pressure, shearing and friction forces. These areas are typically: Heels Sacrum Ischial tuberosities Parts of the body affected by anti-embolic stockings Femoral trochanters Parts of the body where pressure, friction and sheer are exerted in the course of individuals daily living activities. Scapular and shoulder region Vertebrae Individuals who are wheel chair users should be encouraged to use a mirror to inspect areas that they cannot see easily or get others to inspect them. Page 6 of 8

7 Health care professionals should be aware of the following signs which may indicate incipient pressure ulcer development: Persistent Erythema Non-blanching hyperaemia Blisters Discolouration Localised heat Localised oedema Localised induration In those with darkly pigmented skin: Purplish / bluish localised areas of skin Localised heat, which, if tissue becomes damaged, is replaced by coolness. Signs of Infection; one or more of the following indicate a possible infection and prescribing guidelines if applicable should be followed: Heat New Slough Increasing Pain Increasing Exudate Increasing Odour Friable Granulation Tissue Skin changes should be documented / recorded immediately on the formal wound assessment chart and a care plan developed and appropriate action taken. A plan of care should be documented within the integrated health records, and wound treatment care plan and reviewed at least weekly or more often if there is a change in an individual s condition. Patient / carers should be included within the assessing and planning and information / education provided on the following: 9. Treatment of Existing Pressure Ulcers To help to heal as quickly as possible NICE recommends the use of modern dressings. Some examples are listed below but in addition consult the local Wound Care Formulary available from the Chief Operating Officer s Directorate. Hydrocolloids an adhesive dressing that gels over the wound but sticks to the surrounding skin Hydrogels a simple gel that keeps wounds moist and can help clean wounds Foams available in different shapes and sizes. Foams are designed to absorb and retain fluid. These specialist dressings should be used in preference to basic dressings such as gauze, paraffin gauze and simple dressing pads. Sometimes in complex wounds, other treatments may be needed including electrical stimulation, which uses electrical currents to promote healing, and negative pressure therapy where suction is applied to the wound. For advice consult with the Thief Operating Officer s Directorate. Page 7 of 8

8 10. Removing Damaged Skin In some cases it may be necessary to remove dead tissue from an ulcer to encourage healing. This is called debridement and can be done with dressings or cutting away areas of dead tissue. Advice on this should be sought from the Chief Operating Officer s Directorate 11. Education All relevant healthcare professionals will be updated in the prevention and treatment of pressure damage and will attend up-dates every 2 years or as directed. The training will ensure that staff are well informed in order to advise patent/client and their carers of the elements of risk of pressure damage and their role in maintaining tissue integrity. 12. Process for Monitoring Compliance and Effectiveness Information to follow 13. References Information to follow Page 8 of 8