Pressure ulcers

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Pressure ulcers

• Key slides

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Pressure Ulcers

• What are we worried about?
• Costs (not just , but also QoL) to patients and
  the NHS
• Ensuring pressure ulcers are prevented
• 2. What management options do we have?
• Assessing risk and preventing ulcers from
  occurring
• Managing pressure and ulcers according to
  guidance
• Preventing infection
• Useful reviews and reading
• NICE Clinical Guideline 29 Pressure ulcers The
  management of pressure ulcers in primary and
  secondary care September 2005

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Pressure ulcer DefinitionEuropean Pressure Ulcer
Advisory Panel 2003NICE Pressure ulcer
management CG29 September 2006

• An area of localised damage to the skin and
  underlying tissue caused by pressure, shear,
  friction and/or a combination of these
• Damage is believed to be caused by a combination
  of factors including pressure, shear forces,
  friction and moisture
• Pressure ulcers can develop in any area of the
  body. In adults damage usually occurs over bony
  areas, such as the sacrum. Presentation in
  infants and children is more likely to occur, for
  example, on the occipital area or ears

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Prevention and treatment of pressure ulcers NICE
Clinical Guideline 29 September 2005
Assess and record risk
Patient with pressure ulcer
People vulnerable to pressure ulcers
Assess pressure ulcer
Re-ssess
Re-assess
Prevent pressure ulcer
Treat pressure ulcer and prevent new ulcers
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Classification of pressure ulcer severity NICE
Clinical Guideline No29 September 2005
Reproduced by kind permission of EPUAP (2003)

• Grade 1- non-blanchable erythema of intact skin.
  Discolouration of the skin, warmth, oedema,
  induration or hardness can also be used as
  indicators, particularly on individuals with
  darker skin
• Grade 2 - partial thickness skin loss involving
  epidermis or dermis, or both. The ulcer is
  superficial and presents clinically as an
  abrasion or blister

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Classification of pressure ulcer severity NICE
Clinical Guideline No29 September 2005
Reproduced by kind permission of EPUAP (2003)

• Grade 3 - full thickness skin loss involving
  damage to or necrosis of subcutaneous tissue that
  may extend down to, but not through, underlying
  fascia
• Grade 4 - extensive destruction, tissue necrosis,
  or damage to muscle, bone or supporting
  structures with/without full thickness skin loss

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Risk factors for pressure ulcer developmentNICE
Clinical Guideline 29 September 2005

• Pressure
• Shearing
• Friction
• Level of mobility
• Sensory impairment
• Continence
• Level of consciousness
• Acute, chronic and terminal illness

• Co morbidity
• Posture
• Cognition, psychological status
• Previous pressure damage
• Extremes of age
• Nutrition and hydration status
• Moisture to the skin

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Pressure ulcer preventionSkin assessmentNICE
Clinical Guideline 29 September 2005

• Assess skin regularly - inspect most vulnerable
  areas
• Frequency - based on vulnerability and condition
  of patient
• Encourage individuals to inspect their skin
• Look for

• Persistent erythema
• Non-blanching hyperaemia
• Blisters
• Localised heat
• Localised oedema

• Localised induration
• Purplish/bluish localised areas
• Localised coolness if tissue death occurs

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Assessment of pressure ulcer NICE Clinical
Guideline No 29, September 2005

• Assess
• Cause
• Site/location
• Dimensions
• Stage or grade
• Exudate amount and type
• Local signs of infection
• Pain
• Wound appearance
• Surrounding skin
• Undermining/tracking, sinus or fistula
• Odour

• Record
• Document
• - Depth
• - Estimated surface area
• - Grade using EPUAP
• Support with photography and/ or tracings
• Document all pressure ulcers graded 2 and above
  as a clinical incident
• Pressure ulcers should not be reverse graded

Initial and ongoing ulcer assessment is the
responsibility of a registered healthcare
professional
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Treatment of pressure ulcer NICE Clinical
Guideline 29 September 2005

• Choose dressing/topical agent or method of
  debridement or adjunct therapy based on
• Ulcer assessment
• General skin assessment
• Treatment objective
• Characteristic of dressing/technique
• Previous positive effect of dressing/techniques
• Manufacturers indications/contraindications for
  use
• Risk of adverse events
• Patient preference

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What does NICE say about pressure ulcer wound
dressings? NICE Clinical Guideline 29 September
2005

• There is insufficient evidence to indicate
  which dressings are the most effective in the
  treatment of pressure ulcers
• However, professional consensus recommends the
  creation of the optimum wound healing environment
  by using modern dressings in preference to basic
  dressing types such as paraffin gauze

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Managing infected pressure ulcers NICE Clinical
Guideline 29 September 2005

• Consider oral antimicrobial therapy in the
  presence of systemic and/or local clinical signs
  of infection
• Do not routinely take a swab. If there are
  clinical signs of infection cultures may be taken
  
• Reduce the risk of infection and enhance wound
  healing by hand washing, infection control, wound
  cleansing and debridement
• If purulent material or foul odour is present,
  more frequent cleansing and possibly debridement
  are required
• Protect wounds from exogenous sources of
  contamination (e.g. faeces)
• Dressings need to be reapplied daily or on
  alternate days to allow assessment of the wound
  and infection

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Treatment Prevention NICE Clinical Guideline 29
September 2005

• Patients assessed as having a Grade 1 or 2 ulcer
  should, as a minimum, be placed on a high
  -specification mattress or cushion with pressure
  reducing properties combined with close
  observation of skin changes and a documented
  positioning and re-positioning regime
• Patients with a Grade 3 or 4 ulcer should, as a
  minimum, be placed on an alternating pressure
  mattress (replacement or overlay) or
  sophisticated continuous low pressure system
  for example low air loss, air fluidised, viscous
  fluid

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Treatment Reassessment NICE Clinical Guideline
29 September 2005

• Reassessment of the ulcer should be performed at
  least weekly but may be required more frequently,
  depending on the condition of the wound and the
  result of holistic assessment of the patient
• Treatment plan should be changed in line with
  reassessments
• Refer to a surgeon if indicated e.g. failure of
  previous conservative management interventions

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Prevention and treatment of pressure ulcers NICE
Clinical Guideline 29 September 2005

• Record pressure ulcer grade using European
  Pressure Ulcer Advisory Panel Classification
  System
• All pressure ulcers graded 2 and above should be
  documented as a local clinical incident
• Patients with pressure ulcers should receive
  initial and ongoing ulcer assessments
• Patients should have access to pressure relieving
  support surfaces and strategies
• All patients with Grade 1 or 2 ulcers should have
  pressure relieving mattress or cushion, close
  observation of skin changes and documented
  repositioning regime. If any deterioration use an
  alternating pressure (AP) or continuous low
  pressure (CLP) system
• Patients with Grade 3 or 4 ulcers should use an
  AP or CLP mattress.
• Create the optimum wound healing environment