Pressure Ulcer Prevention Prevention Is The Cure

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1 The new name for Central Essex Community Service Pressure Ulcer Prevention Prevention Is The Cure Lorraine Grothier Clinical Nurse Specialist Tissue Viability

2 Is Prevention Important? An estimated 4-20% of patients admitted to an acute hospital develop a pressure ulcer (Clark M, Bours G, Defloor T; 2004). Estimated up to 30% new pressure ulcers develop in the patients own home and 20% within a nursing home environment Major cause of secondary infection, reduced quality of life and morbidity. Associated with a 2-4-fold increase in risk of death in older people in intensive care units (Bo M,Massaia M et al, 2003).. Substantial financial costs. (NHS Institute for Innovation and Improvement, 2009)

3 Organisational Responsibilities All incidents of preventable pressure damage (EPUAP category 2 and above) are reported to UK commissioning boards Financial penalties of (UK) for grade 3 and 4 No reimbursement in the US for hospital acquired pressure damage Maintain good organisational reputation and clinical credibility Pressure ulcer incidence data publically available

4 A UK Perspective Prevention a Priority? Cost of pressure ulcer management within the NHS in the UK 1.4 billion to 2.1 billion The cost of a pressure ulcer is per day depending on the category (Dealy, Posnett and Walker, 2012) The potential costs of litigation Prevention therefore has to be better than cure?

5 Human Costs Cannot Be Quantified

6 Harm Free Care In The UK Prevention of four harms Urinary catheters infection prevention Falls Pressure Ulcers STOP THE PRESSURE Blood clots

7 Definition Of Pressure Ulcers A pressure ulcer is localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. (EPUAP 2009) Pressure ulcers are caused when an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair it s blood supply. (NICE, 2014)

8 The Skin

9 Protection Functions Of The Skin Barrier to microorganisms Sensory perception Temperature regulation

10 Potential Impact of Damaged Skin Infection Pain Affect on perceived body image Potential effect on quality of life Social Economic Psychological Death

11 Causes of Pressure Damage

12 Unrelieved Pressure High Pressure for short periods of time. Low pressure for prolonged periods of time. Occlusion of capillaries Reperfusion Tissue ischemia Formation of a pressure ulcer.

13 Pressure compresses the skin and tissue between the bone and support surface Pressure

14 A mechanical stress that is parallel to a plane of interest Shear

15 Friction Tissues are distorted Abrasive action as the skin slides against a surface

16 Pressure Points

17 The Prevention Challenge Identify the patients at risk of developing pressure damage Accurate baseline assessment to identify actual and potential problems to inform individual planning and delivery of care

18 Who Is At Risk?

19 Risk Factors Activity and mobility Skin assessment and vulnerability of skin Nutritional status Compromised cardiovascular system Extremes of age Poor general health Poor sensory perception

20 Risk Factors Level of consciousness Terminal illness Posture Cognition/psychological status Hydration status

21 Other Considerations Mental capacity/ability to give consent Ability to self care/access to care Pain Pressure damage caused by medical devices

22 Prevention Strategy SSKIN Surface Skin inspection Keep moving Incontinence/moisture Nutrition

23 Skin Inspection Skin inspection: early inspection means early detection. Encourage patients & carers to inspect their own skin Frequency determined by condition of the patient and vulnerability

24 Skin Assessment Persistent erythema Non-blanching hyperaemia Blisters Localised heat Localised oedema Localised induration Purple/blue localised areas Localised coolness if tissue death occurs

25 Surface Surface: make sure your patients have the right support

26 Support Surfaces - Considerations General Level of mobility within the bed Patient comfort/acceptability The setting and circumstances of the care provision Knowledge of carers and availability of appropriate equipment At home Weight of the bed Structure of the home Width of the doors Availability of uninterrupted power supply Adequate ventilation Sharing of bed Ensure appropriate use according to manufacturers guidelines

27 Pressure Reducing/Relieving Equipment Pressure reducing foam mattresses Foam overlays and cushions Gel cushions Silicone gel pads Air filled overlays, cushions and pads Fluid filled replacement devices (RIK) Air replacement devices

28 Keep Moving Keep your patients moving Early mobilisation whenever possible Teach individuals and carers how to redistribute individual s weight Consider passive movements for patients with compromised mobility

29 Repositioning Consider repositioning in all at risk patients High pressure over bony prominence for short period of time is equal to low pressure over a longer period of time Aim to reduce the time and amount of pressure the patient is exposed to

30 Repositioning Frequency Consider the patients general condition, comfort and the support surface in use Consider method of repositioning and availability of manual handling aids Consider availability of carer support Record position, time and observations of the skin in the patients clinical record

31 Repositioning Consider comfort, dignity, privacy and functional ability Avoid positioning the patient over medical devices such as drains and tubes Avoid positioning over vulnerable or damaged areas Avoid a slouched position when in bed Consider 30 degree tilt

32 Incontinence/Moisture Incontinence / moisture: patients need to be clean and dry Do not use creams/ointments that prevent the absorption of moisture into incontinence pads Ensure patients are reviewed with regard to causes of incontinence or excessive moisture Correct underlying causes where possible including changes to medication, diet, treatments. Consult with the wider disciplinary team including medical colleagues and specialist continence services

33 Nutrition All patients should be screened using a recognised risk assessment tool (MUST) to identify risk of poor hydration or malnutrition Provide advice to patients and carers on how to follow a balanced diet to maintain adequate nutrition and hydration Do not routinely offer nutritional supplements unless nutrition is inadequate Refer to a dietician if patient is considered at risk of dehydration or malnutrition

34 Prevention should include: Evaluation of the persons clinical condition and pressure ulcer risk factors A plan and implementation of interventions which are consistent with individual needs and goals. Monitoring and evaluation of interventions Revision of interventions where appropriate

35 Most Common sites Of Pressure Damage The two most common sites for pressure ulcer development are the sacrum and the heels (Wilson, 2007) The thin layer of subcutaneous tissue between the skin and the bone provides minimal protection from the applied forces of pressure, shear and friction. There is often a reduced blood supply to the extremity due to comorbidities that compromise the vascular system (eg diabetes). Pressure ulcers may also occur where devices such as tubes, masks and catheters press into the body.

36 Heel Pressure Ulcers

37 Preventing Heel Pressure Ulcers Ensure heels are free of the surface of the bed Heel protection devices may be used for treatment and prevention Pillows may be used to elevate the limb The leg should be distributed along the calf without putting pressure on the Achilles tendon, the knee should be in slight flexion Ensure heels are inspected regularly in accordance with the repositioning regime

38 Other Equipment Leg troughs Bed cradles Hoists Slide sheets Foam wedges Splints Orthotic devices/ soft heel casting Electrically operated profiling bed frames

39 Dermapad/Aderma A localised prevention device Designed to redistribute pressure Cost effective Easy to apply by patient, carer or clinician Suitable for grade 1 pressure damage or patients at medium to high risk.

40 Aderma in Clinical Practice

41 Aderma in Clinical Practice Evaluation across 4 wards in an acute hospital Evaluation for a 3 month period post implementation of using Aderma compared to the previous 3 months Products (Aderma pads) used in conjunction with standard pressure ulcer prevention nursing practice 70% reduction in hospital acquired pressure damage (Woods, 2012)

42 Care Home Evaluation A evaluation of 15 care home residents immobile or with poor mobility Dermapad/Aderma heels applied Non blanching erythema on the heels followed up over a period of 2 months Quantitative data including grading of damage and ultrasound scan Outcomes indicated prevention of progression of skin damage (Hampton et al,2012)

43 Moisture Lesions Redness or partial thickness skin loss involving the epidermis, dermis or both caused by excessive moisture from urine, faeces or sweat. These lesions are not associated with a bony prominence. They can however be seen alongside a pressure ulcer of any grade.

44 Moisture Lesion

45 Moisture Lesions Not to be confused with pressure ulcers/damage May be distinguished by location, shape and depth Refer to skin excoriation tool for classification and action required (NATVNS Scotland)

46 Differential Diagnosis Likely to indicate a pressure ulcer Likely to indicate a moisture lesion Shape Limited to one spot Diffuse different superficial spots Circular or regular shape with In a kissing ulcer shape the exception of friction damage Depth Partial thickness skin loss top layer (grades 1 & 2) Superficial partial thickness skin loss which can deepen if infected Full thickness skin loss (grades 3 & 4) Necrosis Occurs with pressure ulcers No necrosis in moisture lesions Edges If friction is exerted on a moisture lesion it will result in superficial skin loss. Colour Edges tend to be distinct Red skin non-blanching (grade 1) Often irregular lesions diffused or irregular edges Erythema

47

48 Barrier Preparations Consider using a barrier preparation to prevent skin damage in adults who: Are at high risk of developing a moisture lesion Incontinence associated dermatitis including those with incontinence, dry or inflamed skin (NICE, 2014)

49 Unavoidable - Definition All risk assessments and preventative care have been implemented and re-evaluated, yet a pressure ulcer still occurs. A life threatening event may have occurred. A patient may have end-of-life skin changes. A patient with mental capacity may have refused preventative interventions. A patient may have been in a collapsed state, unknown to health professionals. (Bedfordshire & Herts TVN Forum 2010: DH undated)

50 Unavoidable Pressure Damage Points to consider: Think about your current clinical practice are you doing everything you can to prevent pressure damage? Have you involved your patient/carers? Have you involved appropriate members of the extended team? Does your documentation reflect this?

51 Principles Of Care Delivery Relief or reduction of pressure Removal of extrinsic factors that may exacerbate the pressure effect Alleviate intrinsic factors that reduce tissue tolerance Provide an optimum environment for healing On-going evaluation of the treatment plan. A team approach to care is crucial

52 Thank You For Listening

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