pressure ulcer prevention and management policy

Pressure Ulcer Prevention and Management Policy v4 1

Policy Title

Pressure Ulcer Prevention and Management Policy

Policy Number

RM72

Version Number

4.0

Ratified By

SI Panel for Pressure Damage

Date Ratified

01/06/2020

Effective From

01/09/2020

Author(s) (name and designation)

Nichola Russell, Nurse Consultant for Tissue Viability and Patient Safety

Sponsor

Hilary Lloyd, Director of Nursing, Midwifery and Quality

Expiry Date

01/06/2023

Withdrawn Date

Unless this copy has been taken directly from Pandora (the Trust’s Sharepoint document management system) there is no assurance that this is the most up to date version This policy supersedes all previous issues


Version Control Version Release Author/

Reviewer Ratified By/ Authorised By

Date Changes (Please identify page no)

1.0 Oct 2010 M Bainbridge SafeCare Council

Jun 2010

2.0 February 2014

N.S Russell Nursing and Midwifery Professional Forum

February 2014

Rewritten

3.0 June 2017 N.S Russell Nursing and Midwifery Professional Forum

June 2017 Rewritten

3.1 02/04/2019 N.S Russell Y.Evans

Deputy Director of Nursing Midwifery and Quality

29/03/2019 Pages 8 - 10

4.0 01/09/2020 N.S Russell SI Panel for Pressure Damage

01/06/2020 Appendices – 5 / 8 / 9


CONTENTS

Section Page Number

1 Introduction 5

2 Policy Scope 5

3 Aims of the Policy 5

4 Roles and Responsibilities 6

4.1 The Chief Executive 6

4.2 Divisional Directors 6

4.3 Assistant Divisional Managers 6

4.4 Modern Matron 6

4.5 Ward Manager / Designated Deputy 6

4.6 Tissue Viability Team 6

4.7 Clinical Ergonomics 6

4.8 Nursing Staff 6

4.9 Patients and Cares 6

5 Pressure Ulcer Definition 8

5.1 Pressure Ulcer Classification 9

5.2 Moisture Lesion 10

5.3 Kennedy Ulcer 11

6 Prevention and Management of Pressure Ulcers 11

6.1 Extrinsic Factors 11

6.2 Intrinsic Factors 11

6.3 Risk Assessment 11

6.4 Save Our Skin 11

6.5 The SSKIN Bundle 11

6.6 Skin Assessment 11

6.7 Support Surface 12


6.8 Keep Moving 12

6.9 Incontinence 13

6.10 Nutrition 13

6.11 Preventative Aids 13

6.12 Gel Heel Pads 13

6.13 Slipper Socks 13

6.14 Heel Cushions 14

6.15 Chair cushions 14

6.16 Slidesheets 14

6.17 Documentation 14

6.18 Intentional Rounding Chart 14

6.19 Care Standard 15 / Pictorial Guide to Mattress Selection

15

6.20 Wound Management Booklet 15

6.21 Bariatric Patients 15

6.22 Datix 15

6.23 Safeguarding 16

6.24 Root Cause Analysis 16

6.25 Safety Cross 16

6.26 Advice for Patients and Relatives 17

6.27 Discharge 17

7 Training 17

8 Equality and Diversity 18

9 Monitoring Compliance and Effectiveness of the Policy

18

10 Consultation and Review 18

11 Implementation of Policy 18

12 References 18


Appendices

1 Pressure Ulcer Risk Assessment Tool 20

2 Care Standard 15 22

3 Flow Chart for the Selection Of Pressure relieving Equipment in Community

25

4 Pictorial Guide for the Selection of Mattress and Cushion Selection in Community

26

5 Guideline for Patients who are reluctant to comply with Pressure Ulcer Prevention and Management Techniques

28

6 Integrated Intentional Rounding Chart 29

7 Wound Management Booklet 33

8 Orthotics Devices / Splint Guidance – Prevention of Pressure Ulcers

38

9 Management of Plaster Casts – prevention of Pressure Ulcers

40

10 Pressure Ulcers – Advice for Patients and Relatives 42


Pressure Ulcer Prevention and Management Policy 1. Introduction: Preventing pressure ulcers remains one of the greatest healthcare challenges today in terms of reducing patient harm. Despite progress being made in the management of pressure ulcers since 2012, they remain a significant healthcare problem affecting 700,000 people per year. They are associated with reduced quality of life, affecting an individual’s physical, social and emotional wellbeing. Estimates on pressure ulcer incidence and prevalence from hospital-based studies vary widely according to the definition and category of ulcer, the patient population and care setting. Reported prevalence rates range from 4.7% to 32.1% in hospital populations in comparison to 22% in nursing home populations (AHSN 2015).Treating a pressure ulcers cost the NHS more than £3.8 million every day (NHS Improvement 2016), In the most severe cases the cost can range from £11,000 to £40,000 per person. Pressure ulcer prevention can improve patient outcomes and reduce the cost to the NHS. When combined with the human suffering there is an increased need to find innovative and simple ways for all members of the multi-disciplinary team to address this fundamental aspect of nursing care into everyday clinical practice.

2. Policy Scope: This is a Trust wide policy which applies to all clinical staff both qualified and unqualified who are involved in the direct care of the patient within Gateshead Health NHS Foundation Trust. It reflects a multi-disciplinary approach to the prevention and management of pressure ulcers across both hospital and community. 3. Aim of the Policy

The purpose of this Policy is to standardise care and aims to be equitable and accessible to all healthcare professionals and carers by; • Preventing the development of pressure ulcers where ever possible and implementing

individualised treatment plans to effectively manage existing pressure ulcers • Standardising the assessment and management of individuals who are at risk of

developing pressure ulcers or who have existing pressure ulcers • Supporting families, carers and healthcare professionals with a framework for the

prevention and management of pressure ulcers


4. Duties – Roles and Responsibilities Roles Responsibility

4.1 Chief Executive • Has the overall responsibility for the implementation of this policy, however the day to day accountability for the provision of pressure ulcer prevention and management is the sole responsibility of the individual practitioner

4.2 Directors • Ensuring that this policy is adhered to within all areas across the Trust covering both hospital and community

4.3 Associate Directors • Ensuring the implementation of this policy and ensuring that adequate resources are available for staff to deliver care to the appropriate standard.

4.4 Modern Matrons

• Ensuring the implementation of this Policy at ward level

• Ensuring that staff attend training on a regular basis regarding the Prevention and Management of Pressure Ulcers

4.5 Ward Managers / Departmental Managers

• Ensuring that all nursing staff adheres to the Policy for Pressure Ulcer Prevention and Management within their own clinical area / base

4.6 Tissue Viability Team

• Act as a specialist resource for all aspects of Tissue Viability incorporating evidence based practice

• Monitoring and reporting prevalence and incidence rates of pressure damage

• Validate all Trust reported incidence of pressure damage within the hospital setting.

• Validate all Category 3 and 4 Community related pressure damage incidence within the hospital setting including Unstageable and Deep Tissue Injuries

• Validate all Category 3 and 4 Trust reported incidence of pressure damage within the community setting including Unstageable and Deep Tissue Injuries

• To deliver a comprehensive training programme of the prevention and management of pressure ulcers

4.7 Clinical Ergonomics

• Act as specialist advisors in Manual Handling on behalf of the Trust

4.8 Nursing Staff

• Are aware of the risks of pressure ulcer formation and development and ensure that no action or omission on his/her part leads to either pressure ulcer development or deterioration of an existing pressure ulcer (NMC 2008)

• Report all incidence of pressure damage via the Datix reporting system

4.9 Patients and carers • Patients have a responsibility to comply with pressure prevention strategies as initiated by the


5.0 Pressure Ulceration Definition:

5.1 Pressure Ulcer Classification: The National Pressure Ulcer Advisory Panel (NPUAP, 2016) classification of pressure ulceration is the validated tool used to categorise the severity of the pressure damage across the Trust.

nursing team and inform staff of any discomfort.

‘A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue’ (NPUAP 2016 / NHS Improvement 2018)

Category 1 Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury


Category 4

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Category 3 Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Category 2 Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD)

Unstageable Damage

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Category 3 or Category 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed.

https://www.google.com/imgres?imgurl=http://wwwoundcare.ca/Uploads/ContentDocuments/5.a.%20Unstageable%20Pressure%20Ulcer%20image%201.png&imgrefurl=http://wwwoundcare.ca/88/Provide_Local_Wound_Care/&docid=1loudjvp0LMSdM&tbnid=7PirA-3XcRbaOM:&vet=1&w=160&h=160&hl=en-GB&bih=929&biw=1280&ved=0ahUKEwiVkIWKpp3hAhWUVBUIHVjTD4EQwJUBCAMwAA&iact=c&ictx=1


Please do not use the classification system in reverse order to describe

improvement Any pressure ulcer that has developed as a result of a medical device should be referred to as a medical device related pressure ulcer.

Where skin damage is caused by a combination of moisture associated skin damage and pressure it should be reported based on the category of damage All wounds are required to be dressed appropriately with products available on the Wound Formulary. Special care and attention should be taken to the vulnerable heel area. All diabetic patients with an ulcer on their foot should be kept dry and referred to a Podiatrist for an assessment. For those patients with suspected reduced arterial blood flow it is essential to not hydrate necrosis and refer to the Vascular Service for expert advice. 6. Prevention and Management of Pressure Ulcers:

Recognising which patients’ are at risk of developing pressure damage early is an essential part of our Prevention Pathway. According to NICE 2014 neonates, infants, children, young people and adults are at risk of developing pressure damage. However

5.2 Moisture Associated Skin Damage

A combination of moisture and friction may cause moisture lesions in skin folds, but most commonly they are present in the anal cleft. Moisture lesions are superficial (partial thickness skin loss). In cases where the moisture lesion becomes infected, the depth and extent of the lesion can be enlarged.

An appropriate barrier product should be applied

Deep Tissue Injury (DTPI) Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Category 3 or Category 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.


there are many external factors which predispose an individual to develop a pressure ulcer. The critical determinants of pressure ulcer formation are the intensity and duration of pressure, and the tolerance of the skin and its supporting structure for pressure, shear and friction. The factors that contribute to pressure ulcer development are divided into two groups: extrinsic and intrinsic factors:

6.3 Risk Assessment: Within the organisation it is an essential requirement that all patients’ have a pressure ulcer risk assessment (PURS assessment) undertaken within 6 hours of admission based on the adapted ‘Waterlow Score’ and the appropriate action taken (Appendix 1 ). Within Paediatrics the adapted Glamorgan risk assessment tool should be used. However before a PURS assessment can be undertaken a Malnutrition Risk Score must be completed. This assessment is required to be repeated on transfer / if the patients’ condition changes and on a weekly basis.

6.1Extrinsic Factors External Forces

Pressure Pressure damage occurs when the skin and other tissues are directly compressed between bone and another surface, the capillary blood flow is cut off and over time the skin will die.

Shear Shear occurs when tissues are wrenched in opposite directions such as when reclining: external skin stays in contact with the chair but internally the tissues are sliding down resulting in disruption or angulation of capillary blood vessels.

Friction Friction occurs when the skin has rubbed against another surface. This most often produces a blister or scuffed‟ area as a result of poor moving and handling techniques or involuntary movement of limbs.

Moisture Moisture can be caused by incontinence, sweating, high temperature and wound exudate

6.2 Intrinsic Factors Factors within the Patient

Malnutrition Malnutrition caused by chronic disease major surgery, being nil by mouth or deprived of food

Dehydration Dehydration slows down the body’s metabolism, reduces skin turgor making it more vulnerable to new wounds

Immobility Immobility caused by, sedation, anaesthesia, pain paralysis, major trauma and disease

Age Age causes a loss of sensation in the tissues

Medical Condition Medical conditions such as congestive cardiac failure, chronic respiratory disease, diabetes, anaemia and neurological disease


Within the community setting patients’ assessed at risk should be reassessed weekly or if/ when the patient’s condition changes. Patients at high or very high risk should be reviewed at each visit. If any form of pressure damage is detected then a Datix must be completed, the wound dressed appropriately and a wound management chart completed in order to monitor any improvement or deterioration of the wound. Risk assessment tools should only be used as a guide to action and should not replace clinical judgement (NICE, 2003) and are the responsibility of a registered health care profession.

6.4 Save Our Skin Strategy:

Once a patient has been identified as requiring assistance to change their position as part of the Trust’s ‘Save our Skin Strategy’ within the hospital setting an SOS sticker is required to be placed on the patients white board above the patient’s bedside as a visual prompt to staff that the patient requires intervention and that they are at high risk of developing pressure damage or may have existing pressure damage.

Red clip boards are also being used to highlight to staff those patients’ are at risk 6.5 The SSKIN Bundle: Within the Trust an Integrated Intentional Rounding Chart has been devised to incorporate the SSKIN bundle: a five step model to prevent pressure ulcers: S = Skin inspection S = Support surface K = Keep moving I = Incontinence N = Nutrition 6.6 Skin Assessment: An initial skin inspection is an essential part of your assessment when a patient is admitted to your department or onto your case load. All dressings including compression bandaging are required to be removed to enable a full skin assessment to be undertaken.

Refusal to allow a skin to be inspected needs to be clearly documented.

The anatomy of the heels provide very little protection against the applied forces of pressure, shear and friction as there is only a thin layer of subcutaneous tissue between the skin and the bone (Wilson 2012). The heels are the second most common site of pressure damage. A mirror can be used when inspecting the heels to aid all round visualisation of any potential or existing damage


6.7 Support Surface: As an organisation all patients are placed on a high specification foam mattress on admission within the hospital setting which is endorsed by the European Pressure Ulcer Advisory panel for those patients who are at risk of developing pressure damage / or have Category 2 pressure damage (EPUAP, 2014) To enable the safe repositioning of patients and to minimise pressure and shear forces (EPUAP, 2014) all ward areas store a provision of slide sheets appropriate to meet the individual patients’ needs. 6.8 Keep Moving: For those patients who have been deemed at risk of developing pressure damage they are required to have their position changed at least every 2 hours. A 30 degree tilt using pillows can be used to spread the pressure over a larger surface area rather than over bony prominences.

An effective repositioning regime will be indicated by the absence of persistent erythema over bony prominences. If persistent erythema occurs this may indicate that more frequent repositioning is required and that the current support surface is perhaps not optimal for the patient. A range of chair cushions (Appendix 2) are also available for those patients who require additional protection whilst sitting out in their chair. For those patients with Category 3 or 4 pressure damage their time spent up in the chair is limited to 1 hour usually at meal times.

Heels can be floated off the bed using a pillow which must be used along the full length of the calf avoiding the Achilles heel whilst flexing the knee slightly to avoid popliteal vein compression and reducing the risk of developing a deep vein thrombosis (NPUAP, 2014)


6.9 Incontinence: It is essential that those patients’ who are incontinent of either urine or faeces are kept clean and free from moisture by washing the skin with octenisan and applying an appropriate barrier product. 6.10 Nutrition: It has been estimated that 40% of patient’s on admission to hospital are malnourished (Stratton et al, 2005) and are at greater risk of developing pressure damage. The skin becomes inelastic, fragile and prone to breakdown due to reduced tissue perfusion at the wound site. Skin repair is impaired in people whose diets are deficient in protein, vitamin C, or zinc. All patients’ on admission are required to be nutritionally assessed whereby their dietary intake may be monitored throughout the patient’s hospital stay and a referral to a dietician triggered. Patients’ who have had surgery and are at risk / or have existing pressure damage are offered a cooked breakfast and additional snacks on a daily basis to provide additional nutrients. A patients’ fluid intake may also need to be monitored as Dehydration causes the skin to become inelastic, fragile and more susceptible to breakdown reducing tissue perfusion by the blood supply limiting the supply of both oxygen and nutrients (Johnston, 2007). 6.11 Preventative Aids:

Early detection of skin damage and implementation of adequate preventative strategies can prevent tissue damage altogether or reduce the seriousness of the ulceration. Staff must react to the appearance of red skin and take the appropriate action. 6.12 Gel Heel Pads:

The anatomy of the heels provide very little protection against the applied forces of pressure, shear and friction as there is only a thin layer of subcutaneous tissue between the skin and the bone (Wilson 2007). Pressure relieving gel heel pads are utilised across the organisation as clinically proven to be an effective pressure ulcer prevention device and form part of our # NOF Pathway. As a preventative measure gel heel pads are applied to both heels which are made from a unique polymer gel have been designed to redistribute pressure away from the heels whilst simultaneously transferring friction forces away from the skin (Hampton et al. 2011).They are designed to be worn 24 hours per day throughout the patients hospital stay and post discharge until they have regained their optimal level of mobility. 6.13 Slipper Socks:

Slipper socks are to be used as a ‘Falls Prevention Strategy’ and are not used as bed socks except on the Mental Health In patient areas.


6.14 Heel Cushions:

6.15 Chair Cushions: A range of chair cushions are also available from the Equipment Library throughout the twenty four hour period for those patients who require additional protection whilst sitting out in their chair (Appendix 2). For those patients with category 3 or 4 pressure damage their time spent up in the chair will be limited to 1 hour per session usually at meal times. 6.16 Slide sheets:

6.17 Documentation: Good record keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow (NMC 2009). Photographic evidence of pressure damage may also be recorded by using a Trust camera following consent from the patient or relative by completing a consent form from the Clinical Photography and Audio Visual Recording of Patients Confidentiality and Consent Policy (IG09). However photographs must only be stored in a confidential envelope in the patients’ medical notes and be clearly identified on the reverse by using a black pen recording the patient’s name / date of birth; date / time the photograph was taken and exact location of the wound and size. 6.18 Intentional Rounding Chart:

The concept of Intentional rounding can be described a structured process where nurses on the wards carry out regular checks with individual patients at set intervals. During these checks, nursing staff carrying out scheduled tasks or observations with patients; addressing patients’ pain, positioning and toilet needs; assessing and attending to the patient’s comfort, dietary intake and checking the environment for any risks to the patient’s comfort or safety. During these checks nursing staff are required to complete their actions on the Intentional Rounding Chart (Appendix 3) concerning positional changes as it is essential that nursing staff are vigilant at the patient’s bedside. If an Orthotic device / Splint has been applied it is essential that a Orthotic Monitoring Chart is completed (Appendix 5) or if the patient has a plaster applied please refer to Appendix 9.

To enable the safe repositioning of patients and to minimise pressure and shear forces (EPUAP, 2014) all ward areas will use a slide sheet (Manual Handling Policy (RM 06). Slide sheets can be obtained from the Trust Laundry Facility.

Heel cushions are available from the Equipment Library for patients at high risk of pressure damage to their heels whilst sitting up in the chair in order to aid the redistribution of pressure away from the vulnerable heel area.


6.19 Care Standard 15 / Pictorial Guide to Mattress Selection: Care Standard 15 ‘Prevention and Treatment of Pressure Ulceration’ is required to be initiated on admission regarding the expected standard of care to be provided at the bedside (Appendix 2). A pictorial guide has been incorporated into this document to act as an aide memoire to staff regarding the appropriate selection of mattresses or cushions available in house across the 24 hour period according to the patient’s level of risk or severity of pressure damage. For Community staff please refer to Appendix 3 contact for the appropriate equipment which is available. 6.20 Wound Management Chart: It is an essential requirement that a comprehensive wound assessment is undertaken (Appendix 4) and appropriate dressing regime initiated and documented on the Wound Management Chart or Wound Care Document. 6.21 Bariatric Patients: The Trust’s Bariatric Guidelines define a Bariatric patient or larger patient as one who weighs over 160 kg (25 stone).It should be remembered that if a person requires the use of bariatric equipment e.g., beds, commodes, hoists etc that the person will have enhanced Tissue Viability needs. A patient can be nursed in a seated position if they are on an electric bed however the safe working load of the mattress must be checked to ensure that it is sufficient to accommodate the patient’s weight in order to maintain the integrity of pressure areas. Careful consideration should all be given to the following;

• Assessing and monitor for cellulitis • Assessing and managing skin folds from skin breakdown from perspiration and

friction particularly under the breasts, in the groin, neck, abdominal, and perineal areas as these are high risk for bacterial and fungal infections.

• Check that lines, catheter tubing and equipment are not caught in skin folds • Check skin folds are not pressing against or caught in safety sides of bed frame • Frequent turning and repositioning is required often requiring additional staff

Further advice can be sought from the Clinical Ergonomics Team. If out of hours and at weekends staff are required to contact the 1200 bleep holder for further advice. 6.22 Datix: If any form of pressure damage is detected then a Datix must be completed, the wound dressed appropriately and a Wound Management Chart completed in order to monitor any improvement or deterioration of the wound. Validation of this damage is then verified at the bedside by the Tissue Viability Service for all Trust damage Category 1 – 4 and Community damage Category 3 and Category 4. 6.23 Safeguarding: If a member of staff believes that any form of skin damage has been caused as a result of neglect either in hospital or community it is essential that their concerns are raised via the


Trust’s Safeguarding Procedures (Safeguarding Policy OP75d). Neglect is the deliberate withholding or unintentional failure to provide appropriate and adequate care and support, where this has resulted in, or is highly likely to result in preventable skin damage. 6.24 Root Cause Analysis: A mini root cause analysis is required to be undertaken for all Category 2 Trust related pressure damage for Hospital staff and Community staff as part of the Datix system. A full in depth root cause analysis for all Category 3 and 4 Trust related damage is required to be undertaken; the findings of which must be presented to the Director or Deputy Director of Nursing within 2 weeks of its occurrence. The findings are required to be shared at ward level / sector base so lessons can be learnt. For all Trust related Category 3 and 4 pressure damage the patient will be informed that a full investigation into the cause of the pressure damage will be undertaken as part of our Duty of Candour process. 6.25 Safety Cross: As part of the Pressure Ulcer Prevention Strategy across the organisation staff are required on a daily basis to completed a pressure ulcer calendar in the form of a ‘Safety Cross’ which graphically shows how many days since the last pressure ulcer on the ward.

6.26 Advice for Patients and Relatives: It is vital that patients are encouraged to take an active role in their care and devise a mutually agreed management plan; which according to Moore and Cowan (2009) has a positive effect on patients as they feel they have been part of the decision making process. However if the patient is non-compliant this must be clearly documented please refer to Appendix 6.

Safety Cross

1 2 Month

3 4 April 2020

5 6 7 9 11 13 15 17 19 21

8 10 12 14 16 18 20 22 23 24

25 26 Days without incident 27 28

29 30 10 31

Trust Damage

Community Damage

No damage


All in patients will be informed of the Trusts Information Leaflet ‘Pressure Ulcers’. The information is available in leaflet format on all ward areas or can be downloaded from Trust Patient Information Website (Appendix 7). 6.27 Discharge: If it has been identified that pressure relieving equipment is required for discharge it is the discharging nurses’ responsibility to ensure that this has been arranged prior to discharge. Patient to be discharged home Discharging nurse to arrange pressure relieving

mattress / cushion if required and inform Community Nursing service

Patient to be transferred to a Residential Home

Discharging nurse to arrange pressure relieving mattress / cushion if required and inform Community Nursing service

Patient to be transferred into a Nursing Home

Matron from home to visit ward to complete assessment to ensure they can meet the patients nursing needs and provide equipment required prior to transfer

Ward nursing staff must complete a Primary Care Nursing Service Referral Form when planning to discharge a patient with pressure damage into the community (Please refer to the Trusts Discharge Policy OP13 for further guidance).

7. Training: The Tissue Viability Team will be responsible for the delivery of training across the organisation on a formal basis. Pressure Ulcer Prevention and Management Day Wound Assessment and Management Day Preceptorship Programme for Allied health Care Professionals / Midwives / Nurses / Pharmacists Care Certificate Programme Divisional Training events Clinical Leads Link Nurse Forums Away Days Bite size training sessions at ward level / sector bases 8. Equality and Diversity: The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.


9. Monitoring compliance and effectiveness of the policy: Annual monitoring of the effectiveness and implementation of Pressure Ulcer Prevention and Management Policy including documentation requirements across the organisation will be the responsibility of the Tissue Viability Team which will reported to the Nursing and Midwifery Professional Forum.

Additional monitoring measures in place:

• Daily Pressure Damage Datix Dashboard based on individual incident of harm

• Root cause analysis report / action plans

10. Consultation and review: This policy has been devised by adopting a collaborative approach using a multi professional and multi-agency focus on Pressure Ulcer Prevention and Management for all patients across the organisation. The views and opinions of these professionals have been sought and this policy has been devised based on their expert knowledge, experience, and the relevant legislation and supporting guidance documents. 11. Implementation of the Policy (including raising awareness) : This policy will be embedded across the organisation following its ratification by the Tissue Viability Team via a number of forums:

• Away Days for Modern Matrons / Ward Mangers

• Link Nurses for Pressure Damage

• SI Panel for Pressure Damage


12. References Academic Health Science Network (2015) Patient Safety Collaborative: Preventing Avoidable Pressure Ulcers Gateshead Health NHS Foundation Trust (2015) Clinical Photography and Audio Visual Recording of Patients – Confidentiality / Consent policy (IG09). Gateshead Health NHS Foundation Trust (2016) Hospital Discharge Policy (OP 13) Gateshead Health NHS Foundation Trust (2016) Manual Handling Policy (RM 06) Gateshead Health NHS Foundation Trust (2017) Safeguarding Policy (OP 75d) Johnson, E (2007) The Role of Nutrition in Tissue Viability Wounds Essential (2), pp.10-12 International Guidelines (2009) Pressure ulcer prevention: prevalence and incidence in context. London: MEP Ltd, 2009. Available from www.woundsinternational.com Hampton, S. Tadejond, M. Young, S. (2011) An evaluation of Gel Heel Pads. Eastbourne: Wound Healing Centre. National Institute for Health and Clinical Excellence (2005). Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary Care. London: NICE.

The National Pressure Ulcer Advisory Panel redefined the definition of a pressure injuries during the NPUAP 2016 Staging Consensus Conference that was held April 8-9, 2016 in Rosemont (Chicago), IL NICE (2014) Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary Care: A Clinical Guideline. National Institute for Health and Clinical Excellence, London NHS Improvement (2016) Stop The Pressure Campaign NHS Improvement (2018) Pressure Ulcers: revised definitions and measurement NMC (2008). Record Keeping: Guidance for Nurses and Midwives. London, Nursing and Midwifery Council. Stratton RJ, Elia M (2005) A review of reviews: a new look at the evidence for oral nutritional supplements in clinical practice. Clin Nutr Suppl. 2: 5 pg.23 Wilson M (2012) Managing patients vulnerable to pressure ulceration. Wounds Essentials 7(1):45-8


Pressure Ulcer Risk Assessment Tool Appendix 1

PRESSURE ULCER RISK SCORE Every section must be completed to obtain a score

Date Date Date Date Date Date Date

Time Time Time Time Time Time Time

Sex/Age Male 1 1 1 1 1 1 1 Female 2 2 2 2 2 2 2 14 – 49 1 1 1 1 1 1 1 50 – 64 2 2 2 2 2 2 2 65 – 74 3 3 3 3 3 3 3 75 – 80 4 4 4 4 4 4 4 81 + 5 5 5 5 5 5 5 Build / Weight for height Average (BMI= 20 – 24.9) 0 0 0 0 0 0 0 Above average (BMI= 25 -29.9) 1 1 1 1 1 1 1 Obese (BMI>30) 2 2 2 2 2 2 2 Below average(BMI<20) 3 3 3 3 3 3 3 Continence Continent/catheterised 0 0 0 0 0 0 0 Occasionally incontinent 1 1 1 1 1 1 1 Cath/incontinent of faeces 2 2 2 2 2 2 2 Doubly incontinent 3 3 3 3 3 3 3 Skin Type / condition Healthy 0 0 0 0 0 0 0 Tissue paper 1 1 1 1 1 1 1 Dry 1 1 1 1 1 1 1 Oedematous 1 1 1 1 1 1 1 Clammy 1 1 1 1 1 1 1 Discoloured ( Grade / Category 1 ) 2 2 2 2 2 2 2 Broken area ( Grade / Category 2 – 4 ) 3 3 3 3 3 3 3 Mobility Fully 0 0 0 0 0 0 0 Restless / Fidgety 1 1 1 1 1 1 1 Apathetic or loss of interest 2 2 2 2 2 2 2 Restricted 3 3 3 3 3 3 3 Bedbound e.g.traction 4 4 4 4 4 4 4 Chair bound e.g. wheelchair 5 5 5 5 5 5 5 MUST Score 0 0 0 0 0 0 0 0 1 ( Implement Care Standard ) 1 1 1 1 1 1 1 2 (Refer to dietician) 2 2 2 2 2 2 2 Major Surgery / Trauma ( This admission only) Not applicable Spinal or orthopaedic surgery or surgery below the waist On theatre table for > 2hrs

0 0 0 0 0 0 0 5 5 5 5 5 5 5 5 5 5 5 5 5 5

On theatre table > 6 hrs 8 8 8 8 8 8 8 Tissue Malnutrition Not applicable Terminal cachexia

0 0 0 0 0 0 0 8 8 8 8 8 8 8

Cardiac failure 5 5 5 5 5 5 5 Peripheral vascular disease 5 5 5 5 5 5 5 Anaemia 2 2 2 2 2 2 2 Smoking 1 1 1 1 1 1 1 Medication Not applicable 0 0 0 0 0 0 0 Anti-inflammatory or high dose steroids or cytotoxics drugs 4 4 4 4 4 4 4 Neurological deficit Not applicable 0 0 0 0 0 0 0 Motor /sensory loss, eg CVA. MS / Paraplegia / Diabetes 6 6 6 6 6 6 6 TOTAL SCORE INITIALS 10 + AT RISK 15+ HIGH RISK 20+ VERYHIGH RISK


Pressure Ulcer Risk Score

(PURS) Intervention Guidance Notes

10 + AT RISK

• Implement Care Standard Prevention and Treatment of Pressure Ulcer

• Implement Intentional Rounding Chart

PURS assessment to be completed: On admission / on transfer / if the patient’s condition deteriorates / weekly. Mattress / cushion selection guide: Category / Grade 1 : Foam mattress and Prima 3 foam cushion Category / Grade 2: Foam mattress and Primagel cushion Category / Grade 3 or 4 : Primo mattress / reflex cushion Category / Grade 4: Clinactiv mattress ( additional heel protection) / reflex cushion Duo 2 mattress also available for those patients at very high risk- please contact Tissue Viability for further advice. Datix to be completed if pressure damage found for all Category / Grades (1 – 4) Community and Trust related. Nutritional snacks / hot breakfast can be offered to those patients who are at high risk or have pressure damage.

15+ HIGH RISK

• Implement Care Standard Prevention and Treatment of Pressure Ulcer

• Implement Intentional Rounding Chart • Offer nutritional snacks / hot breakfast

20+ VERY HIGH RISK

• Implement Care Standard Prevention and

Treatment of Pressure Ulcer • Implement Intentional Rounding Chart • Offer nutritional snacks / hot breakfast

23

Appendix 2 Gateshead Health NHS Foundation Trust

PREVENTION AND TREATMENT OF PRESSURE ULCERATION Care Standard 15

1. Ensure a Nutrition Risk Score is completed at the time of the patients’ admission and take the appropriate action if required. (Care Standard 9C).

2. Ensure a Pressure Ulcer Risk Score (PURS) assessment is recorded within 6 hours of the patients’ admission or transfer to your Ward / Dept or if the patient’s condition changes and take the appropriate action.

3. Ensure a full head to toe skin inspection is undertaken as part of the admission process whilst maintaining the patient’s privacy and dignity and record any abnormalities.

4. For those patients’ with pressure damage a detailed wound assessment must be undertaken and the findings recorded in the Wound Management Booklet and an appropriate dressing regime exercising clinical judgement initiated.

5. All pressure damage must be categorised using the European Pressure Ulcer Advisory Panel Classification System (pressure ulcers cannot be reverse graded).

6. Report all pressure damage irrespective of Category as a clinical incident via the Datix system and record ID number

7. Ensure that the appropriate pressure relieving mattress and / or chair / floor cushion is selected and ordered using the pictorial guide overleaf.

8. For those patients’ with existing pressure damage or who are at risk of developing damage please use an SOS sticker at the bedside as a visual prompt to clinical staff indicating that the patients’ position is required to be changed every 2 hours. All positional changes must be recorded within the Integrated Intentional Rounding Chart.

9. For those patients’ with existing pressure damage or who are at risk of developing damage or who will be undergoing surgery please offer a cooked breakfast on a daily basis

10. Ensure all patients’ skin integrity is checked on a daily basis and record any abnormalities 11. Involve the patient and their relatives / carers in the decision making process around their care needs

and that they are aware of their condition / disease process. 12. Ensure you have considered making reasonable adjustments to meet the needs of patients with

disabilities

For further advice and support please contact the Tissue Viability Team on Ex 2787 References: European Pressure Ulcer Advisory Panel (2009) www.epuap.org/grading.html Gateshead Health NHS Foundation Trust (2014) Pressure Ulcer Prevention and Management Policy NICE (2014) Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary Care: A Clinical Guideline. National Institute for Health and Clinical Excellence, London The Royal Marsden Manual of Clinical Nursing procedures (Ninth Edition , 2015)

http://www.epuap.org/grading.html

24

Category of Damage Category 1 or 2

Mattress Selection Guide

Pressure Reduction Foam Mattress NP150 / Thermocontour mattress

*For those patients’ with multi areas of Category 2 damage please consider the use of

an alternative mattress*

Category 3 or 4 Can be ordered via

I Tracker

Primo Continuous Low-pressure system suitable for patients’ medium to high risk / Category 3 or 4 tissue damage. Max Weight Limit: 150kg (23.5 stone) Min Weight Limit: 30kg (4 stone 10lbs)

Category 4 Can be ordered via

I Tracker

Clinactiv

Continuous Low-pressure system suitable for patients high to very high risk / Category 4 tissue damage. Specialist heel section. Max Weight Limit: 180kg (28 stone) Min Weight Limit: 30kg (4 stone 10lbs)

Category 4 *Can only be authorised by Tissue Viability*

Duo®2 Mattress Dual therapy system suitable for patients high to very high risk. Therapeutic Weight limit: 150kg (23.5 stone) Min weight limit: 30kg (4 stone 10lbs)

Category 1 Category 2 Category 3 Category 4

Chair Cushion A chair cushion can be ordered via Equipment Library EXT 3871 / Bleep 2780 Prima 3 Foam Primagel Reflex Reflex

All Categories of heel damage

Floor Cushion A floor cushion can be ordered via Equipment Library EXT 3871 / Bleep 2780

25

Flowchart for the Selection of Pressure Relieving Equipment To be used alongside Clinical Judgement, Pressure Ulcer Policy and Patient/Carer Education

For patients who are at risk of or have existing pressure damage to HEELS ONLY unable to reposition independently?

Yes

No

Currently NO risk Yes No Equipment required

No

Currently LOW Risk (No existing pressure damage

Yes

Can the patient re-position independently?

Yes

Prevention Equipment: Mattress Level 1

Pressure Reduction

No

Currently MEDIUM Risk (No existing pressure damage

No

Yes

Yes

No

Is the patient likely to be at risk for a short time?

No

Yes

No Damage

Does the patient have?:

Yes

Yes Patient weight in excess of 20 No

stone

Yes

Patient weight in excess of 20 No

stone

Prevention Equipment:

Mattress Level 1

Pressure Reduction

Treatment/Prevention Equipment: Mattress

Level 2 Pressure Relief

Treatment/Prevention Equipment: Mattress


And

And

And

And

Currently HIGH Risk (or existing pressure damage) Yes Non blanching erythema - Category 1

Partial skin loss - Category 2 BUT CAN TURN INDEPENDENTLY Treatment Equipment: Mattress

And

Yes

Does the Patient have?: Full thickness skin loss - Category 3

Full thickness tissue loss - Category 4

Yes

No

Yes


No

Is the patient very difficult to move or able to lie in

only one position

Yes

And

CONSIDER: Treatment Equipment: Mattress and Cushion


plus Profiling Bed

ConsiderLeg Trough

Aderma Heel Padvia TVN or FP10

Refer to the seating

checklist for the provisionof cushions

Regular Position Changes

Patient and Carer

Education

Delegation of Care

Use of Moving andHandling AIds

(this is not an exhaustive

list)

Appendix 3

26

Mattress / Cushion Selection for Community Staff Appendix 4

Level One

Dyna-Form Mercury (Direct healthcare)

• Designed for patients considered to be ‘at high risk’ of pressure ulcer development

• Castellated cut CMHR foam • Weight limit: 40 stone, no minimum

weight limit • Side wall construction enables primary

stability

Level One

Permaflex Plus Advance (Park house Healthcare)

• Contoured Mattress Surface • Castellated foam surface • Side Formers and Base Support • Designed for patients considered to

be ‘at high risk’ • Weight Limit: 39 Stone

Level Two

Dyna-Form Static Air HZ (Direct Healthcare)

• Designed for patients considered to be ‘at very high risk’ of pressure ulcer development

• A new ‘air only’ intelligent heel zone • Incorporates air and foam and air only

cells in the unique low pressure heel zone

• Weight limit: 40 stone no minimum weight limit

Level Two

Elite (Park House Healthcare)

• Designed for patients considered ‘at very high risk’

• Alternating cell cycle • Adjustable Weight Settings • Weight limit: 30 Stone • CRP tag

Level Three

Dyna-Form Mercury Advance (Direct Healthcare)

• Designed for patients considered to be ‘at high risk’ of pressure ulcer development

• Weight limit: 40 Stone no minimal weight limit

• Can be upgraded/downgraded depending on patient clinical requirements

• Level 3 with pump • Equivalent to level 1 without pump

Level Three

Phase III (Park House Healthcare)

• Designed for patients considered to be ‘at very high risk’

• 20 figure of 8 cells, 3 static head cells • Weight limit: 39 stone • Alternating mode automatically self

regulates to suit patients weight

27

Level One Dyna-Tek Pad Cushion

• Designed for patients considered

to be ‘at risk’ of pressure ulcer development

• Castellated cut CME foam surface • Multi-stretch, vapour permeable

cover and non-slip base • Weight limit: 20 Stone • Colour: Light Blue

Level Two Dyna-Flex Cushion

• Combination of visco elastic &

CME foam technology • Temperature sensitive memory

foam • Suitable for patients considered

to be at ‘High Risk’ of pressure ulcer development

• Weight limit: 24 Stone • Colour: Wine

Level Three Dyna-Tek Gel Cushion

• Designed for patients who are

considered to be at ‘Very high risk’ of pressure ulcer development

• Designed using the latest polyurethane gel and CME foam

• Enhances postural management

• Weight Limit: 25 Stone • Colour: Dark Blue

Please note that this is designed as visual aid memoire for staff and all patients should have a full holistic assessment including risk assessment and clinical judgement should be used when assessing for all types of equipment.

All requests for wheelchair cushions and recliner chair cushions must be requested via Lucy Goy (Clinical Specialist Occupational Therapist) [email protected]

mailto:[email protected]

28

Appendix 5

Guideline for Patients’ Who Are Reluctant To Comply with Pressure Ulcer Prevention and Management

Techniques

Think SSKIN throughout your decision making process

S: Skin Inspection S: Support Surface K: Keep Moving I: Incontinence N: Nutrition

Does Your Patient Appear to Have Capacity To Consent to Treatment and Care?

YES N0

Mental Capacity Assessment Form Part 1 to be completed by appropriate placed person

Lacks Capacity

Patient to be provided with “Pressure Ulcer Leaflet – Advice for Patients and Relatives” The patient is required to be fully informed of the potential consequences regarding their actions in relation to either • Development of a pressure ulcer / • Deterioration of an existing pressure ulcer

Reasons for reluctance to be explored: For example: pain / discomfort / fear The outcome of this frank and open discussion must be clearly recorded in your nursing documentation and revisited at each visit in Community or on a daily basis within the Ward setting

Has Capacity

Mental Capacity Assessment Form Part 2 to be completed by

appropriate placed person Best Interest Decision

Mental capacity is the ability to make decisions (RM 74 Mental Capacity Act 2005)

“Every adult has the right to make his or her own decision and must be assumed to have capacity to do so

unless it is proved otherwise”

A person is unable to make a particular decision if they cannot do one or more of the following four

things: 1) Understand information given to them

2) Retain information long enough to be able to make a

decision

3) Weigh up information available to make a decision

4) Communicate their decision

Have you involved the patients’ next of kin / family? Do you require assistance from any other member of the multi-disciplinary team?

• Mental Health Liaison Service • Learning Disability Service • Tissue Viability Service

29

Appendix 6 Integrated Intentional

Rounding Chart

Intentional Rounding

Intentional rounding is a structured process where nurses on the wards carry out regular checks with individual patients at set intervals. During these checks, nursing staff carrying out scheduled tasks or observations with patients; addressing patients’ pain, positioning and toilet needs; assessing and attending to the patient’s comfort; and checking the environment for any risks to the patient’s comfort or safety. This form has been devised to incorporate the SSKIN bundle: a five step model to prevent pressure ulcers S = Support surface S = Skin inspection K = Keep moving I = Incontinence N = Nutrition and also Incorporates measures staff can take as part of our falls prevention strategy. F = Footwear O = Observation level C = Call bell U = Understanding patient needs S = Sensor

SSKIN FOCUS Save our Skin (SOS) Stickers Action to be Taken Falls

Please place a SOS sticker on the patients’ white name board at the bedside for those patients who require assistance to change their position. Visual prompt to staff

Please refer to Care Standard 15 for

appropriate action to be taken for the prevention and

treatment of pressure ulcers.

“Remember react to red skin”

If patient is identified as at risk of falls please place a falling star on the patients white board as a visual prompt for staff.

Please ensure patient are risk assessed using the falls assessment and intervention pathway. Please be reminded that care standard 21 has been integrated within the pathway and all documentation relating to falls prevention should be written in this document.

Equipment in Place: (Please tick) Mattress

Support Surface

NP 150 / Thermocontour Protecta Primo Clinactiv Duo 2 Dolphin Other:

Bed and chair sensor (please refer to Bed and chair sensor guidelines prior to use)

Please remember disposable pads are for single patient use to be changed after 14 days of first use

Date bed and chair sensor in use

Date: Preventative Products Gel products:

Other: Date for change of disposable

pads Chair Cushion: Prima 3 Foam

Primagel Reflex

Date: Heel Floor Cushion ( not to be used in bed)

Invacare Other:

File in section 3 medical notes

References Gateshead Health NHS Foundation Trust (2015) Slips, Trips and Falls Policy (RM 50) Gateshead Health NHS Foundation Trust (2014) In-Patient Falls Assessment and Intervention Pathway NICE (2015) Falls in Older People Quality Standard 86 National Institute for Health & Care Excellence. Orsted, H. L. Ohura. T (2010) Pressure, shear, friction and microclimate in Context International Review. European Pressure Ulcer Advisory Panel (2009) National Pressure Ulcer Advisory Panel (2009) www.healthcareimprovementscotland.org (2011) Gateshead Health NHS Foundation Trust (2014) Pressure Ulcer Prevention and Management Policy The Royal Marsden Manual of Clinical Nursing Procedures (Ninth edition, 2015) NICE (2014) Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary Care: A Clinical Guideline. National Institute for Health and Clinical Excellence, London

http://www.healthcareimprovementscotland.org/

30

If Pressure area care is not required staff nurse please sign

Signature: If Falls Focus is not required staff nurse please sign

Signature:

Print name:

Print name:

Dat

e :_

____

____

____

__

Rec

ord

time

of in

terv

entio

n

S K I N F O C U S

Skin

Insp

ectio

n Y

– Y

es

N –

No

1 Pl

ease

reco

rd a

ny c

hang

es in

dai

ly c

are

reco

rd a

nd re

port

to th

e nu

rse

in c

harg

e

Kee

p M

ovin

g

2

L –

Left

side

C

- C

hair

R –

Rig

ht s

ide

W –

Wal

ked

B –

Bac

k

P - P

hysi

o S

– St

ood

O –

Oth

er p

leas

e st

ate

Inco

ntin

ence

3

I – In

cont

inen

ce/s

kin

clea

ned

barri

er p

rodu

ct u

sed

T –

Toile

t / C

omm

ode/

Bed

pan

N

A –

Not

app

licab

le

C –

Cat

hete

r Che

cked

S

– St

oma

Che

cked

Nut

ritio

n Pl

ease

com

plet

e fo

od c

hart

4 D

– D

rink

F - F

ood

N –

Nil

by m

outh

M

– m

outh

car

e gi

ven

Foot

wea

r

5

Y –

Yes

N –

No

R –

Pat

ient

rem

ovin

g fo

otw

ear

N/A

– P

leas

e ex

pand

in F

alls

Ass

essm

ent a

nd In

terv

entio

n Pa

thw

ay

reas

on

Obs

erva

tion

Leve

l

6

I – In

tent

iona

l rou

ndin

g C

– C

ohor

t / B

ay /

Zone

Nur

sing

O

– O

ne to

One

obs

erva

tion

Cal

l Bel

l Is

cal

l bel

l with

in re

ach

of p

atie

nt

7 Y

– Ye

s N

– N

o N

/A -

Plea

se e

xpan

d w

ithin

Fal

ls A

sses

smen

t and

Inte

rven

tion

Path

way

Und

erst

andi

ng p

atie

nt n

eeds

ask

pat

ient

if th

ey w

ish

8

to

go

to to

ilet,

requ

ire a

drin

k, re

quire

pai

n re

lief

Y –

Yes

need

s m

et

N –

No

need

s no

t met

ple

ase

expa

nd in

fFal

ls A

sses

smen

t and

In

terv

entio

n Pa

thw

ay

Sens

or: I

f pat

ient

has

bed

/cha

ir se

nsor

is it

con

nect

ed a

nd w

orki

ng.

9 Y

– Ye

s N

– N

o N

/A -

No

sens

or re

quire

d

Non

com

plia

nce

(Ple

ase

spec

ify w

hich

asp

ect o

f car

e / n

umbe

r)

Patie

nt n

ot o

n W

ard

- Ple

ase

Stat

e

Initi

als

00.__m__m____

01.__m__m____

02.__m__m____

03.__m__m____

04.__m__m____

05.__m__m____

06.__m__m____

07.__m__m____

08__m__m____

09__m__m____

10.__m__m____

11.__m__m____

12.__m__m____

13.__m__m____

14.__m__m____

15.__m__m____

16.__m__m____

17.__m__m____

18__m__m____

19__m__m____

20.__m__m____

21.__m__m____

22.__m__m____

31

If fluid chart is NOT needed RN to sign and print name:

Integrated Fluid Chart

Offer Oral

intake or Mouth care & record

IV Other Peg / NG

Running Total In

Offer toileting

and Record Urine

Record Bowel

Activity NG

Other (drains

etc) Running Total out Initial

00.00

01.00

02.00

03.00

04.00

05.00

06.00

07.00

08.00

09.00

10.00

11.00

12.00

Total in = Total out =

Patients with midday totals of Intake of less than 300mls and/or Output less than 300mls Must have: Tick and initial when in place

Accurate fluid balance recorded Daily target of fluid intake set Red drinking glasses Red jug lids Information about importance of hydration Identified on Handovers that patient requiring encouragement/assistance to drink If safe to do so, relatives should be encouraged to give patient drinks.

If urine output drops to below 30 mls per hour for more than four hours then the patient should be escalated as though they are at medium risk as per NEWS

• if catheterised, please check urinary catheter is patent, • if not catheterised already, consider if pt is in urinary retention and/ or need for catheter

Offer Oral intake or

Mouth care & record

IV Other Peg / NG

Running Total In

Offer toileting

and Record Urine

Record Bowel

Activity NG

Other (drains

etc) Running Total out Initial

13.00

14.00

15.00

16.00

17.00

18.00

19.00

20.00

21.00

22.00

23.00

Total in = Total out =

24 Hrs Balance =

Previous 24hr Balance =

32

Any patient NBM must have a plan including reason and review date in medical notes

Food Chart Guidance

Tick and initial when in place Any patient in the red Any patient in the yellow

Must be offered alternative meal/Build Ups at every meal that is missed

Must have a red placemat Ensure likes and dislikes form is completed Re calculate NRS

Offer alternative meals

Ensure likes and dislikes form is completed

If in yellow for 3 days consider fortifying food and giving ward snacks / Build Ups

Remember Nutrition & Hydration is as important as medication

Food Chart All ¾ ½ ¼ 0 record all dietary intake after every meal

Breakfast Record what has been refused by patient

Lunch Record what has been refused by patient

Supper Record what has been refused by patient

Snacks offered

WHAT assistance/support IS required to eat or drink?

If Food Chart is Not Applicable; a RN must tick box and Print Name:

33

Wound Management Booklet Appendix 7 Mark location of wound with an X on the Body Images below: One booklet to be completed for each wound

FRONT BACK

Patients Name: D.O.B.: Unit No: NHS No:

Ward / Base

Type of Wound Please Tick

Pressure Damage Category: 1 2 3 4 Unstageable or Deep Tissue

Datix Number

Diabetic Ulcer

Leg Ulcer

Surgical Wound

Cellulitis

Other (Please Specify)

Factors that could delay wound healing by affecting the systemic and local blood supply (Please Tick)

Immobility Medication

Poor Nutrition Weight

Diabetes Wound Infection

Incontinence Other (Please specify)

Oedema

Referral date if appropriate:

Discipline Date

Tissue Viability Team Vascular Nurse Podiatrist Orthotist Physiotherapist Dietician Other ( Please Specify)

Skin Sensitivities/Allergies:

Information given to patient written or verbal

Impact of wound on quality of life

Physical Social Emotional

34

Necrotic Wound Sloughy Wound Infected Wound Granulating Wound

Epithelialising Wound

Diabetic Foot Ulcer

Lacerations/ Trauma

Fungating/ Malodorous

Over granulation Surgical Wounds

Appearance Appearance Appearance Appearance Appearance Appearance Appearance Appearance Appearance Appearance

Necrotic area of hard dead tissue

If diabetic – do not hydrate

Dead cells accumulated in exudate presents as yellow tissue

Signs of inflammation / redness /heat / odour /Cellulitis

Granular appearance bright red and moist

Silvery pinky-white

Deep or superficial ulcer with or without necrotic/sloughy tissue

Superficial or deep skin loss

Cauliflower like appearance with increase malodour

Granular appearance bright red and moist, appears as tissue raised above level of peri-wound

Superficial or deep incision

Management Management Management Management Management Management Management Management Management Management Rehydrate, soften

and remove necrotic tissue if visible

signs of infection

Rehydrate and remove sloughy tissue

Reduce levels of bacteria, eliminate infection and promote healing

Promote granulation and wound healing

Protect new tissue, maintain a moist warm clean wound

Prevent infection Remove necrotic/sloughy tissue / Promote healing

Remove debris Prevent infection Promote healing

Absorb excess exudate / Reduce risks of infection Reduce odour

Reduce level of over granulation tissue

Prevent Infection Promote healing

Treatment Options

Treatment Options

Treatment Options

Treatment Options

Treatment Options

Treatment Options

Treatment Options

Treatment Options

Treatment Options

Treatment Options

Primary Dressing Activheal hydrogel Flaminal Hydro L Mesitran Ointment (SNO) Secondary Dressing Activheal non-adhesive foam Mepilex XT Softban / comfifast to secure

Primary Dressing Activheal hydrogel Flaminal Hydro L Mesitran Ointment (SNO) Iodoflex Debrisoft (SNO) Larvae Therapy (SNO) Secondary Dressing Activheal non-adhesive foam Mepilex XT Softban / comfifast to secur

Primary Dressing Iodoflex Aquacel Ag (SNO) Inadine (A&E only) L Mesitran Ointment ( SNO) Secondary Dressing Activheal non-adhesive foam Mepilex XT Softban / comfifast to secure

Primary Dressing Adaptic Touch Zetuvit E Activheal aquafiber Secondary Dressing Activheal non-adhesive foam Mepilex XT Mepilex Border Aquacel Adhesive (SNO)

Primary Dressing Adaptic Touch NA Ultra Atrauman Secondary Dressing Activheal non-adhesive Mepilex XT Softban / comfifast to secure

Complete an urgent referral to Podiatry Keep the area dry until Specialist advice sought Do not apply adhesive dressings to diabetic foot ulcers Secondary Dressing Activheal non adhesive foam Mepilex XT Softban / comfifast to secure

Primary Dressing Adaptic Touch Activheal Aquafiber Secondary Dressing Activheal non-adhesive foam Softban / comfifast to secure Mepilex boarder Aquacel Adhesive (SNO)

Primary Dressing Activheal aquafiber Actisorb Silver 220 (SNO) Zetuvit E Secondary Dressing Activheal non-adhesive foam Mepilex XT Softban / comfifast to secure

Primary Dressing Apply double layer Activheal foam (2 week period) If no improvements apply Ag foam (2 week period) If no improvements apply Hydrocortisone 1% (2 week period) If still no improvement contact Tissue Viability Nurse

Primary Dressing Opsite post-op Tegaderm + pad Activheal Aquafiber Aquacel Ag (Specialist Nurse Only) Secondary Dressing Activheal non-adhesive Mepilex XT Softban / comfifast to secure Mepilex boarder Topical Negative Therapy(SNO)

35

Wound Management Assessment Chart Date Date Date Date

Tissue type by % rate (Please complete) T

Necrotic (Black)

Sloughy (Yellow/Green)

Granulating (Red)

Epithelialising (Pink)

Hypergranulating (Red)

Bone/tendon exposed

Other:

Signs of infection / Inflammation (Please tick) I

Heat

Erythema (Red)

Level of pain (0 No pain – 10 Severe pain)

Odour

Oedema

Wound swab taken for C&S

Moisture level and type (Please Tick) M

None

Low

Moderate

High

Serous (Straw)

Haemoserous (Red/Straw)

Purulent (Green/Brown/Yellow)

Edge of Wound (measurement to be recorded) E

Length (mm)

Width (mm)

Depth (mm)

Rolled

Raised

Undermining / tracking

Photograph taken (yes or no)

Condition of Surrounding Skin (Please Tick) S

Macerated (White)

Excoriated (Red)

Dry/scaly

Healthy/intact

To facilitate the assessment process the TIMES acronym has been used

T = tissue type I = infection / inflammation M = moisture level E = edge of wound S = Surrounding skin

Assessors Initials:

Treatment Aim:(Please Circle)

To promote healing Reduce odour Reduce pain Treat infection Conservative management Reduce exudate

36

Date Dressing Regime If Pressure Ulcer

State Category

Review Date

Signature

37

Gateshead Health NHS Foundation Trust Appendix 8

Orthotic Devices/Splint Guidance – Prevention of Pressure Ulcers

Patient name (Please place addressograph label if available)

D.O.B NHS Number Unit Number. Consultant Ward

SECTION A Name of Orthotic device Date device first applied Fitted by Print Name: Signature:

Orthotics or Prescriber to complete Name: Band: Contact Number:

SECTION B Observation assessment to be completed by Ward staff

Name: Band: Date: Time:

Frequency of application of splint to be worn as discussed with ward Nurse During day � Night use � Remove splint at night. Duration of wearing splint

Every- (e.g. 3 hours per day/all day) Other Yes � No �

Observation Checklist Frequency of observation: Observations to look for on skin of Body part: Is there any • Orthotic indentation • Presence of blisters • Redness • Swelling • Skin integrity • Skin discolouration • Skin sweating • Other observations

found

CHECKLIST TO BE COMPLETED ON INITIAL FITTING AND AT EACH OBSERVATION 1hr � 2hr � 3hr � 4hr � Daily � Complete Chart overleaf and observe at least 3 times daily

Yes � No � Yes � No � Yes � No � Yes � No � Intact � Broken � Yes � No � Yes � No � Yes � No �

If any of the above are yes document pressure prevention plan actions in Daily Care Record

Has the patient any known allergies for example, nickel, plastic, latex etc Check relevant pulses in relation to splint / appliance. Is patient a Diabetic

Yes � No � Record any allergies: Yes � No � NA � Yes � No �

Body part to be applied to. Specify left/right! Other

Left � Right �

Other …………………... …………………………… …………………………….

Signs and symptoms that require referral to a Doctor - Pain from body part supported - Skin temperature! or 1. - Check relevant pulses in relation to splint/appliance

Splint use for; Weight bearing Resting Sitting out Serial casting

Yes � No � Yes � No � Yes � No � Yes � No �

Checklist before reapplying splint/orthotic device • Ensure splint is

correctly fitted • Review and update

pressure Area monitor plan

• Orthotic padding/lining to be inserted

• Straps and fastenings are secure

• Rivets and screws are flush/ covered secure

• There are no loose movements in any of the joints or spurs.

If patient/s condition changes e.g. SEPSIS. Immediately review use of SPLINT/ORTHOTIC DEVICE. SEEK MEDICAL ADVICE IMMEDIATELY.

Yes � No � Yes � No � Yes � No � NA � Yes � No � Yes � No � Yes � No �

Review use of splint/orthotic device if there is any damage to the skin in the area being supported. Request an immediate Orthotic review.

Instruction leaflet supplied to ward Leaflet given to patient

Yes � No � Other � Yes � No � Other �

Special instructions for application from Orthotist or prescriber

ie range of movement

Date of Orthotics review. If appropriate Any Comments ie if high risk of pressure damage

38

Orthotic Devices/Splint Monitor Plan Monitor splint minimum three times a day following fitting or as instructed by the Orthotist

Date

1 2 3 4 5 6 7

Any

othe

r obs

erva

tion

foun

d ( P

leas

e st

ate)

Actio

n to

be

take

n if

yes

has

been

reco

rded

to a

ny

of th

e re

quire

d ob

serv

atio

n

Nur

se in

Cha

rge

to b

e in

form

ed /

Dai

ly C

are

reco

rd to

be

com

plet

ed

W

ound

Man

agem

ent C

hart

to b

e in

itiat

ed if

ap

prop

riate

Has

the

patie

nt re

fuse

d an

y ob

serv

atio

ns (P

leas

e re

cord

num

ber)

Patie

nt n

ot o

n w

ard

Plea

se

reco

rd O

ff w

ard

( OW

)

Initi

als

Orth

otic

Inde

ntat

ion:

Ye

s (Y

) or N

o (N

) Pr

esen

ce o

f blis

ters

Ye

s (Y

) or N

o (N

)

Red

ness

Ye

s (Y

) or N

o (N

)

Swel

ling

Yes

(Y) o

r No

(N)

Skin

Inte

grity

In

tact

(I)

or b

roke

n (B

)

Skin

Dis

colo

urat

ion

Yes

(Y) o

r No

(N)

Skin

Sw

eatin

g Ye

s (Y

) or N

o (N

)

39

Appendix 9 Management of Plaster Casts – Prevention of Pressure Ulcers

Patient Name: D.O.B: Unit Number: NHS Number:

Consultant:

Ward:

Section 1: To be completed by Orthopaedic Practitioner on arrival to Plaster Room

Section 2: To be completed by Orthopaedic Practitioner on transfer back to Ward Limb to be observed ( Please tick) 1 hour □ 2 hour □ 3 hour □ 4 hour □

Type of appliance:

Limb cast applied too:

Arm: Leg: Left: Right:

Is the patient to be nursed in bed? Yes No

Is the patient diabetic?

Yes No Can the patient be sat up in the chair? Yes No

If lower limb, Is it a weight bearing cast?

Yes No Is the limb to be elevated higher than the hip / on level with the heart

Yes No

Pre- application observation checklist:

Presence of

blisters:

Capillary refill of

fingers or toes:

Swelling to limb:

Skin integrity:

Skin discoloration:

Skin sweating:

Wounds dry and

intact?

Wound Management Chart to be completed if wound detected

Yes No

Yes No

Yes No

Intact Broken

Yes No

Yes No

Yes No

Any abnormalities to be recorded in nursing documentation

Signs and symptoms that require referral to a Doctor Plaster indentation

Pain from the affected limb

Prolonged pins and needles in the affected limb

Changes in skin temperature ( hot or cold)

Changes in skin colour – ( red / white or mottled)

Unable to locate a limb pulse

Change in patient condition i.e. sepsis / signs of infection / bleeding

Care of a Plaster Cast: Plaster to remain dry at all times

Refrain from wearing jewellery on the affected limb

Do not insert anything inside the plaster cast

Has a red visual prompt been applied to plaster cast?

Yes or No

If a red band around the plaster cast has been applied this is an indication that they are high risk of developing pressure damage: Action to be taken: Patient to be identified on Electronic SOS Board SBAR handover sheet Limb observation to be commenced as directed by Plaster Room

Special instructions from Orthopaedic Practitioner.

(i.e elevation, limb exercises)

Plaster advice form supplied to ward / patient?

Yes

No

Print name: Signed: Band: Date: Time:

Nurse receiving patient from Plaster Room

Print name: Signed: Band: Date: Time:

40

Date +

Time

Any

stai

ning

of b

lood

(B)

urin

e (U

) or f

aece

s (F

) on

plas

ter (

Plea

se s

tate

)

Actio

n to

be

take

n if

any

abno

rmal

ities

hav

e be

en

iden

tifie

d

N

urse

in C

harg

e to

be

info

rmed

/ Pl

aste

r Roo

m /

Dai

ly C

are

reco

rd to

be

com

plet

ed

W

ound

Man

agem

ent C

hart

to b

e in

itiat

ed if

ap

prop

riate

Has

the

patie

nt re

fuse

d an

y ob

serv

atio

ns (Y

es (Y

) or

No

(N)

Patie

nt n

ot o

n w

ard

Plea

se

reco

rd o

ff w

ard

( OW

)

Initi

als

Plas

ter I

nden

tatio

n:

Yes

(Y) o

r No

(N)

Pres

ence

of b

liste

rs

Yes

(Y) o

r No

(N)

Dis

colo

urat

ion

of s

kin

Yes

(Y) o

r No

(N)

Swel

ling

of li

mb

Yes

(Y) o

r No

(N)

Skin

Inte

grity

In

tact

(I)

or b

roke

n (B

)

Pins

and

nee

dles

Ye

s (Y

) or N

o (N

)

Skin

Sw

eatin

g Ye

s (Y

) or N

o (N

)

41

Appendix 10

Pressure Ulcers Advice for patients and relatives

What is a pressure ulcer? A pressure ulcer is caused when someone sits or lies in the same position for too long. The pressure cuts off the blood supply, damaging the skin What does a pressure ulcer look like? When a pressure ulcer first appears it can show as a change of colour, blister, swelling or patches of hot or cold skin Where could I develop a pressure ulcer? Pressure ulcers are more likely to appear on parts of the body which take weight and where the bones are close to the surface. Areas most at risk are heels, base of spine, elbows, bottom, shoulders and hips Who can develop a pressure ulcer? Anyone can develop a pressure ulcer. If you, your partner, your child or someone you are looking after has an illness that means they need to sit or lie in one position for any length of time you, or they, could be at risk of developing a pressure ulcer. What can be done to prevent pressure ulcers developing? To prevent pressure ulcers developing the following tips are recommended: Check the skin at least once a day for signs of pressure damage. Keep your skin clean and dry, avoid heavily perfumed products or

talcum powder as these can soak up the skin natural oils and dry it out Make sure you turn and change your position regularly Eat a well balanced diet and drink plenty

42

If you have to sit or lie for long periods of time make sure you have cushions or mattresses to reduce the risk of damage If I develop a pressure ulcer what should I do? If you think someone you know is at risk of developing a pressure ulcer make sure you speak to a health professional immediately RM72 Pressure Ulcer Prevention and Management Policy – V 5 Where can I obtain more information? If you require more information about how pressure ulcers develop and what you can do to prevent them, contact a member of the nursing staff within the hospital or community or access information by: Telephoning NHS Response Line on 0870 1555 455 and asking for a printed copy of Pressure Ulcers - Prevention and Treatment N0913 (Information for the public) or visit the website www.nice.org.uk where you can download a copy. Also information can be found if you log onto Your-Turn website www.your-turn.org.uk References National Pressure Ulcer Advisory Panel (2016) National Institute for Health and Clinical Excellence (2014) The Prevention and Treatment of Pressure Ulcer

Information Leaflet: NoIL207 Version: 1 Title: Pressure Ulcers First Published: March 2019 Review Date: March 2021 Author: Tissue Viability Service

http://www.nice.org.uk/

http://www.your-turn.org.uk/