best practice statement: care of the older person’s · pdf filebest practice statement:...

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3M is a trademark of the 3M Company. © 3M Health Care, 2006. Date of preparation: October 2006

Best Practice Statement:

Care of the Older Person’s Skin

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1Best Practice Statement: Care of the Older Person’s Skin

CONTENTS

Foreword 2

Development team 3

Review panel 3

Introduction 4

Dry, vulnerable tissue 4 Pressure ulcers 5 Incontinence 7 Maceration 8 Skin tears 8

Section 1: Management of dry, vulnerable tissue 9

Section 2a: Presure ulcers — risk assessment 10

Section 2b: Pressure ulcers — skin inspection 11

Section 2c: Pressure ulcers — classification 12

Section 2d: Pressure ulcers — stabilisation, positioning 13

Section 2e: Pressure ulcers — stabilisation, mattresses, chairs and cushions 14

Section 2f: Pressure ulcers — promoting healing 15

Section 3a: Skin care — incontinence 16

Section 3b: Skin care — maceration 17

Section 4: Skin tears 18

Appendix 1: Definitions of topical skin applications 19

Table 1: Quantities of dermatological preparations prescribed for specific areas of the body 19

Appendix 2: Skin examination 20

Appendix 3: Formal risk assessment scales, examples 20

Appendix 4: Pressure ulcer classification scales, examples 21

Appendix 5: Skin tear classification system 21

References 22

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Best Practice Statement: Care of the Older Person’s Skin2

Foreword

Those charged with caring for the sick and vulnerable in the UK are faced with the challenge of ensuring that their practice is of the highest standards, while often working with heavy workloads which can be a barrier to reviewing research literature on a regular basis. Where practitioners can access the latest published research, it can often be difficult to establish what changes, if any, a practitioner should make to their practice to ensure that it is optimal. Frequently, research papers call for fur ther research to be conducted, or arrive at conclusions which can leave the practitioner unclear as to how practice should be developed.

In view of these challenges, there is a need for clear and concise guidance as to how to deliver the optimal care. One method of supporting clinicians in this aim is the provision of Best Practice Statements. These types of statements were pioneered in the area of pressure ulcers by Quality Improvement Scotland, and we are grateful to them for their permission to reproduce the relevant sections of their statements in this document. In Best Practice Statements, the relevant research is reviewed, and expert opinion and clinical guidance is provided in clear, accessible table form.

The key principles of best practice (listed below) ensure that due care and process is followed to promote the delivery of the highest standards of care across all care settings, and by all care professionals.

v Best Practice Statements (BPS) are intended to guide practice and promote a consistent and cohesive approach to care.

v BPS are primarily intended for use by registered nurses, midwives and the staff who support them, but they may also contribute to multidisciplinary working and be of guidance to other members of the healthcare team.

v Statements are derived from the best available evidence, including expert opinion at the time they are produced, recognising that levels and types of evidence vary.

v Information is gathered from a broad range of sources to identify existing or previous initiatives at local and national level, incorporate work of a qualitative and quantitative nature, and establish consensus.

v Statements are targeted at practitioners, using language that is both accessible and meaningful.

The aim of this Best Practice Statement is to provide relevant and useful information to guide those active in the clinical area, who are responsible for the management of skin care in an ageing patient population. The Best Practice Statement: Care of the Older Person’s Skin has been developed by a team of specialists, chaired by Pam Cooper. During the peer review process, practitioners from across the UK have been able to comment on the various drafts. Their expertise has been sought to cover the variety of skin issues found in the elderly. This has led to the development of a guideline to support clinicians in their decision-making, which is up-to-date at the time of printing.

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Development team

Pam Cooper, Clinical Nurse Specialist in Tissue Viability, Department of Tissue Viability, NHS Grampian, Aberdeen

Dr Michael Clark, Senior Research Fellow, Wound Healing Research Unit, Cardiff University, Cardiff

Professor Sue Bale, Associate Director of Nursing, Gwent Healthcare NHS Trust, Gwent

Review panel

Alison Bardsley, Editor, Continence UK, Manager, Oxfordshire Continence Services, Oxford

Andrew Kingsley, Tissue Viability Nurse Specialist, North Devon District Hospital, Barnstaple

Rebecca Penzer, Editor, Dermatological Nursing, Independent Nurse Consultant, Opal Skin Solutions, Oxford

John Timmons, Tissue Viability Nurse, Department of Tissue Viability, NHS Grampian, Aberdeen

For the treatment and protectionof damaged or at-risk skin

This statement is a Wounds UK initiative, sponsored by 3M Health Care

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Introduction

As the largest organ of the body, comprising 15% of the body’s weight, the skin reflects the individual’s emotional and physical well-being. The skin varies in thickness from 0.5–4.0 mm, depending on which part of the body is involved (Stephen-Haynes, 2005). The skin consists of three main layers; the outer epidermis, the middle dermis and the subcutaneous tissue. Combined, these three layers of tissue provide the following functions:

v Protection: the skin acts as a protective barrier, preventing damage to internal tissues from trauma, ultraviolet (UV) light, temperature, toxins and bacteria (Butcher and White, 2005).

v Barrier to infection: part of this barrier function is the physical barrier of intact skin; the other is the presence of sebum, an antibacterial substance with an acidic pH which is produced by the skin (Günnewicht and Dunford, 2004).

v Pain receptor: nerve endings within the skin respond to painful stimuli. They also act as a protective mechanism.

v Maintenance of body temperature: to warm the body, the vessels vasoconstrict (become smaller), thus retaining heat. If the vessels vasodilate (become wider), this leads to cooling (Timmons, 2006).

v Production of vitamin D in response to sunlight: this is important in bone development (Butcher and White, 2005).

v Production of melanin: this is responsible for skin colouring and protection from sunlight radiation damage.

v Communication, through touch and physical appearance: this gives clues to the individual’s state of physical well-being (Flanagan and Fletcher, 2003).

The changes in the skin that occur as an individual ages affect the integrity of the skin, making it more vulnerable to damage. The epidermis gradually becomes thinner, (Baranoski and Ayello, 2004) and thus more susceptible to the mild mechanical injury

forces of moisture, friction and trauma (pp. 6–7). In the dermis, there is a reduction in the number of sweat glands and in the production of sebum. These changes add vulnerability to the skin, and, when this is coupled with an increased necessity to cleanse the skin, damage will occur. Most soaps increase the skin’s pH to an alkaline level, thus putting the skin’s surface at risk of the effects of dehydration and altering the normal bacterial flora of the skin, which allows colonisation with more pathogenic species (Cooper and Gray, 2001).

As the skin sees a reduction in elastin fibres, it becomes more easily stretched, increasing the risk of tearing and trauma.

The most dramatic loss that the skin experiences during the ageing process is a 20% reduction in the thickness of the dermis (Bryant, 1992). This gives the skin its paper-thin appearance, commonly associated with the elderly (Kaminer and Gilchrist, 1994). This thinning of the dermis sees a reduction in the blood vessels, nerve endings and collagen, leading to a decrease in sensation, temperature control, rigidity and moisture retention (Baranoski and Ayello, 2004).

This document aims to provide clinicians with best practice guidance in five key areas of skin care for older persons, namely:

v dry, vulnerable tissuev pressure ulcersv incontinencev macerationv skin tears.

Dry, vulnerable tissue

As already said, with the ageing process, the skin undergoes a number of changes. Not only is there a significant reduction in the skin’s thickness, but because of the changes within the epidermis and dermis, there is also a reduction in the number of sweat glands, leading to dryness of the skin. Once the

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skin becomes dry, it is more vulnerable to splitting and cracking, exposing it to bacterial contamination, and further adding to the likelihood of breakdown from infection.

Altering an individual’s position, or nursing them on an appropriate support surface in conjunction with position changes can prevent pressure damage. If the pressure is unrelieved for a long period of time, the damage will extend to the bone. A cone-shaped ulcer is created, with the widest part of the cone close to the bone, and the narrowest on the body surface. This may be seen as a non-blanching red mark, or an area of superficial skin loss on examination (Dealey, 1994). The ulcer will then appear to deteriorate rapidly, often causing alarm — however, the damage has already been present for some time. In some situations, this deep damage may have occurred in the days prior to admission to health or social care, which is a good reason for inspection within the first six hours following admission (National Institute for Clinical Excellence [NICE], 2005). Inspection Pressure ulcers

A pressure ulcer is an area of localised damage to the skin and underlying tissue, due to the occlusion of blood vessels which leads to cell death (Collier, 1996). Pressure ulcers are believed to be caused by direct pressure, shear and friction (Allman, 1997; European Pressure Ulcer Advisory Panel [EPUAP] Review, 1999). The forces of pressure are further exacerbated by moisture, and factors relating to the individual’s physical condition, such as altered mobility, poor nutritional status, medication, and underlying medical conditions. Pressure ulcers are also referred to as pressure sores, decubitus ulcers and bedsores (Beldon, 2006).

Pressure ulcers usually occur over a bony prominence, such as the sacrum, ischial tuberosity and heels. However, they can appear anywhere that tissue becomes compressed, such as under a plaster cast or splint.

Direct pressure is the major causative factor in the development of pressure ulcers. This occurs when the soft tissue of the body is compressed between a bony prominence and a hard surface. This occludes the blood supply, leading to ischaemia and tissue death.

Figure 1: Dry skin

Figure 2: Pressure ulcer body map (Bryant, 1992)

Chin 0.5%

Iliac crest 4%

Trochanter 15%

Knee 6%

Pretibial crest 2%

Malleolus 7%Heel 8%

Ischium 24%

Sacrum 23%

Elbow 3%

Spinous process 1%

Scapula 0.5%

Occiput 1%

Prone position

Supine position

Sitting position

Lateral pressure

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is necessary to check for skin blemishes, and to initiate a risk assessment and start a pressure prevention care plan to prevent further damage.

Shear can also contribute to pressure ulcer development. This usually occurs when the skeleton and underlying tissue move down the bed under gravity, but the skin on the buttocks and back remain stuck to the same point on the mattress. This twisting and dragging effect occludes blood vessels which causes ischaemia, and usually leads to the development of more extensive tissue damage. Shear force can be further exacerbated by the presence of surface moisture through incontinence or sweating (Collier, 1996), and by friction when the skin slides over the surface with which it is in contact.

Friction occurs when two surfaces move or rub across one another, leading to superficial tissue loss. Prior to the use of lift aids, patients were manually lifted up the bed and, if the sacrum and heels were not clear of the surface, they would be dragged up causing friction to these areas. The majority of pressure ulcers to the heel are caused by a combination of both pressure and friction. Initially, they present as a blister (friction), with purple discoloration to the underlying tissue (pressure).

The effects of pressure, shear and friction can be further exacerbated by the individual’s physical condition. These factors should be considered when carrying out a full assessment, including:

v general health v age v reduced mobility v nutritional status v incontinencev certain medications.

Staff and carers involved in looking after individuals at risk, or with existing pressure ulcers may use this document to support

Figure 4: Pressure ulcer to the sacrum, caused by the combined effects of pressure and shear

Figure 5: Pressure ulcer to the sacrum caused by pressure and friction. The effects of friction cause the removal of the epidermis

Figure 3: Pressure ulcer to the sacrum, which presents with exposed bone, slough and granulation tissue

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their decision-making to ensure that best practice is provided.

Sections relating to pressure ulcers have been amended from the BPS for the prevention and treatment/management of pressure ulcers by NHS Quality Improvement Scotland (Best Practice Statement for the Prevention of Pressure Ulcers, NHS Quality Improvement Scotland, 2003 updated 2005. Best Practice statement for the Treatment/Management of Pressure Ulcers, NHS Quality Improvement Scotland, 2005).

Incontinence

Some studies have shown that older people are more prone to incontinence. In one study, 29% of older people cared for in a nursing home were incontinent of urine, 65% were doubly incontinent, and 6% were catheterised (Bale et al, 2004).

Skin has a mean pH of 5.5, which is slightly acidic. Both urine and faeces are alkaline in nature, therefore, if the individual is incontinent there is an immediate change in pH which affects the skin. Ammonia is produced when Figure 7: Incontinence skin reaction

microorganisms digest urea from the urine. Although urinary ammonia alone is not a primary irritant, urine and faeces together increase the pH around the perianal area, causing increased skin irritation (Berg, 1986; Le Lievre, 2000). This is responsible for the dermatitis excoriation seen in individuals with incontinence (Fiers, 1996).

The increase in moisture resulting from episodes of incontinence, combined with bacterial and enzymatic activity, can result in the breakdown of vulnerable skin, due to an increased friction co-efficient,

Figure 6: Thirty-degree lateral position at which pressure points are avoided (Bryant, 1992)

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particularly in those who are very young or elderly. For those individuals experiencing incontinence and the effects of irritation from incontinence, it is important to avoid exacerbating this fur ther through inappropriate methods of cleansing the skin (Whittingham, 1998). A protective barrier spray or cream can be used to prevent sore skin from breaking down further. Advice on appropriate products to aid management of incontinence can be sought from your local continence advisor.

Maceration

It is accepted that a degree of moisture is essential for moist wound healing to occur (Winter, 1963). However, the correct moisture balance is difficult to define. The wound needs to be moist, but not too moist or too dry, as this may affect the rate of healing. Maceration of the skin may be due to any of the following factors:

v incontinence (see Section 3a, p. 16) v excess moisture from sweating in hot

environments and induced by waterproof chair and bed surfaces

v wound exudate v peri-stomal exudate.

When the skin is in contact with fluid for sustained periods of time, it becomes

Figure 9: Skin tear to a limb caused by trauma

soft and wrinkled allowing for breaks in the epidermis (White and Cutting, 2003). This softening of the tissue, along with attack from enzymes within urine, faeces and wound exudate, can cause the skin to become red, broken and painful. It is important that the skin is protected from these enzymatic onslaughts.

Skin tears

Skin tears are a common problem in the elderly because the skin becomes thin and fragile (Bryant, 1992). They usually occur on the shin and the arm, and are normally caused by trauma exacerbated by shear and friction (Morris, 2005). Due to the thin nature of the skin, skin tears tend to involve some damage to the epidermis and the dermis, and may take some time to heal. Therefore, to optimise healing, management of these wounds is best carried out at the time of injury.

Figure 8: Pressure ulcer to the heel. The surrounding white tissue indicates the presence of maceration

Each of the sections that follow, contain a table showing:

v the optimum outcomev the reason for, and how best to

succeed in reaching this outcomev how to demonstrate that best practice is

being achieved.

In addition, each section identifies key points/challenges, and is supported by appendices, a table, and references (where available).

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Sec

tio

n 1

: Man

agem

ent

of

dr

y, v

uln

erab

le t

issu

eK

ey p

oin

ts:

l If

iden

tified

as

havi

ng d

ry, v

ulne

rabl

e sk

in, t

he s

kin

shou

ld b

e fr

eque

ntly

ass

esse

d.l R

egul

ar t

reat

men

t w

ith a

moi

stur

iser

will

mai

ntai

n sk

in in

tegr

ity.

Stat

emen

tRe

ason

for s

tate

men

tH

ow to

dem

onst

rate

stat

emen

t is

bein

g ac

hiev

ed

v

All in

divid

uals

are

asse

ssed

to d

eter

mine

cond

ition

of s

kin

(dry

*, fla

ky, e

xcor

iated

, disc

olou

red,

etc)

v

Asse

ssm

ent e

nable

s the

corr

ect a

nd su

itable

pre

vent

ative

m

easu

res t

o be

initi

ated

and

main

taine

dv

Th

e he

alth

reco

rds o

f all

indi

vidua

ls ad

mitt

ed to

, or

resid

ent i

n a f

acilit

y m

ust i

nclu

de e

viden

ce o

f skin

co

nditi

on as

sess

men

t

v

Emol

lient

soap

subs

titut

es sh

ould

be

used

in in

divid

uals

with

dry

, vuln

erab

le sk

in, o

r skin

det

erm

ined

to b

e vu

lnera

ble w

hen

wash

ing/cl

eans

ing d

uring

rout

ine

pers

onal

hygie

ne

v

Was

hing s

kin w

ith an

em

ollie

nt so

ap su

bstit

ute

redu

ces

the

dryin

g effe

cts a

ssoc

iated

with

soap

and

wate

r (C

alian

no, 2

002)

v

Hea

lth re

cord

s inc

lude

evid

ence

that

the

appr

opria

te

emol

lient

is u

sed

v

Skin

shou

ld b

e th

orou

ghly

dried

to p

reve

nt fu

rthe

r de

hydr

atio

n. D

rying

shou

ld in

volve

a lig

ht p

attin

g and

not

ru

bbing

, as r

ubbin

g may

lead

to ab

rasio

n an

d/or

wea

kenin

g of

the

skin

(Brit

ton,

2003

)

v

If th

e sk

in is

left

dam

p, it

is vu

lner

able

to e

xces

s dry

ing

from

the

envir

onm

ent a

nd a

t risk

from

bac

teria

l and

fu

ngal

cont

amin

atio

n

v

Hea

lth re

cord

s hav

e ev

iden

ce th

at al

l indi

vidua

l’s sk

in is

dried

in an

appr

opria

te m

anne

r

v

All in

divid

uals

with

dry

, vuln

erab

le sk

in sh

ould

hav

e a b

land

moi

sturis

er o

r bar

rier c

ream

appli

ed at

leas

t twi

ce d

aily t

o pr

even

t the

adve

rse

effec

ts of

dry

skin

(App

endix

1, p

. 19)

v

Appli

catio

n of

a bla

nd m

oistu

riser

or b

arrie

r cre

am

rehy

drat

es th

e sk

in an

d re

duce

s the

irrit

ant e

ffect

s fro

m

perfu

mes

and

addi

tives

(Bale

, 200

4)

v

Ther

e is

evid

ence

with

in th

e he

alth

reco

rds t

hat t

he

appr

opria

te m

oist

urise

r and

am

ount

is u

sed

(see

Ap

pend

ix 1,

p. 19

)

v

Appli

catio

n of

the

moi

sturis

er o

r bar

rier c

ream

shou

ld

follo

w th

e di

rect

ion

of th

e bo

dy h

air, a

nd b

e ge

ntly

smoo

thed

into

the

skin

(am

ount

s rec

omm

ende

d by

the

Britis

h Na

tiona

l For

mula

ry [B

NF] a

re o

utlin

ed in

Table

1, p

. 19)

v

Rubb

ing th

e m

oistu

riser

or b

arrie

r cre

am in

to th

e sk

in ca

n lea

d to

irrit

atio

n

* D

ry sk

in in

the

elder

ly is

diffe

rent

to u

nder

lying

der

mat

olog

ical c

ondi

tions

such

as e

czem

a, ps

orias

is an

d un

derly

ing sk

in se

nsitiv

ities.

Indi

vidua

ls w

ith e

czem

a, ps

orias

is an

d un

derly

ing sk

in se

nsitiv

ities a

re lik

ely to

ben

efit

from

the

abov

e gu

idan

ce b

ut sh

ould

be

refe

rred

for s

pecifi

c, ap

prop

riate

trea

tmen

ts

BPS2.indd 9 3/11/06 16:04:18


Sec

tio

n 2

a: P

res

sur

e u

lcer

s —

ris

k a

sses

smen

tK

ey p

oin

ts:

l A

ll in

divi

dual

s ‘at

ris

k’, o

r w

ith e

xist

ing

pres

sure

ulc

ers

shou

ld b

e as

sess

ed.

l In

spec

tion

of id

entifi

ed in

divi

dual

s sh

ould

be

carr

ied

out

regu

larl

y an

d, in

bet

wee

n as

sess

men

ts, i

f hea

lth s

tatu

s ch

ange

s fo

r be

tter

or

wor

se.

l T

hose

indi

vidu

als

cons

ider

ed ‘a

t ri

sk’,

or t

hose

with

pre

ssur

e ul

cers

, sho

uld

rece

ive

appr

opri

ate

inte

rven

tions

.

Stat

emen

tRe

ason

for s

tate

men

tH

ow to

dem

onst

rate

stat

emen

t is

bein

g ac

hiev

ed

v

All in

divid

uals

are

asse

ssed

usin

g bot

h fo

rmal*

(App

endix

3,

p. 20

) and

info

rmal*

* ass

essm

ent t

ools

to d

eter

mine

their

lev

el of

risk

of p

ress

ure

ulcer

dev

elopm

ent

v

Risk

asse

ssm

ent e

nable

s the

corr

ect a

nd su

itable

pr

even

tativ

e m

easu

res t

o be

initi

ated

and

main

taine

dv

Co

mbin

ing b

oth

form

al an

d inf

orm

al ris

k as

sess

men

t pr

ovid

es e

arly

iden

tifica

tion

of th

e ind

ividu

al’s l

evel

of ri

sk

v

The

healt

h re

cord

s of a

ll ind

ividu

als ad

mitt

ed to

, or r

esid

ent

in a f

acilit

y mus

t inc

lude

evid

ence

of p

ress

ure

ulcer

risk

as

sess

men

t

v

Ther

e is

evid

ence

that

all in

divid

uals

with

exis

ting n

on-

blanc

hing e

ryth

ema (

Appe

ndix

2, p.

20), o

r exis

ting p

ress

ure

ulcer

s, re

ceive

pre

vent

ative

inte

rven

tions

. This

is re

cord

ed

in th

e ind

ividu

al’s h

ealth

reco

rds

v

Choi

ce o

f ass

essm

ent t

ool u

sed,

as th

is re

flect

s the

ca

re se

tting

v

Ther

e is

evid

ence

with

in th

e ind

ividu

al’s h

ealth

reco

rd th

at

staff

act o

n ind

ividu

al co

mpo

nent

s of t

he ri

sk as

sess

men

t pr

oces

s, eg

. poo

r diet

ary i

ntak

e, inc

ontin

ence

v

Indi

vidua

ls ar

e re

asse

ssed

at re

gular

inte

rvals

and

if th

eir

cond

ition

or t

reat

men

t alte

rsv

Ch

ange

s with

in th

e ind

ividu

al’s p

hysic

al or

men

tal c

ondi

tion

can

lead

to an

incr

ease

d ris

k of

pre

ssur

e ulc

er d

evelo

pmen

tv

Th

ere

is ev

idenc

e th

at in

dividu

als ar

e re

asse

ssed

in re

spon

se

to ch

ange

s in

their

phy

sical

and/

or m

enta

l con

ditio

n

v

Ther

e is

evid

ence

that

indi

vidua

ls id

entifi

ed as

bein

g at r

isk

rece

ive p

reve

ntat

ive in

terv

entio

ns w

hich

is re

cord

ed w

ithin

the

healt

h re

cord

s

* Fo

rmal

risk a

ssessm

ent i

s the

use

of a

reco

gnise

d ris

k asse

ssmen

t too

l (re

fer to

App

endix

3, p

. 20)

**

Infor

mal

risk a

ssessm

ent, o

r clin

ical ju

dgem

ent, i

s the

clini

cian’s

or c

arer

’s ow

n cli

nical

expe

rienc

e, th

eir u

nder

stand

ing o

f the

clien

t gro

up, a

s well

as th

e ind

ividu

al’s e

nviro

nmen

t and

phy

sical

cond

ition

BPS2.indd 10 3/11/06 16:04:19


Sec

tio

n 2

b: P

res

sur

e u

lcer

s —

sk

in i

nsp

ecti

on

Key

po

ints

: l A

ll in

divi

dual

s ‘at

ris

k’, o

r w

ith e

xist

ing

pres

sure

ulc

ers

shou

ld b

e as

sess

ed.

l In

spec

tion

of id

entifi

ed in

divi

dual

s sh

ould

be

carr

ied

out

regu

larl

y an

d, in

bet

wee

n as

sess

men

ts, i

f hea

lth s

tatu

s ch

ange

s fo

r be

tter

or

wor

se.

l T

hose

indi

vidu

als

iden

tified

sho

uld

rece

ive

appr

opri

ate

inte

rven

tions

.

Stat

emen

tRe

ason

for s

tate

men

tH

ow to

dem

onst

rate

stat

emen

t is

bein

g ac

hiev

ed

v

All in

divid

uals

at ri

sk o

f pre

ssur

e ulc

er d

evelo

pmen

t, or

wi

th e

xistin

g pre

ssur

e ulc

ers,

will h

ave

their

skin

asse

ssed

as

par

t of t

he w

hole

asse

ssm

ent p

roce

ss. F

or th

ose

with

ex

isting

pre

ssur

e ulc

ers,

a clas

sifica

tion

scor

e wi

ll be

used

(se

e Se

ction

2c o

n ‘Cl

assifi

catio

n’, p

. 12)

v

The

majo

rity o

f pre

ssur

e ulc

ers t

hat o

ccur

are

supe

rficia

l in

natu

re. E

arly

iden

tifica

tion

of sk

in ch

ange

s may

pre

vent

fu

rthe

r det

erio

ratio

n

v

Follo

wing

asse

ssm

ent o

f risk

, insp

ectio

n of

the

skin

is do

cum

ente

d wi

thin

the

indivi

dual’

s hea

lth re

cord

s

v

Gen

eral

visua

l insp

ectio

n of

all a

reas

of t

he sk

in fo

rms p

art

of th

e as

sess

men

t pro

cess

, with

spec

ial at

tent

ion

being

paid

to

bon

y pro

mine

nces

(se

e Fig

ure 2

, p. 5

).

v

The

majo

rity o

f pre

ssur

e ulc

ers t

hat o

ccur

are

loca

ted

on

the

sacr

um an

d he

els (C

lark

and W

atts,

199

4)

v

Findi

ngs f

rom

skin

inspe

ctio

n ind

icate

that

furt

her

inter

vent

ion

is re

quire

d. Th

is, alo

ng w

ith th

e su

bseq

uent

ac

tion

take

n, is

reco

rded

in th

e he

alth

reco

rds

v

Any i

nter

vent

ions

und

erta

ken,

eg. m

attre

ss, c

ushio

n, he

el pr

otec

tors

, spe

cialis

t refe

rral

mus

t be

reco

rded

in th

e he

alth

reco

rds

v

Whe

re an

area

of r

edne

ss o

r skin

disc

olor

atio

n (e

ryth

ema/

hype

raem

ia) is

not

ed, fu

rthe

r exa

mina

tion

is re

quire

d. Se

e Ap

pend

ix 2

(p. 2

0) if

dea

ling w

ith d

ark

skin

pigm

enta

tion

v

Furth

er e

xam

inatio

n wi

ll ind

icate

if th

e sk

in ch

ange

s are

the

early

stag

e of

pre

ssur

e ulc

er d

evelo

pmen

t (Ap

pend

ix 2,

p. 20

) v

Sk

in co

nditi

on an

d su

bseq

uent

exa

mina

tion

is do

cum

ente

d wi

thin

the

indivi

dual’

s hea

lth re

cord

s

BPS2.indd 11 3/11/06 16:04:19


Sec

tio

n 2

c: P

res

sur

e u

lcer

s —

cla

ssif

icat

ion

Key

po

ints

: l A

ll in

divi

dual

s w

ith p

ress

ure

ulce

rs s

houl

d ha

ve t

he u

lcer

ass

esse

d us

ing

a re

cogn

ised

gra

ding

sca

le.

l A

sses

smen

t of

the

pre

ssur

e ul

cer

enab

les

appr

opri

ate

trea

tmen

t an

d in

terv

entio

n.

Stat

emen

tRe

ason

for s

tate

men

tH

ow to

dem

onst

rate

stat

emen

t is

bein

g ac

hiev

ed

v

All in

divid

uals

iden

tified

with

exis

ting p

ress

ure

ulcer

s sho

uld

have

their

ulce

r(s) a

sses

sed

to d

eter

mine

leve

l of t

issue

da

mag

e us

ing a

reco

gnise

d cla

ssific

atio

n to

ol, s

uch

as; t

he

EPUA

P G

uide

to P

ress

ure

Ulce

r Gra

ding

(199

9), t

he S

tirlin

g Pr

essu

re S

ore

Seve

rity S

cale

(SPS

SS) (

Reid

and

Mor

rison

, 19

94), a

nd th

e Pr

essu

re U

lcer S

cale

for H

ealin

g (PU

SH) t

ool

(Sto

tts et

al, 2

001)

v

Gra

ding

of p

ress

ure

ulcer

dam

age

enab

les co

rrec

t and

su

itable

trea

tmen

t and

inte

rven

tion

to b

e ini

tiate

d an

d m

ainta

ined

v

The

healt

h re

cord

s of a

ll ind

ividu

als id

entifi

ed as

hav

ing an

ex

isting

pre

ssur

e ulc

er(s)

will

includ

e ev

iden

ce o

f pre

ssur

e ulc

er gr

ading

from

the

initia

l iden

tifica

tion

v

Doc

umen

ted

evid

ence

with

in th

e he

alth

reco

rds o

f all

thos

e wi

th e

xistin

g pre

ssur

e ulc

ers o

f ong

oing a

ssessm

ent,

treatm

ent r

ation

ale an

d int

erve

ntion

s tak

en

v

The

pres

sure

ulce

r(s) s

hould

be

reas

sess

ed re

gular

ly, at

lea

st we

ekly,

or ac

cord

ing to

the

indivi

dual’

s con

ditio

n an

d/or

if th

e ind

ividu

al’s c

ondi

tion

chan

ges f

or b

ette

r or w

orse

v

Ong

oing

asse

ssm

ent e

nable

s an

accu

rate

and

indivi

duali

sed

treat

men

t plan

to b

e de

vised

v

Doc

umen

ted

evid

ence

that

the

indivi

dual’

s con

ditio

n an

d pr

essu

re u

lcer i

s rea

sses

sed

regu

larly,

at le

ast w

eekly

, or

mor

e fre

quen

tly ac

cord

ing to

the

indivi

dual’

s con

ditio

n

v

Whe

n as

sess

ing p

ress

ure

ulcer

s, th

e fo

llowi

ng sh

ould

be

cons

ider

ed: c

ause

, loca

tion,

grad

e (a

ccor

ding

to cl

assifi

catio

n to

ol), d

imen

sions

, wou

nd b

ed ap

pear

ance

, exu

date

, pain

, su

rrou

nding

skin

cond

ition

, and

, if in

fectio

n is

pres

ent

v

A co

mple

te h

istor

y and

phy

sical

exam

inatio

n of

the

indivi

dual

shou

ld b

e un

dert

aken

v

Early

iden

tifica

tion

of sk

in ch

ange

s and

/or t

horo

ugh

asse

ssm

ent o

f the

pre

ssur

e ulc

er(s)

shou

ld lea

d to

ap

prop

riate

trea

tmen

ts an

d int

erve

ntio

nsv

A

pres

sure

ulce

r sho

uld b

e as

sess

ed co

nside

ring t

he

indivi

dual’

s ove

rall p

hysic

al an

d ps

ycho

socia

l hea

lth

v

Evid

ence

with

in th

e ind

ividu

al’s h

ealth

reco

rds t

hat t

he

inter

vent

ions

take

n ar

e ba

sed

on fa

ctor

s ide

ntifie

d by

the

histo

ry an

d ph

ysica

l exa

mina

tion

of th

e ind

ividu

al

v

Pres

sure

ulce

rs sh

ould

be

asse

ssed

at le

ast w

eekly

, or m

ore

frequ

ently

acco

rding

to th

e ind

ividu

al’s c

ondi

tion

v

The

pres

sure

ulce

r req

uires

regu

lar as

sess

men

t to

obse

rve

for i

mpr

ovem

ent o

r det

erio

ratio

n in

cond

ition

v

Hea

lth re

cord

s con

tain

evid

ence

of r

egula

r rea

sses

smen

t, at

leas

t wee

kly, o

r mor

e of

ten

acco

rding

to th

e ind

ividu

al’s

cond

ition

BPS2.indd 12 3/11/06 16:04:19


Sec

tio

n 2

d: P

res

sur

e u

lcer

s —

sta

bili

sati

on

, po

siti

on

ing

Key

po

ints

: l In

divi

dual

s ‘at

ris

k’, o

r w

ith e

xist

ing

pres

sure

ulc

ers

are

not

left

out

of b

ed s

ittin

g fo

r lo

ng p

erio

ds.

l A

cute

ly il

l pat

ient

s ar

e re

turn

ed t

o be

d fo

r at

leas

t on

e ho

ur.

Stat

emen

tRe

ason

for s

tate

men

tH

ow to

dem

onst

rate

stat

emen

t is

bein

g ac

hiev

ed

v

Indi

vidua

ls at

risk

of p

ress

ure

ulcer

dev

elopm

ent,

or w

ith

exist

ing p

ress

ure

ulcer

s sho

uld b

e su

itably

pos

ition

ed w

hile

in be

d, or

up

sittin

g, to

mini

mise

pre

ssur

e, fri

ctio

n an

d sh

ear,

and

the

pote

ntial

for f

urth

er ti

ssue

dam

age

v

Indi

vidua

ls wh

o ca

n m

ove

indep

ende

ntly

shou

ld b

e en

cour

aged

to d

o so

v

Indi

vidua

ls wh

o re

quire

assis

tanc

e wi

th m

ovem

ent s

hould

, alo

ng w

ith as

socia

ted

care

rs, b

e ed

ucat

ed in

the

bene

fits

and

tech

nique

s of w

eight

dist

ribut

ion

v

Shor

t per

iods

(up

to tw

o ho

urs)

of su

staine

d pr

essu

re ca

n be

as d

amag

ing to

the

skin

as lo

ng p

erio

ds o

f sitt

ingv

Th

e tim

e pe

riod

betw

een

posit

ion

chan

ges i

s bas

ed o

n as

sess

men

t of e

ach

indivi

dual

and

their

cond

ition

v

Evid

ence

sugg

ests

that

indi

vidua

ls at

risk

of p

ress

ure

ulce

r dev

elopm

ent s

houl

d no

t be

posit

ione

d in

a sit

ting

posit

ion

for m

ore

than

two

hour

s with

out s

ome

form

of

repo

sitio

ning

(DeF

loor

, 200

0)v

D

evice

s to

assis

t with

the

repo

sitio

ning o

f ind

ividu

als ar

e av

ailab

le, su

ch as

elec

tric

and

non-

elect

ric p

rofili

ng b

eds,

spec

ialist

seat

ing. B

enefi

ts fro

m th

ese

have

bee

n re

cord

ed

v

Hea

lth re

cord

s sho

w ev

iden

ce o

f how

freq

uent

ly po

sitio

n ch

ange

s are

bein

g car

ried

out.

v

Hea

lth re

cord

s ind

icate

that

:

l

indivi

duals

at ri

sk o

f pre

ssur

e ulc

er d

evelo

pmen

t, or

with

exis

ting p

ress

ure

ulcer

s are

not

pos

ition

ed in

a se

at

for m

ore

than

two

hour

s, wi

thou

t bein

g rep

ositi

oned

. In

dividu

als w

ho ar

e ac

utely

ill m

ust b

e re

turn

ed to

bed

fo

r no

less t

han

one

hour

(Geb

hard

t and

Blis

s, 19

94)

l

when

pos

sible,

the

indivi

dual

and/

or ca

rer a

re in

volve

d in

the

man

agem

ent

l

for i

ndivi

duals

in b

ed, d

ifferin

g pos

ition

s suc

h as

the

30-

degr

ee ti

lt* (Y

oung

, 200

4) ar

e us

ed (F

igure

6, p

. 7)

l

hoist

sling

s and

slid

ing sh

eets

are

not l

eft u

nder

ind

ividu

als af

ter u

se**

l

skin

inspe

ctio

n sh

ould

be ca

rried

out

whe

n alt

ering

the

indivi

dual’s

pos

ition:

thes

e ins

pect

ions

can

help

guide

de

cisio

ns o

n th

e len

gth o

f tim

e bet

ween

pos

ition

chan

ges

v D

ocum

ent t

he re

sults

of s

kin in

spec

tion

and

any c

hang

es

mad

e to

the

repo

sitio

ning r

egim

e wi

thin

the

indivi

dual’

s he

alth

reco

rds

v

Indi

vidua

ls wi

th sp

ecific

mov

ing an

d ha

ndlin

g req

uirem

ents

(eg.

spina

l injur

ies) s

hould

hav

e th

eir n

eeds

asse

ssed

by t

he

prof

essio

nal w

ith th

e m

ost r

eleva

nt sk

ills

v

Mov

ing an

d ha

ndlin

g aids

can

help

repo

sitio

n ind

ividu

alsv

D

evice

s to

alter

an in

dividu

al’s p

ositi

on, s

uch

as e

lectri

c pr

ofilin

g bed

s, ar

e of

value

v

Hea

lth re

cord

s sho

w re

ferr

al to

the

appr

opria

te in

divid

ual,

ie. p

hysio

ther

apist

, occ

upat

iona

l the

rapi

st, s

pecia

list

mob

ility

serv

ices

* Th

e 30

-deg

ree

tilt is

whe

n th

e ind

ividu

al is

place

d in

the

later

ally-

inclin

ed p

ositio

n, su

ppor

ted

by p

illows

, with

their

bac

k mak

ing a

30-d

egre

e an

gle w

ith th

e su

ppor

t sur

face

**

With

asso

ciate

d m

anua

l han

dling

issu

es co

ncer

ning t

he re

mov

al of

a ho

ist o

r slin

g, eg

. pain

man

agem

ent, o

r com

fort

for t

erm

inally

ill p

atien

ts, a j

oint a

ssessm

ent b

y tiss

ue vi

abilit

y and

man

ual h

andli

ng ad

visor

s may

be

appr

opria

te

BPS2.indd 13 3/11/06 16:04:19


Sec

tio

n 2

e: P

res

sur

e u

lcer

s —

sta

bili

sati

on

, mat

tres

ses,

ch

air

s an

d c

ush

ion

sK

ey p

oin

ts:

l In

divi

dual

s ‘at

ris

k’, o

r w

ith a

pre

ssur

e ul

cer

mus

t be

car

ed fo

r on

an

appr

opri

ate

mat

tres

s.l In

divi

dual

req

uire

men

ts m

ay c

hang

e, b

ased

upo

n th

e co

nditi

on a

nd a

sses

smen

t.

Stat

emen

tRe

ason

for s

tate

men

tH

ow to

dem

onst

rate

stat

emen

t is

bein

g ac

hiev

ed

v

Indivi

duals

at ri

sk o

f pre

ssure

ulce

r dev

elopm

ent, o

r with

a pr

essu

re u

lcer(s

) ar

e not

care

d fo

r sole

ly on

stan

dard

NHS

ma

ttres

ses*

, or o

n ba

sic d

ivan

mattr

esse

s; at

a mini

mum,

they

ar

e pro

vided

with

a pr

essu

re-re

ducin

g foa

m ma

ttres

s or o

verla

yv

Facto

rs to

cons

ider w

hen

decid

ing o

n wh

ich p

ressu

re-re

ducin

g eq

uipme

nt to

pur

chas

e or h

ire in

clude

:

l

clini

cal e

fficac

y

l

ease

of m

ainte

nanc

e

l

impa

ct on

care

pro

cedu

res

l

patie

nt ac

cept

abilit

y

l

cost

l

ease

of u

sev

The d

ecisi

on to

pro

vide a

ny p

ressu

re-re

ducin

g equ

ipmen

t is

taken

as p

art o

f a co

mpre

hens

ive tr

eatm

ent/m

anag

emen

t str

ategy

, nev

er as

a so

le int

erve

ntion

v

Indivi

duals

bein

g car

ed fo

r on

spec

ialist

equip

ment

hav

e th

eir sk

in ins

pecte

d fre

quen

tly to

asse

ss th

e suit

abilit

y of t

he

equip

ment

; equ

ipmen

t req

uirem

ents

may c

hang

e with

chan

ges

in th

e pati

ent’s

cond

ition

v

Indivi

duals

at ri

sk, o

r with

pres

sure

ulce

rs, ar

e pro

vided

with

ap

prop

riate

pres

sure

-redu

cing e

quipm

ent w

hen s

itting

in a

chair

or

whe

elcha

ir, in

addit

ion to

whe

n the

y are

being

care

d for

in be

dv

Long

-term

whe

elcha

ir or

stati

c sea

t use

rs h

ave t

heir

need

s as

sesse

d by

thos

e with

relev

ant s

pecia

list s

kills

v

Ther

e is c

lear e

viden

ce th

at ind

ividu

als a

t risk

, or w

ith p

ressu

re

ulcer

s ben

efit f

rom

the p

rovis

ion o

f diffe

rent

/addit

ional

prod

ucts

from

the s

tanda

rd N

HS p

rovis

ion (C

ullum

et al

, 200

1; M

cInne

s, 20

04). I

ndivi

duals

with

an ex

isting

pre

ssure

ulce

r who

ar

e acu

tely

ill, o

r who

hav

e res

tricte

d mo

bility

in b

ed, a

re lik

ely

to re

quire

an ai

r-fille

d ma

ttres

s or o

verla

y (wh

ich is

comm

only,

thou

gh n

ot ex

clusiv

ely, a

ltern

ating

)

v

Ther

e is n

o cle

ar ev

idenc

e to

dete

rmine

whic

h typ

e of p

rodu

cts

are b

est t

o us

e in

any p

artic

ular s

ituati

on (C

ullum

, 200

1)

v

Indivi

duals

iden

tified

as re

quirin

g pre

ssure

-redu

cing e

quipm

ent

(matt

resse

s, sea

ting a

nd cu

shion

s) re

ceive

it as

soon

as po

ssible

, as

delay

may

resu

lt in f

urth

er tis

sue d

amag

e

v

Furth

er ti

ssue d

amag

e may

occ

ur w

hen

patie

nts a

re si

tting

in

chair

s (De

floor

, 200

0)

v

Chair

s and

/or c

ushio

ns d

esign

ed to

redu

ce th

e risk

of p

ressu

re

ulcer

dev

elopm

ent m

ust b

e suit

ed to

indiv

idual

need

s, in

relat

ion to

heig

ht, w

eight

, pos

tura

l alig

nmen

t and

foot

supp

ort

v

The s

afety

of st

atic s

eats

can

be co

mpro

mise

d du

e to

chan

ges

in he

ight, b

alanc

e and

lumb

ar su

ppor

t with

the u

se o

f cus

hions

(C

ollins

, 200

0)

v

Thes

e ind

ividu

als h

ave s

pecifi

c req

uirem

ents

base

d on

their

ov

erall

phy

sical

cond

ition,

inclu

ding t

he co

nditio

n of

their

skin

v

Ther

e is a

clea

r org

anisa

tiona

l poli

cy co

ncer

ning t

he p

rovis

ion

of sp

ecial

ist eq

uipme

nt fo

r ind

ividu

als at

risk

, or w

ith ex

isting

pr

essu

re u

lcers

v

The p

olicy

inclu

des g

uidan

ce o

n wh

en to

seek

advic

e fro

m a

spec

ialist

in th

e field

of t

issue

viab

ility

v

The d

ecisio

n to

use a

ny pr

oduc

t bey

ond a

basic

NHS

matt

ress

or

divan

is do

cume

nted

in th

e ind

ividu

al’s he

alth r

ecor

d v

Ch

airs a

nd/o

r cus

hions

desig

ned t

o re

duce

the r

isk o

f pre

ssure

ulc

er de

velop

ment

mus

t be s

uited

to in

dividu

al ne

eds, i

n rela

tion t

o th

e ind

ividu

al’s he

ight, w

eight

, pos

tura

l alig

nmen

t and

foot

supp

ort

v

The s

afety

of st

atic s

eats

can

be co

mpro

mise

d du

e to

chan

ges

in he

ight, b

alanc

e and

lumb

ar su

ppor

t with

the u

se o

f cus

hions

(C

ollins

, 200

0)v

Docu

ment

any m

easu

res b

eing i

mplem

ente

d in

addit

ion to

the

use o

f spe

cial m

attre

sses a

nd o

verla

ys

v

Docu

ment

the d

ate o

f firs

t use

of s

pecia

list e

quipm

ent

v

Re

gular

skin

inspe

ction

s, at

least

week

ly or

acco

rding

to

the i

ndivi

dual’

s con

dition

, and

any s

ubse

quen

t acti

ons t

aken

/de

cision

s mad

e are

doc

umen

ted

in th

e hea

lth re

cord

v

The i

ndivi

dual’

s hea

lth re

cord

doc

umen

ts th

e asse

ssmen

t of

their

nee

ds in

relat

ion to

whe

elcha

ir/sta

tic se

at us

ev

Lo

ng-te

rm w

heelc

hair

and

static

seat

user

s’ he

alth

reco

rds

carr

y asse

ssmen

t rec

ords

by a

suita

bly tr

ained

spec

ialist

* A

stand

ard

NH

S m

attre

ss is

one

with

out a

ny p

artic

ular p

ressu

re-re

ducin

g qua

lities

men

tione

d in

the

prod

uct l

itera

ture

. In ge

nera

l, it i

s les

s tha

n 15

cms t

hick ,

has

a sin

gle d

ensit

y foa

m th

at is

not

caste

llate

d or

cut t

o en

hanc

e pr

essu

re d

istrib

utio

n, an

d do

es n

ot h

ave

a sem

i-per

mea

ble tw

o-wa

y stre

tch

cove

r

BPS2.indd 14 3/11/06 16:04:20


Sec

tio

n 2

f: P

res

sur

e u

lcer

s —

pr

om

oti

ng

hea

lin

gK

ey p

oin

ts:

l Ex

tens

ive

supe

rfici

al p

ress

ure

ulce

rs, o

r an

y se

vere

pre

ssur

e ul

cers

, req

uire

spe

cial

ist

refe

rral

. l Pr

essu

re u

lcer

s ca

n be

life

-thr

eate

ning

.

Stat

emen

tRe

ason

for s

tate

men

tH

ow to

dem

onst

rate

stat

emen

t is

bein

g ac

hiev

ed

v

Exte

nsive

supe

rficia

l pre

ssure

ulce

rs, o

r any

seve

re p

ressu

re

ulcer

s, sh

ould

be co

nside

red

for r

eferr

al on

to sp

ecial

ist se

rvice

s, ie.

tissu

e viab

ility s

pecia

list n

urse

s (TV

Ns)

or p

lastic

surg

eon

v

Alwa

ys en

sure

that

the m

edica

l staf

f in ch

arge

of

an in

dividu

al’s

care

are n

otifie

d of t

he ex

isten

ce an

d ext

ent o

f pre

ssure

dama

ge

v

The m

anag

emen

t of in

dividu

als w

ith la

rge a

reas

of s

uper

ficial

ulc

ers,

or an

y sev

ere u

lcers

, requ

ires s

pecia

list i

nput

due

to th

e po

tent

ial fo

r the

dev

elopm

ent o

f life-

thre

atenin

g com

plica

tions

, eg

. sep

ticae

mia

v

Healt

h re

cord

s sho

w th

at ind

ividu

als w

ith ex

tens

ive su

perfi

cial

pres

sure

ulce

ratio

n ha

ve b

een

refer

red

for a

spec

ialist

revie

w,

unles

s the

indiv

idual’

s con

dition

dict

ates o

ther

wise

v

Healt

h re

cord

s sho

w th

at ind

ividu

als w

ith se

vere

pre

ssure

ulc

erati

on h

ave b

een

refer

red

for a

spec

ialist

revie

w un

less t

he

indivi

dual’

s con

dition

dict

ates o

ther

wise

v

Healt

h re

cord

s of t

he in

dividu

al re

ferre

d fo

r spe

cialis

t rev

iew

shou

ld re

flect

the n

ature

of r

eferr

al, eg

. telep

hone

or l

ette

r, an

d th

e out

come

of t

he re

ferra

l, eg.

telep

hone

advic

e or d

irect

cons

ultati

on

v

Each

indiv

idual

with

a pr

essu

re u

lcer s

hould

hav

e a cl

ear p

lan o

f ma

nage

ment

out

lined

in th

eir h

ealth

reco

rd, in

cludin

g:

l

full in

dividu

al as

sessm

ent

l

any i

nter

vent

ions,

eg. s

pecia

list m

attre

sses,

cush

ions o

r ot

her d

evice

s

l

full a

ssessm

ent o

f the

pre

ssure

ulce

r, cau

se, lo

catio

n, cla

ssific

ation

, des

cript

ion o

f the

wou

nd, tr

eatm

ent a

ims a

nd

objec

tives

, revie

w da

te

v

Pres

sure

ulce

rs ar

e like

ly to

requ

ire a

numb

er o

f wee

ks o

r mo

nths

to he

al, de

pend

ing o

n the

ir se

verit

y and

the i

ndivi

dual’s

co

re m

orbid

ity, p

artic

ularly

ambu

lator

y cap

acity

and t

heir

abilit

y to

chan

ge th

eir o

wn po

sition

v

Healt

h re

cord

s inc

lude e

viden

ce th

at a f

ull as

sessm

ent o

f th

e pre

ssure

ulce

r has

bee

n un

derta

ken,

along

with

a pla

n of

ma

nage

ment

: this

shou

ld inc

lude s

teps

to en

sure

cont

inuity

of

care

bet

ween

care

setti

ngs. T

he h

ealth

reco

rd sh

ould

includ

e all

form

al re

ferra

ls, or

info

rmal

discu

ssion

s with

spec

ialist

s re

gard

ing th

e man

agem

ent o

f the

indiv

idual

v

Evide

nce o

f initia

l and

ong

oing m

anag

emen

t to

prev

ent f

urth

er

tissu

e dam

age s

hould

be e

viden

t

v

The m

anag

emen

t of t

he w

ound

bed

of a

pre

ssure

ulce

r sho

uld

adhe

re to

the p

rincip

les o

f mois

t wou

nd m

anag

emen

t unle

ss th

e ind

ividu

al’s c

ondit

ion d

ictate

s oth

erwi

se (t

his m

ay b

e co

ntra

indica

ted

when

an in

dividu

al is

term

inal a

nd d

ebrid

emen

t of

the p

ressu

re u

lcer i

s not

appr

opria

te). T

he d

ressi

ngs u

sed

will

not c

ause

trau

ma to

the w

ound

bed

v

Wou

nds m

anag

ed us

ing pr

oduc

ts wh

ich pr

omot

e mois

t wou

nd

heali

ng re

sult

in en

hanc

ed he

aling

rate

s and

redu

ced i

nfecti

on

v

Using

pro

ducts

whic

h pr

omot

e a m

oist w

ound

envir

onme

nt,

unles

s con

traind

icate

d by

the i

ndivi

dual’

s con

dition

, and

then

do

cume

nting

them

in th

e hea

lth re

cord

sv

Do n

ot u

se d

ressi

ng m

ateria

ls wh

ich ad

here

to th

e wou

nd b

ed

and/

or ca

use t

raum

a to

the w

ound

bed

BPS2.indd 15 3/11/06 16:04:20


Sec

tio

n 3

a: S

kin

car

e —

in

co

nti

nen

ce

Key

po

ints

: l In

cont

inen

ce c

an in

crea

se t

he r

isk

of s

kin

brea

kdow

n.

l C

lean

sing

with

soa

p an

d w

ater

can

incr

ease

the

ris

k of

ski

n br

eakd

own.

l A

ppro

pria

te m

easu

res

shou

ld b

e ta

ken

to p

reve

nt s

kin

brea

kdow

n.

Stat

emen

tRe

ason

for s

tate

men

tH

ow to

dem

onst

rate

stat

emen

t is

bein

g ac

hiev

ed

v

Indivi

duals

with

inco

ntine

nce s

hould

und

ergo

a ho

listic

nurs

ing

asse

ssmen

t, whic

h inc

ludes

que

stion

s reg

ardin

g blad

der a

nd/o

r bo

wel fu

nctio

n/ha

bit

v

Indivi

duals

with

inco

ntine

nce h

ave t

heir

cont

inenc

e stat

us

reas

sesse

d re

gular

ly, or

acco

rding

to th

e ind

ividu

al’s c

ondit

ion

v

Cont

inenc

e man

agem

ent s

hould

be r

eview

ed re

gular

ly

v

Soap

and

wate

r sho

uld n

ot b

e use

d wh

en cl

eans

ing fo

llowi

ng

episo

des o

f inco

ntine

nce

v

The u

se o

f foam

clea

nser

s is r

ecog

nised

as a

clean

sing r

egim

e fo

r ind

ividu

als w

ith in

cont

inenc

e

v

If sk

in is

exco

riate

d or

bro

ken,

prod

ucts

which

pro

mote

a mo

ist

woun

d en

viron

ment

shou

ld be

use

d. Un

less c

ontra

indica

ted

by

the i

ndivi

dual’

s phy

sical

cond

ition,

a full

asse

ssmen

t to

asce

rtain

th

e cau

se o

f the

inco

ntine

nce i

s req

uired

v

Urina

ry in

cont

inenc

e is a

comm

on p

roble

m aff

ectin

g up

to 1

0%

of th

e pop

ulatio

n (R

oe et

al, 1

996)

. Inco

ntine

nce i

s a sy

mpto

m,

not a

diag

nosis

. Asse

ssmen

t is c

rucia

l, as e

ffecti

ve m

anag

emen

t is

dete

rmine

d by

accu

rate

diag

nosis

of t

he ty

pe o

f inco

ntine

nce

(Che

ater e

t al, 1

992)

v

Incon

tinen

ce ca

n inc

reas

e an

indivi

dual’

s risk

of s

kin d

amag

e due

to

chem

ical ir

ritati

on fr

om b

oth

urine

, and

faec

es an

d/or

the

inapp

ropr

iate s

kin cl

eans

ing re

gime

v

Chan

ges i

n inc

ontin

ence

(inc

ontin

ence

patt

ern,

clean

sing r

egim

e us

ed, c

ontin

ence

aids

) can

cont

ribut

e to

the d

evelo

pmen

t of

skin

brea

kdow

n

v

Clea

nsing

with

soap

and

wate

r can

cont

ribut

e to

the

deve

lopme

nt o

f pre

ssure

ulce

rs (C

oope

r and

Gra

y, 200

1)

v

Barr

ier cr

eams

and

barr

ier fi

lms c

an b

e use

d on

intac

t and

/or

brok

en sk

in to

act a

s a b

arrie

r aga

inst f

urth

er ir

ritati

on fr

om

incon

tinen

ce. R

eapp

licati

on an

d us

e sho

uld b

e in

acco

rdan

ce

with

man

ufactu

rers

’ instr

uctio

ns

v

Reco

rds o

f all h

olisti

c nur

sing a

ssessm

ents

includ

e refe

renc

e to

cont

inenc

e stat

us an

d an

y cur

rent

trea

tmen

t

v

All n

urse

s hav

e acc

ess t

o inf

orma

tion

on as

sessi

ng

incon

tinen

ce an

d as

socia

ted

cont

inenc

e car

e plan

ning

v

All n

urse

s hav

e acc

ess t

o an

asse

ssmen

t too

l

v

Healt

h re

cord

s inc

lude e

viden

ce th

at re

gular

skin

inspe

ction

tak

es p

lace a

t opp

ortu

ne ti

mes,

eg. d

uring

assis

tance

with

pe

rson

al hy

giene

v

Findin

gs fr

om sk

in ins

pecti

on in

dicati

ng th

at fur

ther

actio

n is

requ

ired,

along

with

subs

eque

nt ac

tion

taken

, are

reco

rded

in

the i

ndivi

dual’

s hea

lth re

cord

s

v

The h

ealth

reco

rds d

ocum

ent e

pisod

es o

f inco

ntine

nce a

nd

indica

te ac

tion

taken

, inclu

ding s

kin cl

eans

ing p

rodu

cts u

sed

v

The a

dvice

of a

cont

inenc

e adv

isor i

s sou

ght w

here

cont

inenc

e ma

nage

ment

pro

ducts

are c

ompr

omise

d by

the i

ndivi

dual’

s co

nditio

n, or

oth

er in

terv

entio

ns af

fectin

g qua

lity o

f life,

ie.

pres

sure

-redu

cing m

attre

sses

v

The i

ndivi

dual’

s hea

lth re

cord

s con

tain

evide

nce o

f ong

oing

asse

ssmen

t, tre

atmen

t rati

onale

and

inter

vent

ions t

aken

BPS2.indd 16 3/11/06 16:04:20


Sec

tio

n 3

b: S

kin

car

e —

mac

erat

ion

Key

po

ints

: l M

acer

atio

n of

the

ski

n ca

n ca

use

skin

bre

akdo

wn.

l A

ppro

pria

te m

easu

res

shou

ld b

e ta

ken

to p

reve

nt s

kin

brea

kdow

n.

Stat

emen

tRe

ason

for s

tate

men

tH

ow to

dem

onst

rate

stat

emen

t is

bein

g ac

hiev

ed

v

Asse

ssmen

t sho

uld b

e car

ried

out t

o de

term

ine th

e cau

se o

f ma

cera

tion

of sk

in as

it m

ay b

e due

to an

y of t

he fo

llowi

ng

facto

rs: in

cont

inenc

e (se

e Sec

tion 3

a), e

xces

s mois

ture

, wou

nd

exud

ate, p

eri-s

toma

l exu

date

v

Early

det

ectio

n of

skin

mace

ratio

n th

roug

h ide

ntific

ation

of t

he

caus

e may

pre

vent

skin

brea

kdow

nv

He

alth

reco

rds h

ave e

viden

ce th

at as

sessm

ent h

as b

een

carr

ied

out t

o de

term

ine ca

use o

f mac

erati

on

v

Area

s of m

acer

ation

may

ben

efit f

rom

the a

pplic

ation

of a

ba

rrier

film

or c

ream

to p

reve

nt fu

rther

det

erior

ation

of

skin

cond

ition

v

Mace

ratio

n is l

ikely

to o

ccur

arou

nd w

ound

s and

with

in sk

in fol

ds

which

are i

n con

tact w

ith ea

ch o

ther

v

Appli

catio

n of a

barri

er ag

ent, e

g. ba

rrier

film

or cr

eam

may h

elp

redu

ce th

e irri

tant e

ffects

of m

acer

ation

of h

ealth

y tiss

ue

(Bale

, 200

4)

v

Asse

ssmen

t sho

uld in

clude

exam

inatio

n of

area

s at r

isk o

f ma

cera

tion

which

is re

cord

ed in

the i

ndivi

dual’

s hea

lth re

cord

s

v

Whe

n se

lectin

g a b

arrie

r film

or c

ream

, ens

ure t

hat i

t doe

s no

t affe

ct th

e pro

perti

es o

f oth

er in

terv

entio

ns, e

g. th

e stic

king

abilit

y of a

n ad

hesiv

e dre

ssing

v

Some

barri

er cr

eams

will

redu

ce th

e adh

esion

of a

dhes

ive

dres

sings

, or r

educ

e the

abso

rben

cy o

f con

tinen

ce ai

dsv

Healt

h re

cord

s sho

w wh

ich b

arrie

r age

nt h

as b

een

used

and

reco

rd fr

eque

ncy o

f rea

pplic

ation

v

The m

anag

emen

t of t

he w

ound

shou

ld be

bas

ed o

n a f

ull

asse

ssmen

t to

dete

rmine

why

exud

ate is

pre

sent

, ie. p

art o

f no

rmal

heali

ng o

r an

infec

tion

is pr

esen

t

v

Trea

tmen

t int

erve

ntion

s will

be ba

sed u

pon e

arly

ident

ificati

on

of th

e cau

se o

f wou

nd ex

udate

v

Evide

nce o

f initia

l and

ong

oing m

anag

emen

t to

prev

ent f

urth

er

tissu

e dam

age s

hould

be p

rese

nt, a

nd re

cord

ed w

ithin

the

indivi

dual’

s hea

lth re

cord

s

v

Reco

rd o

f th

e volu

me an

d vis

cosit

y of e

xuda

te an

d its

qua

lity,

eg. h

aemo

puru

lent, s

eros

angu

inous

, etc

., alon

g with

not

es to

ind

icate

the r

easo

n fo

r its

pres

ence

, eg.

infec

tion,

card

iac fa

ilure

, lim

b sw

elling

, etc

. are

reco

rded

in th

e not

es o

f pati

ents

with

ma

cera

tion

BPS2.indd 17 3/11/06 16:04:20


Sec

tio

n 4

: Sk

in t

ear

sK

ey p

oin

ts:

l If

trea

ted

quic

kly,

re-la

ying

a s

kin

tear

flap

can

enc

oura

ge w

ound

hea

ling.

l A

ppro

pria

te m

easu

res

shou

ld b

e ta

ken

to m

anag

e sk

in t

ears

.

Stat

emen

tRe

ason

for s

tate

men

tH

ow to

dem

onst

rate

stat

emen

t is

bein

g ac

hiev

ed

v

Asse

ssmen

t sho

uld be

carri

ed o

ut to

dete

rmine

the c

ause

of t

he

skin

tear

and t

his sh

ould

be re

move

d to

prev

ent f

urth

er in

jury

v

Early

det

ectio

n of

skin

traum

a thr

ough

iden

tifica

tion

of th

e ca

use m

ay p

reve

nt fu

rther

skin

brea

kdow

n (B

aron

oski,

200

3)v

He

alth

reco

rds h

ave e

viden

ce th

at as

sessm

ent h

as b

een

carr

ied

out t

o de

term

ine th

e cau

se o

f the

skin

tear,

and

that

this

has

been

remo

ved

v

The s

kin te

ar sh

ould

be cl

assifi

ed (A

ppen

dix 4

, p. 2

1) ac

cord

ing

to th

e deg

ree o

f tiss

ue d

amag

ev

Cl

assifi

catio

n of t

he da

mage

enab

les co

rrect

and s

uitab

le tre

atmen

t and

inte

rven

tion t

o be

initia

ted a

nd m

aintai

ned

v

Healt

h re

cord

s sho

w th

at ind

ividu

als w

ith a

skin

tear

hav

e ha

d a f

ull as

sessm

ent a

nd th

at a p

lan o

f man

agem

ent h

as b

een

deve

loped

, whic

h inc

orpo

rate

s rev

iew o

f the

wou

nd an

d co

ntinu

ity o

f car

e bet

ween

diffe

rent

care

setti

ngs

v

Man

agem

ent o

f skin

tear

s sho

uld co

nside

r:

l

stopp

ing b

leedin

g if it

is p

ersis

tent

l

prev

entin

g infe

ction

l

minim

ising

pain

and

disco

mfor

t

l

reco

verin

g skin

inte

grity

v

Wou

nds w

hich a

re m

anag

ed fo

llowi

ng th

e prin

ciples

of m

oist

woun

d hea

ling,

resu

lt in

enha

nced

heali

ng ra

tes a

nd re

duce

d inf

ectio

n rate

s

v

Evide

nce

of in

itial

and

ongo

ing m

anag

emen

t to

prev

ent f

urth

er

tissu

e da

mag

e sh

ould

be re

cord

ed w

ithin

the

indivi

dual’

s he

alth

reco

rds

v

Man

agem

ent o

f wou

nds i

nvolv

es m

aintai

ning s

kin in

tegr

ity:

l

if the

skin

tear

has

drie

d ou

t, it s

hould

be r

emov

ed u

sing

a ste

rile t

echn

ique

l

if the

skin

flap

is sti

ll viab

le, cl

eans

e with

war

m, sa

line o

r tap

wa

ter, a

nd ro

ll the

flap

bac

k int

o pla

ce to

obt

ain o

ptim

um

skin

cove

r

l

if the

skin

tear

is vi

able,

secu

re u

sing o

ne o

f the

sugg

este

d

me

thod

s: ad

hesiv

e wou

nd cl

osur

e stri

ps, s

kin gl

ue, s

ilicon

e

on-ad

hesiv

e dre

ssing

s. Ho

weve

r, the

met

hod

of sk

in

appli

catio

n wi

ll still

requ

ire th

e app

licati

on o

f an

appr

opria

te

se

cond

ary d

ressi

ng to

pro

vide f

urth

er p

rote

ction

v

Trea

tmen

t int

erve

ntion

s and

a pla

n of c

are sh

ould

be ev

ident

wi

thin

the i

ndivi

dual’s

healt

h rec

ords

BPS2.indd 18 3/11/06 16:04:21


Appendix 1: Definitions of topical skin applications

Emollients: also known as moisturisers. These are grease-based substances which, when applied to the skin, either trap water in or allow water to be pulled from the dermis to the epidermis (Loden, 2003). Emollients can be used as wash products in the form of soap substitutes and bath oils. Once washing is complete, emollients can be applied to the skin in the form of lotions, creams or ointments to seal water into the skin (Penzer and Burr, 2005).

Lotions: these are the lightest and least greasy emollients. They are less effective as they contain less oil.

Creams: these have a higher oil content than lotions, allowing the oil to sink into the skin. They are good for daytime use.

Ointments: these have the highest oil content and are very greasy. They can leave the skin looking shiny and clothes greasy. However, if the skin is very dry, ointments should be used and may be best applied at night.

Table 1: Quantities of dermatological preparationsprescribed for specific areas of the body

Creams and ointments Lotions

Face 15–30 g 100 ml

Both hands 25–5 g 200 ml

Scalp 50–100 g 200 ml

Both arms or legs 100–200 g 200 ml

Trunk 400 g 500 ml

Groins and genitalia 15–25 g 100 ml

BPS2.indd 19 3/11/06 16:04:21


Appendix 2: Skin examination

Further examination of erythema or skin discoloration should include the following steps:

v Apply light finger pressure to the area of erythema or discoloration for 10 seconds.

v Release the pressure. If the area is white and then returns to its original colour, the area probably has an adequate blood supply. Observation should continue and preventative strategies should be employed.

v If, on release of pressure, the area remains the same colour as before pressure was applied, it is an indication of the beginning of pressure ulcer development and preventative strategies should be employed immediately.

v If there is an alteration in the skin colour (redness, purple or black), increased heat or swelling, it may imply underlying tissue breakdown. Frequency of assessment should be increased and preventative strategies should be employed.

v With dark skin pigmentation, pressure ulcer development will be indicated by areas where there is localised heat, or where there is damage, coolness, purple/black discoloration, localised oedema and induration.

Appendix 3: Formal Risk Assessment Scales, Examples

Braden Scale Bergstrom N, Braden BJ, Laguzza A, Holman V (1987) The Braden scale for predicting pressure sore risk. Nurs Res 36(4): 205–10

Knoll scale Towey AP, Erland SM (1988) Validity and reliability of an assessment tool for pressure ulcer risk. Decubitus 1(2): 40–8

Norton Scale Norton D, Mclaren R, Exton-Smith AN (1962) An investigation of geriatric nursing problems in hospital. The National Corporation for the Care of Old People, London

Pressure Sore Prediction Score Lowthian P (1989) Identifying and protecting patients who may get pressure sores. Nurs Standard 4(4): 26–9

Waterlow Risk Assessment Score Waterlow J (1988) The Waterlow card for the prevention and management of pressure sores: towards a pocket policy. Care Science and Practice 6(1): 8–12

Pressure Ulcer Risk Assessment Tool (PURAT)

Wicks G (2006) PURAT: is clinical judgement an effective alternative? Wounds UK 2(2): 14–24

Pressure ulcer risk assessment scales for children: Bedi, Cockett, Garvin, Braden Q, Pickersgill, the Pattoid pressure scoring system, the paediatric pressure sore/skin damage risk assessment (Waterlow)

Wilcock J (2006) Pressure ulcer risk assessment in children. In: White R, Denyer J, eds. Paediatric Skin and Wound Care. Wounds UK, Aberdeen: 79–86

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Appendix 4: Pressure ulcer Classification Scales,Examples

European Pressure Ulcer Advisory Panel (EPUAP)

The management of pressure ulcers in primary and secondary care. NICE Clinical Guidelines, September 2005

Pressure ulcers Best Practice Statement for Treatment/Management of Pressure Ulcers. NHS Quality Improvement Scotland, March 2005

Stirling Pressure Sore Severity Scale(SPSSS)

Reid J, Morrison M (1994) Towards a consensus classification of pressure sores.J Wound Care 3(3): 157–60

Pressure Ulcer Scale for Healing(PUSH)

Stotts NA, Rodeheaver GT, Thomas DR, Frantz RA et al (2001) An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH).Journals of Gerontology Series: A Biological Sciences and Medical Sciences 56(12): 795

Appendix 5: Skin Tear Classification System

Category 1 Without tissue loss In a linear or flap type skin tear. The epidermis and dermis have been pulled apart, as if an incision has been made

Category 11 Partial skin loss 25% or less25% or more

Where part of the epidermis is lost. This can be categorised as less than 25% or more than 25% tissue loss

Category 111 Full-thickness skin loss The epidermal flap or tissue is absent in this type of skin tear

(Source: Payne and Martin, 1993)

BPS2.indd 21 3/11/06 16:04:21


References

Allman RM (1997) Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med 13(3): 421–36

Bale S, Tebble N, Jones VJ, Price PE (2004) The benefits of introducing a new skin care protocol in patients cared for in nursing homes. J Tissue Viability 14(2): 44–50

Baranoski S (2003) Skin Tears: Staying on guard against the enemy of frail skin. Nursing 33(10): 14–20

Baranoski S, Ayello EA (2004) Wound Care Essentials, Practice Principles. Lippincott, Williams and Wilkins, Springhouse, PA

Beldon P (2006) Pressure Ulcers: prevention and management. Wound Essentials 1: 68–81

Berg RW (1986) Etiology and pathophysiology of diameter dermatitis. Adv Dermatol 3: 102–6

British National Formulary (2006) British National Formulary, No 51. British Medical Association and the Royal Pharmaceutical Society of Great Britain, London

Britton J (2003) Eczema. Prescribing and using topical treatments for all types of eczema. Available online at: www.dermatology.co.uk

Britton J (2003) The use of emollients and their correct application. J Community Nurs 17(9): 22–5

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Morris C (2005) Skin Trauma. In: White R, ed. Skin Care in Wound Management: Assessment, prevention and treatment. Wounds UK, Aberdeen: 74–86

NHS Quality Improvement Scotland (2005) Best Practice statement for the Treatment/Management of Pressure Ulcers. NHS Quality Improvement Scotland

National Institute for Clinical Excellence (2005) CG29 Pressure ulcer management: Quick reference guide. NICE, London. Available online at: www.nice.org.uk/download.aspx?o=CG029quickrefguide

Payne RL, Martin MC (1993) Defining and classifying skin tears: need for a common language. Ostomy/Wound Management 39(5): 16–26

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Stotts NA, Rodeheaver GT, Thomas DR, Frantz RA et al (2001) An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH). J Gerontology Series: A Biological Sciences and Medical Sciences 56(1): 795

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Notes

BPS2.indd 24 3/11/06 16:04:22

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