28 | Nursing in Practice | Winter 2022 |
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This is particularly important for people with darker skin tones , in whom increased severity of pressure ulcers has been found to be due to a lack of accurate assessment and early identification . 15 Identifying indicators of pressure damage allows for appropriate intervention , such as increasing the frequency of repositioning or offloading . |
S – Surface selection and use Support surfaces , commonly known as pressure relieving or redistributing equipment , are widely accepted methods of preventing and managing pressure ulcers . 4 , 5 These include different types of mattresses , cushions , seating and also site-specific devices ( such as for heels ). Broadly speaking , these aim to reduce , redistribute or offload pressure . 4
For people identified as at risk , it is important to consider adequate support for the whole 24-hour period , as part of person-centred care planning . Current guidance recommends a high-specification foam mattress and cushion , with consideration of seating needs and site-specific devices . 4 Where highspecification foam is not deemed sufficient , and present factors may be modifiable through a dynamic surface , then these should be considered . 4 , 16 Examples may include when the person is completely immobile , has nutritional deficits , lacks capacity or has altered skin , localised skin pain or a category 1 pressure ulcer . 16 However , there is a lack of robust evidence regarding the effectiveness of any particular support surface over another and there is no current standard or definition for high-specification foam . 4 Nurses should use their clinical judgement , refer to local policy and explore options with the person . The most appropriate support surfaces consider the person ’ s individual risk factors , environment , circumstances , movement ability , rehabilitation needs , skin response and preferences .
K – Keep patients moving Pressure ulcers are caused by sustained pressure or shear on tissue , so moving individuals appropriately is essential to alleviating pressure and minimising shear from vulnerable sites , such as bony prominences . Current guidelines recognise repositioning as a key part in preventing and managing pressure ulcers . 4 , 5
Where possible , the person should be encouraged to change their own position , including not lying or sitting
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in the same position for prolonged periods . NICE recommends encouraging those at risk to change position at least every six hours , with assistance and use of moving and handling equipment as required ( for example , slide sheets and glide-and-lock sheets ). 4 This equipment can prevent tissue damage through friction and shear . For those identified as high risk , repositioning every four hours as a minimum is recommended . 4 However , the frequency of repositioning may need to be increased based on the individual , their risk factors , personal circumstances , preferences and the result of skin assessments ( including any existing pressure ulcers ), in conjunction with professional judgement .
People who are completely immobile may require additional repositioning techniques . The 30-degree tilt is recommended for people in bed . 17 This technique ensures that pressure is not placed on the main large bony prominences by the person ’ s body through positioning with pillows or wedges . Alternative repositioning methods may be required for people who are very large .
I – Incontinence assessment and care Long-term exposure to moisture on the skin results in moisture-associated skin damage ( MASD ). There are many potential sources , but incontinence ( either urinary or stool ) is the most common . 18 Those at risk of MASD due to incontinence should be identified and , where possible , the underlying cause should treated . Otherwise , the plan of care should include a structured skin care routine , behavioural management strategies and use of incontinence products . A mild cleanser should be used , with soap products avoided , to maintain the skin ’ s normal pH . Simple moisturisers are also preferable , although a skin barrier product may also be necessary for those with more frequent episodes of incontinence . 18 Product selection will be guided by local formulary , and by the circumstances , routine and preferences of individual patients .
N – Nutrition and hydration assessment and support Malnutrition , and low and high body weight are all risk factors for pressure ulcers , so this is an important consideration in pressure ulcer prevention and management . 19 The Malnutrition Universal Screening Tool ( MUST ) is commonly used in practice to aid identification of people who are undernourished , at risk of malnutrition or who are obese . 20 Depending on the outcome this should trigger initiation of basic nutritional support , care planning and , if necessary , onward referral , in accordance with local policy . The importance of adequate hydration should also not be underestimated , as it plays a key role in the healthy functioning of the body and elasticity of the skin .
g – Giving information Giving information should be tailored to the person so they are enabled to make informed personal choices and take an active role in care of their pressure areas , if they are able to . 5 Family and carers should also be involved , where appropriate .
Conversations with people regarding the risks of pressure ulcers , the early signs , causes and ways to prevent or treat them should be an ongoing process throughout care . 4 , 5 This will ensure that the plan of care is person centred and regularly reviewed .
Rachael Lee is an independent wound consultant and clinical implementation lead for the National Wound Care Strategy Programme
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References 1 NHS England . Pressure ulcers : revised definition and measurement framework . 2018 . bit . ly / 3F46ysg 2 Haesler E ( Ed .). Prevention and Treatment of Pressure Ulcers : Quick Reference Guide . Cambridge Media : Western Australia , 2014 . bit . ly / 3GQDOo7 3 NHS Improvement Pressure Ulcer Categorisation Group . Pressure Ulcer Categorisation . 2019 . bit . ly / 3ilGIao 4 NICE . Pressure ulcers : prevention and management . London : NICE , 2014 . nice . org . uk / cg179 5 Healthcare Improvement Scotland . Standards for prevention and management of pressure ulcers . 2020 . bit . ly / 3EAggAY 6 NHS Improvement . Pressure ulcer core curriculum . 2018 . bit . ly / 3APaHOl 7 Stephenson J and Fletcher J . National Pressure Ulcer Prevalence and Quality of Care Audit . NHS England , 2020 . bit . ly / 3gFJaYE 8 Gorecki C et al . Impact of pressure ulcers on quality of life in older patients : A systematic review . J Am Geriatr Soc 2009 ; 57 ( 7 ): 1175-83 9 Guest J et al . Cohort study evaluating the burden of wounds to the UK ’ s National Health Service in 2017 / 2018 : update from 2012 / 2013 . BMJ Open 2020 ; 10 : e045253 10 Whitlock J . SSKIN bundle : preventing pressure damage across the healthcare community . British Journal of Community Nursing 2013 ; 18 : Suppl 9 : S32-39 11 Nixon J et al . Pressure UlceR Programme Of reSEarch ( PURPOSE ): Using mixed methods ( systematic reviews , prospective cohort , case study , consensus and psychometrics ) to identify patient and organisational risk , develop a risk assessment tool and patient-reported outcome quality of life and health utility measures . Programme Grants for Applied Research 2015 ; 3 ( 6 ) 12 Coleman S et al . Clinical evaluation of a new pressure ulcer risk assessment instrument , the Pressure Ulcer Risk Primary or Secondary Evaluation Tool ( PURPOSE T ). J Adv Nurs 2018 ; 74:407-24 13 Moore Z and Patton D . Risk assessment tools for the prevention of pressure ulcers ( review ). Cochrane Database Syst Rev 2019 ; 1 : CD006471 14 Wounds UK . Addressing skin tone bias in wound care : assessing signs and symptoms in people with dark skin tones . London : Wounds UK , 2021 . bit . ly / 3Ffp2Gk 15 Oozageer Gunowa N et al . Pressure injuries in people with darker skin tones : A literature review . J Clin Nurs 2018 ; 27 ( 17- 18 ): 3266-75 16 Nixon J et al . Comparing alternating pressure mattresses and highspecification foam mattresses to prevent pressure ulcers in high-risk patients : the PRESSURE 2 RCT . Health Technology Assessment 2019 ; 23 ( 52 ) 17 Moore Z et al . A randomised controlled clinical trial of repositioning using the 30 ° tilt , for the prevention of pressure ulcers . J Clin Nurs 2011 ; 20 ( 17- 18 ): 2633-44 18 Wounds International . International best practice recommendations : prevention and management of moisture-associated skin damage ( MASD ). London : Wounds International , 2020 . bit . ly / 3UqKHzw 19 Haesler E ( Ed .). Prevention and treatment of pressure ulcers : clinical practice guideline . Prague : European Pressure Ulcer Advisory Panel et al , 2019 . 20 BAPEN . Malnutrition Universal Screening Tool . 2011 . bit . ly / 2xSKqNu |
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