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Although most pressure ulcers are preventable , and despite extensive programmes of work to reduce their occurrence , 6 a national audit found overall prevalence across 36 hospitals in England was still 9.04 %. 7 Pressure ulcers are a substantial burden on people ’ s quality of life , often resulting in pain and distress . 8 They also negatively impact the allocation of valuable health and care resources , accounting for approximately 71 % of total NHS spend on wound care . 9 Consequently , pressure ulcers remain a challenge to health and care practitioners as well as for patients . 6
Finding ways to improve prevention and management should be a priority for policymakers , managers and health and care practitioners alike . 1 This article will explore and explain best practice according to the aSSKINg framework , which has evolved from guidance and standards relating to pressure ulcer prevention , management and education . 4 , 6
aSSKINg The aSSKINg framework builds on the widely recognised SSKIN bundle 10 , which highlights the fundamental elements of care delivery needed to prevent pressure ulcers occurring or deteriorating . The framework includes two additional elements (‘ a ’ and ‘ g ’), which underpin and support the implementation of effective , personalised care . The aSSKINg acronym stands for :
• a – Assessment of risk .
• S - Skin inspection and care .
• S – Support surface selection and use .
• K – Keep moving .
• I – Incontinence and increased moisture .
• N – Nutrition and hydration .
• g – Giving information . The framework aims to support practitioners by providing a structure for prevention and management . Its individual components are focus on the following aspects of care .
a – Assessment of risk Risk assessment is the first step in preventing pressure ulcers . It forms the basis for planning , implementing and evaluating a personalised plan of preventive care . Formal assessment of a person ’ s risk should be completed and documented as soon as possible after admission to , or contact with , a health or care service . 4 , 5 The frequency depends on national policy , as does the frequency of reassessment . Reassessment ensures that any changes in a person ’ s condition or care setting are documented and , when reviewed alongside the existing plan of care , indicates if existing interventions are effective . 5
Nurses are advised to use a validated pressure ulcer risk assessment tool . 4 , 5 There are many such tools available , but the PURPOSE T has the most robust evidence base ( see Box 2 ). 11 , 12 The advantage of this tool is that it incorporates a ‘ pre-screening ’ section . This allows early identification of those not at risk , without the need to progress to a full risk assessment . For those identified as at risk of developing a pressure ulcer , PURPOSE T supports care planning to reduce the risks identified . It also helps identify people who have existing or previous pressure ulcers who require secondary prevention and treatment .
A systematic review was inconclusive as to whether using a risk assessment tool rather than clinical judgement makes any difference in preventing pressure ulcers . 13 However , such tools do provide a structured
11 , 12
Box 2 PURPOSE-T ( Pressure Ulcer Risk Primary or Secondary Evaluation Tool )
PURPOSE-T comprises a three-step process . The tool uses colour coding for the most important risk factors for pressure ulcer development , to aid the practitioner in the assessment decision
Step 1 : Screening This step enables the practitioner to quickly screen out those clearly not at risk . It comprises assessment of mobility , skin status ( including medical devices ) and a prompt for the practitioner to use clinical judgement to highlight other risk factors .
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Step 2 : Full assessment The full risk assessment incorporates the following :
• Analysis of independent movement
• Detailed skin assessment
• Previous pressure ulcer history
• Medical devices
• Perfusion
• Sensory perception and response
• Moisture ( due to perspiration , urine , faeces or exudate )
• Nutrition
• Diabetes
Step 3 : Assessment decision This is completed based on clinical judgement and the findings of Step 2 , using the colour coding :
• Green : No pressure ulcer – not currently at risk
• Amber : No pressure ulcer but at risk , requiring primary prevention
• Red : pressure ulcer category 1 or above , or scarring from previous pressure ulcer , requiring secondary prevention / treatment
approach to both the assessment and documentation of an individual ’ s risk . This is particularly important when multiple practitioners or services are involved in the person ’ s care . Therefore , the best form of prevention is one that combines the use of a formal risk assessment tool with clinical judgement .
S – Skin assessment and care As the largest organ of the body , the skin often acts as a ‘ window ’ to underlying health issues . This includes displaying early signs of pressure damage , and consequently regular skin assessment is pivotal to pressure ulcer prevention .
While pressure ulcers mainly occur on bony prominences , skin assessment should be a systematic head-to-toe examination . This is important because pressure ulcers can occur in other places , such as under medical devices including catheters , tubing , masks , or any item that the person has been lying or sitting on . A thorough examination will also allow any other forms of skin damage to be noted , such as moisture or dryness , which make the skin more susceptible to breakdown . Identifying these issues allows for appropriate care planning , such as keeping skin clean and dry , moisturised and ensuring adequate hydration to maintain skin integrity .
During examination of the skin for early signs of pressure damage , lighter skin tones this will typically display as erythema or discolouration . Light finger palpation to determine if it blanches will indicate if damage has occurred ( described as non-blanching erythema ). 4 With darker skin tones , erythema may not be so easily visible but there may be colour changes or the skin may appear darkened . 4 , 14
It is important to remember that an effective skin assessment involves more than what the eye can see . Variations in skin temperature ( such as being hot or cold when compared with surrounding area ), changes in texture ( feeling hard or very soft and ‘ boggy ’), or visible swelling or inflammation are all potential indicators of underlying pressure damage . 14 Reported pain over a bony prominence is also a good indicator , so it is important to ask individuals about this during skin assessment .