Pressure Ulcer Prevention and Management Policy

Subject:
Pressure Ulcer Prevention and
Management Policy

Policy Number 3.0

Ratified By: Clinical Policy Approval Group
Date Ratified: 12.12.2012
Version: 1.0
Policy Executive Owner: Bronagh Scott, Director of Nursing, patient
experience
Designation of Author: Jane Preece Tissue Viability Nurse
Specialist Secondary Care
Claire Davies Tissue Viability Team
manager Primary Care
Name of Assurance Committee: Quality committee
Date Issued: January 2013
Review Date: January 2015
Target Audience: All health care staff within Whittington
Health. Nursing homes and General
Practice staff within Haringey and Islington.
Prison service
Key Words: Pressure ulcer, bed sore, pressure sore

Pressure Ulcer policy - December 2012

Version Control Sheet

Version Date Author Status Comment

1.0 April Jane Preece To be Whittington Hospital Pressure ulcer
2007 removed prevention and management guideline.

2.0 2010 Claire Davies To be Haringey and Islington NHS, PCT

removed Pressure Ulcer prevention policy.
New policy to replace both Community and
Whittington Hospital policy/guideline

Pressure Ulcer policy - December 2012

Contents:

Paragraph Title Page

Number
Pressure Ulcer Prevention and management 1
quick reference guide
1.0 Introduction 2
2.0 Purpose 2
3.0 Duties 2
4.0 Pressure ulcer - Definition 5
5.0 Development of Policy 5
6.0 Pressure Ulceration 5
6.1 Primary causes 5
6.2 Common sites for Pressure Damage 6
7.0 Pressure ulcer prevention and treatment 6
7.1 Skin and Risk Assessment 6
8.0 Moisture lesions 9
9.0 Heel pressure ulcer prevention and management 9
10.0 Positioning 10
11.0 Pressure Relieving Devices 12
12.0 Maintain and Protect Skin integrity 13
13.0 Nutritional Status 14
14.0 Pressure ulcer treatment 14
15.0 Transfer within Whittington Health 14
16.0 Education 15
17.0 Reporting pressure ulcers 15
18.0 Useful contacts 16
17
References
17
Relevant websites

Pressure Ulcer policy - December 2012

1
APPENDIX
Paragraph Title Page
Number
A Waterlow risk assessment tool 18
B Pressure Ulcer classification 19
C Pressure Ulcer classification Dark pigmented skin 20
D Differentiation of moisture and pressure ulcers 21
E Positioning using 30 Tilt 22
F Pressure relieving equipment product selection Guide 23
G Repositioning chart 24
H Pressure ulcer reporting system 25

Pressure Ulcer policy - December 2012

Pressure ulcer prevention and management quick reference guide
Assess all patients using Waterlow Risk Assessment Tool Inspect the patients skin & document condition on
(appendix A) within 6 hours of admission to your clinical area admission to clinical area or at first contact.
ASSESSMENT or on first contact in the community Document daily or each visit patients skin condition

Complete datix /
Reassess all patients at least weekly or if condition changes. Assess existing pressure damage using
incident form for all
Community - All patients on long term usage of equipment to be assessed EPUAP classification (appendix B)
grade 2- 4 pressure
monthly
ulcers.

Patients identified at elevated risk (Waterlow >15), and/or

patients with pressure damage Complete Wound Assessment

Documentation
ACTION
Instigate appropriate wound
management according to
wound management guidelines
Positioning/ repositioning Pressure relieving devices Seating
Regular repositioning Consider:
Minimise friction & shearing damage use Restrict sitting to 2
Type of mattress
manual handling devices - Slide sheets hours
Type of cushions
Establish a repositioning schedule and Cushion
document using repositioning chart REFERRAL
(Appendix D).

Refer to local guidance on equipment TVNS

(Appendix F) Physio
OT
Podiatry
Continence advisor

DOCUMENT Community - Implement Pressure ulcer pathway document The GP must be informed of the pressure
Acute - Implement core care plan ulcer Community by DNS
Acute On discharge summary

Pressure Ulcer policy - December 2012 1

1. Introduction
Pressure ulcers are common in healthcare settings and represent a significant burden of suffering for
patients and carers and are costly to the NHS (1, 2). As the population ages and patterns of sickness
change, the prevalence of pressure ulcers is likely to increase unless preventative action is taken (3).

The presence of a pressure ulcer creates a number of difficulties psychologically, physically and clinically
to the patient, carer and family. Pressure ulcer prevention and management should be patient centred
and an integral part of patient care, which requires a multidisciplinary approach.

The financial cost of treating pressure ulcers is substantial. Bennett et al (4) estimated the cost as 1.4
2.1 billion annually, 4% of NHS expenditure (5). Increasingly, there is the real risk of costs incurred by
litigation, for failure to prevent or treat pressure damage effectively. Awards in the region of 100,000
have been given for negligent nursing or medical practice, which has lead to the development of
pressure damage (6, 7)

Whittington Health has a zero tolerance to pressure ulceration and it is everyones responsibility to reduce
the risk of a patient developing pressure ulceration whilst in there care.

Definition:

A pressure ulcer occurs over a bony prominence.

It is an area of localised damage to the skin, and underlying tissue
caused by pressure, shear, friction and/or a combination of these (8).

2. Purpose
To provide guidance for all clinical staff on:

strategies to prevent and reduce the risk of patients from developing pressure ulceration
management of pressure ulceration if one should develop
To ensure best practice at all times, assisting in reducing the number of pressure ulcer developed
whist in Whittington Healths care.
To outline Whittington Health strategy for reduction and prevention of avoidable pressure ulcers
across the organisation
The document takes into account national and international recommendations (8, 9, 10, 11).

2.1 Inclusion and exclusion

The recommendations within this policy apply to all patient populations across Whittington Health,
including infants and children, young people and pregnant women.

3. Duties
Duties within the organisation
All staff within Whittington Health have a responsibility and role in prevention of pressure ulcers.

Specific roles and responsibility:

Pressure Ulcer policy - December 2012 2

The Chief Executive
The chief executive has overall responsibility for the safety of patients in the organisation ensuring we
meet all the statutory requirements.

The Director of Nursing

To ensure pressure ulcer reduction strategies maintain a high profile at board and senior nursing
level

The Tissue Viability Service

The Tissue Viability Team is responsible for the provision of an effective Tissue Viability Service across
Whittington Health
responsible for the development and implementation of policies and guidelines which are evidence
based and reflect best practice to support Pressure ulcer prevention and reduction
provide expert advice on Pressure ulcer prevention and treatment
provide education to all Health Professional
development of strategies to continuously reduce incidence of pressure ulcer
Promote a Zero tolerance to pressure ulcer development
Review incidence data, observe trends and work with teams locally to reduce occurrence of pressure
ulcers
Ensure pressure ulcer prevention equipment and resources are available and fit for purpose
Ensure pressure relieving equipment contract meets the needs of the Organisation
Responsible for the everyday running of the Pressure relieving equipment contract (Whittington
Hospital)
Assist with the development of audit tools
Assist with audits and development of Organisational action plans in response to the audits
Work with specialised areas Emergency department, Theatres to develop strategies for pressure
ulcer prevention
Ensure all Grade 3 and 4 pressure ulcers are investigated using the Root Cause analysis (RCA) and
action plans developed
Report to Director of Nursing and clinical division all concerns
Provide information for reports on pressure ulcer prevention

The clinical governance and risk management

To ensure Whittington Health report and investigate all pressure ulcers in accordance with
department of health requirements.

To ensure system are in place for collection of accurate data, which is disseminated across the
organisation

Heads of Nursing

Ensure pressure ulcer reduction maintains a high profile within the clinical division

Review trends in pressure ulcer development

Address local issues to assist in reduction of pressure ulceration across Whittington Health

Ensure all pressure ulcer prevention strategies are implemented across the division

Pressure Ulcer policy - December 2012 3

Matrons and Service manager leads

To share information on incidence of pressure ulceration across clinical areas and address issues to
reduce pressure ulceration

To review all pressure ulcers incident in there clinical area observing for trends and ensure local
action is taken

To facilitate the completion of Root Cause Analysis investigation for all Grade 3 and 4 pressure
ulcers developed within there clinical areas and action plans are completed

Ward Managers/ Team leaders

All staff attend training on pressure ulcer prevention

All staff follow pressure ulcer prevention policy and guidance
Complete the Essence of care Pressure ulcer prevention audit according to Whittington Health
guidelines and implement actions across there clinical area
Nominate a Link nurse for Tissue Viability and ensure support to enable them to fulfil the role
All pressure ulcers are reported and investigated as per Whittington Health policy
Inform Tissue Viability Service of any service needs or problems
Pressure ulcer incidence data is visible
Pressure ulcer safety Cross/calendar completed (Whittington Hospital)
All patients with Grade 3 and 4 pressure are reported and referred to Tissue Viability Service
Completion of Safety Thermometer data

Tissue Viability Link Nurses

Assist with the implementation of pressure ulcer prevention policy
Ensure pressure ulcer incidence data is displayed
Ensure completion of weekly Waterlow incident form (Whittington Hospital) and sent to Tissue
Viability Service
Participate in audit as requested by Tissue Viability team
Attend meetings and study days
Ensure all resources are available within the clinical area
Provide local induction and training on pressure ulcer prevention

Medical staff
To be familiar and adhere to the Pressure ulcer prevention policy
That all pressure ulcers are assessed, graded and documented within patients case notes.
Any skin changes/ damage reported to the nursing team

Allied Health professionals

To adhere to the policy
Ensure all relevant staff are trained in pressure ulcer prevention
Any skin damages/ changes noted reported to the nursing team

All clinical staff nurses, midwifes, student nurses, health care assistance
Read and understand the policy
Ensure receive training on pressure ulcer prevention
Adhere to the policy
Ensure patients are assessed and appropriate plan of care is developed and implemented
Any pressure ulcer identified reported

Pressure relieving equipment contractors and providers ArjoHuntleigh technician, community

equipment store
All equipment provided is clean and in an working order prior to delivery to clinical area/patients
Follow Whittington Health procedures for decontamination of all pressure relieving equipment

Pressure Ulcer policy - December 2012 4

All equipment to be provided according to contracts.

Facilities support staff Porter, housekeeping

Procedures for delivery of pressure relieving equipment and cleaning are followed

3.1 Consultation and Communication with Stakeholders

This policy has been produced in conjunction with relevant stakeholders and they have been
provided the opportunity to participate in the consultation process.

3.2 Approval of Policy

The Clinical Policy Approval Group

4.0 Pressure Ulcer: A Definition

A pressure ulcer occurs over a bony prominence.
It is an area of localised damage to the skin, and underlying tissue
caused by pressure, shear, friction and/or a combination of these (8).

5.0 Development of the Policy

5.1 Prioritisation of Work

This policy has been updated so it can be referred to by all staff working across Whittington
Health

5.2 Responsibility for Document Development

Tissue Viability Service.

5.3 Equality Impact Assessment

Under the Race Relation (Amendment) Act 2000 the ICO is required to undertake equality impact
assessments on all policies/guidelines and practices. This obligation has been expanded to
include equality and human rights with regard to disability, age, gender and religion.
The Equality Impact Assessment Tool (appendix 2) is designed to help the author to consider the
needs and assess the impact of this policy/guideline and practice.

6.0 Pressure ulceration

Pressure ulceration occurs when the skin and underlying tissues are compressed for a period of time,
between the bone and the surface, on which the patient is sitting or lying. Blood cannot circulate causing
a lack of oxygen and nutrients to the tissue cells. Furthermore, the lymphatic system cannot function
properly to remove waste products.

If the pressure continues, the cells die and the area of dead tissue that results is pressure damage.
The amount of time this takes will vary, but may develop in as little as two hours in patients at greatest
risk.

6.1 Primary Causes:

Pressure

The blood pressure at the arterial end of the capillaries is approximately 32 mmHg, while at the venous
end this drops to 10 mmHg. The average mean capillary pressure equals about 17 mmHg and any
external pressures exceeding this will cause capillary obstruction. Tissues that are dependent on these
capillaries are deprived of their blood supply. Eventually the ischaemic tissues will die.

Pressure Ulcer policy - December 2012 5

Shearing forces

This may occur when the skin rubs against the bed sheets or other surfaces, e.g. when a patient slips
down the bed or is dragged up the bed or chair. This gliding of internal tissue layers causes blood
vessels to stretch and kink, thus obstructing blood supply to the skin area attached.

Friction

This is a component of shearing. Areas caused by friction wounds are more susceptible to damage from
pressure and shearing forces. Therefore, to prevent shearing and friction forces, appropriate moving
and handling techniques and equipment (e.g. sliding sheets and hoists) should be employed in order to
ensure the patient is clear of the support surface.

Moisture

Skin should not be left wet (e.g. perspiration, incontinence, amniotic fluid) as it can become macerated
making it more susceptible to shear and friction.

6.2 Common Sites of Pressure Damage:

Pressure ulcers can occur on any area of the body usually over a bony prominence.

Figure 1.

7.0 PRESSURE ULCER PREVENTION AND MANAGEMENT

Skin and Risk Assessment:

To identify individuals vulnerable to or at elevated risk of pressure ulcers.

7.1 Assessment:

Initial and ongoing assessment of risk of pressure ulcers is the responsibility of registered healthcare
professionals. It should involve both formal and informal (skin inspection) procedures.

All members of the multi-disciplinary team have a responsibility to assess a patients risk of developing a
pressure ulcer and to report and document the risk assessment as appropriate.

Pressure Ulcer policy - December 2012 6

Formal using Waterlow risk assessment tool (Appendix A) (7) or tools designed for clinical area
(Paediatric, maternity)

The primary assessment is the responsibility of the registered nurse/midwife delivering care to the
patient. All patients should be assessed using the appropriate ICO Waterlow risk assessment
documentation for there clinical area.

7.11 Frequency of assessment

All patients should be formally assessed, (except midwifery refer to local guidelines) See Table 1.

Table 1. Frequency of assessment

In patient beds Community

In Emergency Department First visit

On admission, within 6 hours On transfer between clinical areas

On transfer between clinical areas When the condition changes

When the condition changes Initially weekly

Monthly for those patients with no active
nursing need but on long term usage of
equipment
Weekly Patients using pressure relieving mattress
Weekly on DNS caseload and
nursing/ care home
Monthly for those under the DNS with
no active nursing need but on long
term usage of equipment.
post-operatively
post-procedure

Whilst they have an epidural insitu

Note: risk assessment tools should be used as an aide memoire and should not replace clinical
judgement (12)

7.12 Skin Assessment

Skin inspection should occur regularly.

Assess patients skin condition immediately on admission to your clinical area or at first visit by DNS
All bony prominence should be examined. For example Sacrum, heels, hips, ankles, elbows, occipital
and buttocks (Figure 1)
Patients and carers who are willing or able should be taught to assess their own skin and take ongoing
responsibility as appropriate.
Patient and carers will be provided with the Whittington Health pressure ulcer prevention leaflet

Please see Whittington Health:

Preventing pressure ulcer patient information leaflet

Pressure Ulcer policy - December 2012 7

The condition of the skin persistent erythema, non-blanching hyperaemia (redness which does not
disappear on relief of pressure) blisters, discolouration, localised heat, localised oedema and
localised induration (9).
Identifying discolouration on patients with dark skin may be difficult and care should be taken not to rely
solely on visual inspection (9, 13). Points to consider when assessing darkly pigmented skin (Appendix
C)
Any existing or acquired pressure ulcers should be categorised using the European Pressure Ulcer
Advisory Panel Classification System (EPUAP) (Appendix B) (8).
Where pressure damage is present, a comprehensive wound assessment will be completed using
the documentation for your clinical area. A tracing of the wound should be made and, where
possible, a photograph should be taken.

Note: Pressure ulcers should not be reverse/down categorised e.g. a grade 4 does not
become a grade 2. Should be documented as Healing category 4

7.2 Other relevant assessments

These should be carried out in accordance with local guidance and using tools established in your
clinical area.
Assess the patients:

Nutritional status and hydration requirements.

Patient handling assessment
Pain assessment
Continence assessment
Mental health/capacity assessment

7.3 Documentation

Record details of the assessments in the patients assessment documentation, using the nursing model
appropriate to your clinical area.

Ensure the date and time of the assessment is recorded and the information is signed by the assessing
clinician. Name and status should be written in block capitals.

Care provided will be evaluated and progress documented in the patients case notes for each episode
of care, incorporating progress in the condition of any pressure ulcer(s).

7.4 Care Plan

Devise and implement a plan of care to reflect the patients individual needs for the prevention and/or
treatment of pressure ulcers.

All patients deemed at risk of pressure ulcer development (Waterlow >15), will have a written pressure
ulcer prevention plan incorporating:

Positioning and repositioning schedule

Pressure relieving equipment
Nutritional requirements
Pain management
Continence management

A wound assessment chart with plan of care should be completed for all patients with pressure ulcers.

Pressure Ulcer policy - December 2012 8

Please see Whittington Health:
Community Pressure ulcer risk assessment pathway
Core care plan for pressure ulcer prevention
Waterlow assessment tool

Acute Adult Waterlow assessment

Maternity risk assessment documentation
Paediatric risk assessment document
Wound assessment chart and care plan
Core care plan for pressure ulcer prevention

8.0 Moisture Lesions

Moisture associated skin damage affects 50% of patients with incontinence. There is often confusion
between pressure damage and moisture lesions.

Moisture lesion Pressure Ulcer

The aetiology of moisture lesions is complex and multifactorial

The Stratum Cornea provides a protective barrier and with aging thins
Incontinence or frequent cleansing the barrier reduces and permeability increases
The PH of the skin becomes more alkaline and tissue damage occurs
Friction and shearing forces increases the skin damage

It is important that moisture lesions are identified and treated appropriately and not confused with
pressure damage see section 6.1 for management.

Differentiation between Pressure ulcers and Moisture Lesions see Appendix D

9.0 Heel ulcer prevention and management

The Incidence of pressure ulcer on the heels is high and need careful consideration and management as
can lead to prolonged intervention amputation, infection and death.

The heels should be assessed regularly refer to assessment section 7.12

Pressure Ulcer policy - December 2012 9

9.1 Prevention of heel pressure
Patients should be encouraged to mobilise and wear good fitting footwear.
When patients are in bed or elevating the legs the heels should be free floating. This can be achieved
by the use of:
Heel lifts, heel protectors, troughs and pillows placed lengthways.
Antiemoblism stockings should be removed twice daily for a maximum of 30 minutes and skin inspected.
The patient should be informed of when, how and frequency of removal of any compression,
antiembolism stockings and importance of skin inspection.

9.2 Assessment of heel pressure ulcers

Black heels - an area of black necrotic eschar or shell on heel should be treated as grade 4 pressure
ulcers and referred to the TVS.

9.3 Management of necrotic heel pressure ulcers

Heel pressure ulcers with eschar do not require aggressive debridement initially if there is no
oedema, erythema, sponginess or exudate or clinical signs of infection, then keep the area dry and
await autodebridement.
Continue to assess and monitor.
If there is oedema, erythema, with clinical signs of infection then the eschar should be removed by
debridement Refer to TVS.
An ankle brachial pressure index (ABPI) should be performed on all patients with black heels to
determine if there is any arterial insufficiency.

9.4 Referral
All patients with diabetes should be referred to Multidisciplinary Diabetic foot team (Podiatry,
diabetes consultant)
Consideration should be given for the need for vascular surgical referral for patients with an ABPI
<0.8mmHg and >1.3mmHg.

10.0 Positioning

Patients with an elevated risk and/or pressure ulcers should be encouraged to actively
mobilise (10). The patient should be advised to stand hourly and rest, lying on their side for
short periods in the day
Where possible patients should be taught to reposition themselves and redistribute their weight and
carers should be shown how to assist.
Patients who are at risk of pressure damage or have pressure damage should be repositioned and
the frequency of repositioning determined by the results of skin inspection and individual needs, not
by a ritualistic schedule (9, 10,12).
Repositioning should take into consideration other relevant matters, including the patients medical
condition, their comfort, the overall plan of care, the support surface (9,10) and attendance of formal
and informal carers

Pressure Ulcer policy - December 2012 10

Patients should be positioned in such a way as to minimise the impact on bony prominences (e.g.
30 tilt) and pressure ulcer (10) (Appendix E)
Patient should be positioned appropriately to reduce the effect of shear and friction forces
A re-positioning schedule will be agreed with the patient and documented. A repositioning chart or
turning clock (Appendix F) will be used as deemed necessary for individual patients e.g. poor
concordance, Waterlow >21

10.1 Seating

Individuals are at a higher risk of pressure ulcer development when sitting out of bed due to:
inability to reposition
incorrect / inappropriate chair or seating facility
inability to redistribute weight

Patients at risk from pressure damage, who cannot relieve their own pressure independently,
should restrict chair sitting to a maximum of 2 hours at any one time.
After sitting the patient requires 2 hours bed rest (side lying)
Patients with pressure ulcers on the sacrum/coccyx or ischial should be advised or have sitting
limited to two times a day in periods of < 2 hours (9,11)
Modify sitting-time schedules and re-evaluate the seating surface and the individuals posture if the
ulcer worsens or fails to improve.
Some patients may need referral for specialist seating assessment by physiotherapist or
occupational therapist
Pressure redistribution cushions should be considered

10.2 Patient handling

Skin damage can be minimised by using correct positioning, transferring and repositioning techniques
and the use of aids. For example: hoists, sliding sheets, pillows, bed cradles and other aids.

Complete the patient handling risk assessment within 24 hours of admission or on first visit within
the community
Write a plan of care to meet patient handling needs
Patients should be encouraged to move independently where possible. If assistance is required,
safer handling techniques should be employed. Refer to manual handling policy
Slide sheets help to eliminate friction and should be used to assist/move patients with mobility
needs.
When hoisting patients, hoist slings must be the correct size and properly fitted. Hoist slings should
not be left under patients.
The use of four section electric profiling beds can contribute to reducing pressure, friction and
shearing forces. If the bed is used to its full potential.

Raise the end of the bed (reverse trendlenberg)

Use the auto contour mechanism (raises the foot end, when head end is raised)
Use the knee-break facility
Use appropriate manual handling techniques and equipment
Remove slings, slide sheets or other parts of the handling equipment after moving the
patient.
Do not use sheets to move patients

Please see Whittington Health Guideline:

Manual handling policies

Pressure Ulcer policy - December 2012 11

10.3 Pain

Patients who are in pain will be reluctant to reposition and relieve pressure (1).

Patients pain should be assessed individually using local pain assessment tools and aids. A plan of
care will be developed with the patient so the pain is controlled and patient is informed of the need
for adequate analgesia.

11.0 Pressure Relieving Devices:

Pressure relieving mattresses, cushions and devices do not replace the need for patient
repositioning.

11.1 Mattresses
Pressure relieving support surfaces aim to reduce the magnitude and/or duration of pressure between
the individual and support surface.

Choice of pressure relieving support surface should be made by a registered nurse who is trained and
competent in pressure ulcer risk assessment, prevention and management.

Decisions on type of surface should be based on:

Social assessment and support
Pressure ulcer risk assessment
Category (Grade) of pressure ulcer
Ability to reposition
Length of time spent out of bed
Comfort
Patient weight and height
General health
Acceptability by the individual
Requirement for bed side rails (cot sides)

For general guidance on equipment selection refer to Appendix F.

Refer to local product selection guides for specific information for clinical area.

11.2 Cushions
All patients who sit out of bed and at a high risk of development of pressure ulcer should be provided with a
pressure relieving cushion or chair with integrated pressure relieving properties in the seating area.
A specialist seating maybe necessary refer to physiotherapist or occupational therapist

11.3 Safe use of equipment

Ensure mattress does not elevate the individual to an unsafe height in relation to side rails
Ensure the individual is within the recommended weight range for the equipment
Children and alternating pressure mattresses small children can sink into gaps created by deflated
cells risk of discomfort and reduced efficacy

11.4 Accessing Equipment

Acute Community
ArjoHuntleigh Whittington Hospital bed Islington - Integrated Community
store 0207288 5167 Monday Friday Equipment Store (ICES), through the DNS
08.00 17.00 02033161111
Haringey Haringey Integrated
Equipment Store (HICES) through the
DNS 02030742306
Out of Hours refer to Out of Hours
Pressure Ulcer policy - December 2012 12
procedure
ArjoHuntleigh on 08457 342000

All equipment should be cancelled and returned to the store as soon as it is finished with for
maintenance and decontamination.

Remember: when re-assessing patients risk think does the patient still require this
mattress

11.5 Audit and maintenance of equipment

Equipment can deteriorate due to age and usage, therefore all pressure relieving equipment should be
checked and maintained in good working order according to manufactures guidelines

Refer to local guidance on maintenance and decontamination

11.51 Foam Mattress and cushion audit

Audits should be carried out regularly and all pieces of equipment should be checked between patients for:
Condition of the cover no stains, splits, tears

Acute Community
Yearly foam mattress and cushion audit Yearly foam mattress and cushion audit
Ward staff to check in between patients Equipment with motors should be serviced
yearly via HICES

Please see Whittington Health Guideline:

Acute Pressure relieving equipment resource folder
Community Infection Control Policy and ICES catalogue,
HICES catalogue

12.0 Maintain and Protect Skin Integrity:

An individuals skin may be exposed to a variety of moist substances, which may make it more
susceptible to injury.

When handling patients, all health professionals should take care not to damage a patients skin.
Neither rings (other than wedding bands) nor watches should be worn when turning or repositioning
patients, and nails should be kept short and nail varnish removed.
The skin should be kept well hydrated.
If the patient is at high risk of skin damage or incontinent they should be advised to use an emollient
soap substitute (e.g. aqueous cream, emulsifying wax) to wash and apply moisturisers regularly.
The patients skin should be thoroughly dried using a patting motion, particularly over vulnerable
areas. Do not use a rubbing motion or massage when drying patients as this causes friction forces
and is associated with tissue damage (13).
Talcum powder should not be used because of its tendency to cake, thereby increasing friction, clogs
the pores and increase risk of infection (13) and skin damage
Incontinence should be managed effectively

12.1 Incontinence management

Assess the patient and develop a plan of care

Barrier creams should be used with caution as they clog the pores in the pad and effect efficacy
Referral to continence advisor should be considered

Pressure Ulcer policy - December 2012 13

Please see Whittington Health:
Continence assessment
Continence Policy

13.0 Nutritional Status

The link between impaired nutrition and pressure ulcer development and delayed healing is unclear.
Although decreased calorie intake, dehydration and low serum albumin is linked with decreased
tolerance of the skin from pressure, friction and shearing forces therefore reduced wound repair (15, 16).

13.1 Assessment
All patients should be screened on admission, at first visit and reassessed regularly using ICO
assessment tools and receive a well balanced diet in accordance with their wishes.
All patient should have their Body Mass index (BMI) calculated on admission or first visit where
possible and repeated weekly when an in patient, monthly on DNS caseload if practicable.
If patient has a poor intake a food chart should be commenced (in-patient)
Patients with pressure ulcers need monitoring of haemoglobin and serum albumin levels
Patients with pressure ulcer/s should be referred to the dietician for further assessment

13.2 Intervention
Refer for specialist advise as required
Provide patient advise on well-balanced diet and protein-energy foods (16)
Ensure 2 litres of fluid per day.

14.0 Pressure ulcer treatment

Modern dressings should be used to create an optimal wound healing environment. Refer to Whittington
Health wound management guidelines and formulary.
Complete the wound assessment document and develop a plan of care.
Patients with Category 3, 4 and /or necrotic pressure ulcers should be referred to Tissue Viability
Service.
Patients with Category 2 pressure damage which is non healing (after 6 weeks in community)
should be referred to TVS for further advise
Referral for general surgery and/or plastic surgical intervention should be considered on an
individual patient basis.
If a pressure ulcer is non healing osteomyelitis should be considered. Radiography (x-ray, MRI
scan) should be considered in discussion with other health professionals (GP, Consultant)

Please see Whittington Health Guideline:

Wound Management guidelines and formulary

15.0 Transfer within/ from Whittington Health

Acute Community
Referral form to be completed for visit by Transfer letter to be faxed to receiving
DNS area
Referral to DNS for pressure relieving Communicate verbally with the receiving

Pressure Ulcer policy - December 2012 14

equipment at least 5 days before area if e.g.
discharge issues of non concordance
social and family concerns
Supply of wound management products
for 5 days
Give patient written information leaflet
Pressure ulcer information to be written DNS to inform GP
on Discharge letter to GP

16.0 Education

All staff should be familiar with the Pressure ulcer prevention and management policy.
They should attend the Tissue Viability study day in accordance with their personnel
development plan (PDP).
All staff will have pressure ulcer prevention, risk assessment and planning of care within local
induction programmes
A record of individual practitioners education and training will be maintained my the practitioners
manager

16.1 Health care assistance (HCA)

Health care assistant can undertake the following, once they have received training and deemed
competent which will be recorded within their KSF.
Assessment of risk of pressure ulcer development
Manage a Grade 1 pressure ulcer
In the acute setting only- manage a grade 2 pressure ulcer following assessment and
management plan by a RN
HCA will document clearly and escalate any deterioration to RN
Grade 2 pressure ulcers will be assessed regularly by DN

17.0 Reporting of pressure ulcers

All health care professionals are responsible for reporting pressure ulcers.

A Datix/ incident form will be completed for all identified category 2 - 4 pressure ulcers
The TVS should be informed of all grade 3 and 4 pressure ulcers
Care homes will report all grade 2 4 pressure ulcers to CQC and commissioners
Category 3 and 4 pressure ulcer require a full root cause analysis investigation and are
reportable to the DH refer to Appendix G
GP will be informed the patient has a pressure ulcer by DN and on discharge letter

17.1 Safeguarding adults and skin damage

Skin damage has a number of causes, some relating to the individual patient such as poor medical
condition and others relating to external factors such as poor nursing care, lack of resources e.g.
equipment, staffing. It is recognised that not all skin damage can be prevented and therefore the risk
factors in each case should be reviewed on an individual basis before a safeguarding referral is
considered. Not all pressure ulcers in vulnerable adults are the result of neglect.
If there are concerns that observed pressure damage maybe the result of neglect or omissions care
please refers to Whittington Health Safeguarding Adults and Skin Damage Protocol.

Pressure Ulcer policy - December 2012 15

Please see Whittington Health Guideline:
Safeguarding Adults and pressure ulcers Protocol

18.0 Useful Contacts:

Acute Community Haringey Islington

Tissue Viability 02072883369 Tissue Viability 02033168393
Bed store 02072885167 Equipment library 02033161111 02030742306
(ArjoHuntleigh)
ArjoHuntleigh 08457 342000

Pressure Ulcer policy - December 2012 16

References

1. Franks P.J, Winterburg H., Moffatt C. (1999) Quality of life in patients suffering from pressure
ulceration: a case controlled study. Ostomy and Wound Management 45. 56.
2. Allman R.M., Goode P.S., Burst N., Bartolucci A.A., Thomas D.R. (1999) Pressure ulcers: hospital
complications and disease severity: impact on hospital costs and length of stay. Advanced Wound
Care. 12. (1). 22-30.
3. Waterlow J. (2005) Waterlow Pressure Ulcer Risk Assessment. www.judy-waterlow.co.uk
4. Bennett G., Dealey C., and Posnett J. (2004) Cost of pressure ulcers in the UK. Age/Ageing. 33. (3).
230-235.
5. Touche Ross (1993) The Cost of Pressure Sores. Touche-Ross and company, London.
6. Silver, J. (1987) Letters. Care, Science & Practice; 5:3 30
7. Tingle J. (1997) Pressure Sores: counting the legal cost of nursing neglect. British Journal of Nursing 6
(13) 757-758
8. EPUAP & NPUAP (2009) Prevention of pressure ulcers: Quick Reference Guide. European Pressure
Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Washington DC. USA.
http://www.epuap.org/guidelines/Final_Quick_Prevention.pdf
9. NICE (2003) Pressure ulcer risk assessment and prevention, including the use of pressure-relieving
devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and
secondary care. National Institute for Health and Clinical Excellence. London.
www.nice.org.uk/page.aspx?o=20052
10. NICE (2005) Pressure ulcers: the management of pressure ulcers in primary and secondary care.
National Institute for Health and Clinical Excellence. London.
http://www.nice.org.uk/nicemedia/pdf/CG029fullguideline.pdf
11. TVS (2003) Seating and Pressure Ulcers: Clinical Practice Guideline. Tissue Viability Society.
www.tvs.org.uk
12. NICE (2001) Pressure ulcer risk assessment and prevention. Inherited Clinical Guideline B. National
Institute for Clinical Excellence, London
13. DH (2003) Essence of Care Patient-focus benchmarks for clinical governance: Food & Nutrition.
Department of Health.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4
127915.pdf
14. Royal College of Nursing (2000) Pressure ulcer risk assessment and prevention, clinical practice
guidelines. RCN, London
15. Bergstrom N, Braden B (1992) A prospective study of pressure sore risk among institutionalized
elderly. Journal of American Geriatrics Society, 40 (8) 747 758. Cited in NICE (2005) Management
of pressure ulcers in primary and secondary care. www.nice.org.uk
16. EPUAP (2003) Nutritional guidelines for pressure ulcer prevention and treatment. www.epuap.org

Relevant websites:

www.nice.org.uk

www.epuap.org.uk

www.rcn.org.uk

Pressure Ulcer policy - December 2012 17

Appendix A WATERLOW RISK ASSESSMENT
Name: Guidance on scores: 10+ AT RISK
15+ HIGH RISK 20+ VERY HIGH RISK
HOSP No: Date
Time
BUILD / WEIGHT FOR HEIGHT
Average BMI 20 24.9 0
Above Average BMI 25 29.9 1
Obese BMI >30 2
Below Average BMI <20 3
SEX and AGE
Male 1
Female 2
14 49 1
50 64 2
65 74 3
75 80 4
81+ 5
SKIN TYPE and VISUAL RISK AREAS
Healthy 0
Tissue paper 1
Dry 1
Oedematous 1
Clammy/ pyrexia 1
Discoloured Grade 1 2
Broken / Spot Grade 2 - 4 3
MOBILITY
Fully 0
Restless / Fidgety 1
Apathetic 2
Restricted 3
Bed bound e.g. Traction 4
Chair bound 5
CONTINENCE
Complete / Catheterised 0
Urine incontinence 1
Faecal incontinence 2
Urinary & faecal incontinence 3
Persistent diarrhoea 3
NUTRITIONAL RISK
Section A
Has the patient had unplanned weight loss in past
3 6 months or recently
YES Go to section B NO Go to section C
Unsure Go to section C & Score 2
Section B Weight loss score
0 3 kg 1
3 6 kg 2
> 6 kg 3
Section C Patient appetite
Poor appetite 1
Refusing to eat 2
NBM/IV fluids/enteral feed/ IV nutrition 3
TISSUE MALNUTRITION
Terminal Cachexia 8
Multiple organ failure 8
Single organ failure 5
Peripheral Vascular Disease 5
Anaemia (Hb <8) 2
Smoking 1
NEUROLOGICAL DEFICIT
Diabetes 6
MS. CVA. Paraplegia 4-6
MAJOR SURGERY / TRAUMA
Orthopaedic 5*
Below waist spinal 5
On table >2 hours 5 **
On table for > 6 hours 8 **
MEDICATION
Cytotoxics, long term high dose Steroids
or anti-inflammatory 4
Sedated & Paralysing Agent 3
Epidural 4
SCORE

SIGNATURE

JOB TITLE
Pressure Ulcer policy - December 2012 18
Appendix B

EUROPEAN PRESSURE ULCER ADVISORY PANEL

PRESSURE ULCER CLASSIFICATION
Non-blanchable
erythema of intact skin.
Discolouration of skin,
warmth, oedema,
induration or hardness
Category 1 may also be used as
indicators particularly
on individuals with
darker skin.

Partial thickness skin

loss involving epidermis,
Category 2 dermis or both. The
ulcer is superficial and
presents clinically as an
abrasion or blister

Full thickness skin loss

involving damage to or
Category 3 necrosis of subcutaneous
tissue that may extend
down to, but not through
underlying fascia

Extensive destruction,
Category 4 tissue necrosis, or
damage to muscle, bone,
or supporting structures
with or without full
thickness skin loss

NECROSIS Unable to grade whilst necrotic, should be recorded as a

probable Category 3 or 4

Pressure ulcers should not be reverse graded.

Document as a healing grade 4 or grade 3 etc.

Pressure Ulcer policy - December 2012 19

Appendix C Pressure ulcer categorisation in patient with Dark
Pigmented Skin

It is difficult to identify Category 1 pressure damage in dark pigmented skin.

Observe for the following signs and symptoms:

Patient complains of pain, numbness, discomfort over bony

prominence
Localised oedema
Purplish/bluish localised area
Localised induration
Localised heat/ warmth this is replaced with coolness once damage
occurs

Pressure Ulcer policy - December 2012 20

Appendix D
Differentiation between Pressure ulcer and Moisture lesions

Moisture lesion Pressure ulcer

History of faecal and/or urinary Will usually be circular and symmetrical
incontinence
Irregular and asymmetrical shape Over bony prominence
Lesions will be over fatty parts of May take butterfly wing shape if spans
buttocks and thighs, not isolated to out from sacrum
bony prominence
Lesions may extend into perineal area May have necrotic or thick sloughy
tissue present
Superficial Partial to full thickness
A linear shaped lesion in the natal cleft
is likely to be a moisture lesion
No necrotic tissue
Do not Grade/ categorise Categorise using EPUAP

Pressure Ulcer policy - December 2012 21

Appendix E

30 TILT

(Byrant 1992)

Pressure Ulcer policy - December 2012 22

Appendix F
PRESSURE RELIEVING EQUIPMENT PRODUCT SELECTION
GUIDE

Waterlow Risk Skin Mobility Pressure

score level Condition redistributing
equipment
10 - 17 At Risk No damage Mobile Foam mattress

17 - 25 High Risk No damage or Restricted Foam mattress

Grade 1 2 replacement

17 25 High risk Grade 2 3 Bed/ Chair Overlay or

bound mattress
Restricted replacement
alternating
pressure
> 25 Very High No damage Mobile or Foam mattress
can turn self replacement
in bed

> 25 Very high Grade 2 - 4 Restricted. Mattress

Bed/chair replacement
bound

Patients with pressure ulcers or at high risk of pressure ulcer development must
only sit out for maximum 2 hours at anyone time and mist be provided with a
pressure redistributing cushion

Pressure Ulcer policy - December 2012 23

Appendix G Patient Name:
Hospital No:

REPOSITIONING CHART Ward: Date:

Identify patients with pressure areas that are at risk
Ensure patients Waterlow assessment is up to date
Every patient with a pressure ulcer must have a wound assessment chart and care plan
Assess reposition plan daily
Complete European pressure ulcer advisory panel EPUAP Scale when a pressure ulcer is discovered and at
least every 8 hours (for at risk patients)

NB Do not reverse grade e.g. improving grade 4 is graded as healing grade 4 not a grade 2

Reposition plan is: turn patient ______hourly and sit out for ______ hour (s) only
Time *Position Intact or EPUAP Grade Signature & print name
01.00
02.00
03.00
04.00
05.00
06.00
07.00
08.00
09.00
10.00
11.00
12.00
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
24.00

*KEY
M = patient mobilising P = lying prone
L = left side B = lying on their back
R = right side C = to sit out in an arm chair
T = having therapy (Physio, OT) I = gone for investigation (e.g. imaging dept)
TH = in theatre department F = refused repositioning (failed)
Pressure Ulcer policy - December 2012 24
Appendix H

Pressure ulcer reporting system

Pressure
PU
Ulcer 2, 3, 4
reporting Report to GP

DATIX/ I ncident f or m
Completed by the identifier

SI report DH
2 3& 4
Risk M anagement

Level one inves tigation Root caus e anal ysis

Completed wit hin 40 days
Hold meeting wit h t eam
PU SI Panel

Action plan EC
NHS London

Pressure Ulcer policy - December 2012

25
Tool to Develop Monitoring Arrangements for Policies

What key element(s) need(s) Who will lead on this aspect What tool will be used to How often is the need to What committee will the
monitoring as per local of monitoring? monitor/check/observe/Asses monitor each element? completed report go to?
approved policy or guidance? Name the lead and what is the s/inspect/ authenticate that How often is the need
role of the multidisciplinary everything is working complete a report ?
team or others if any. according to this key element How often is the need to
from the approved policy? share the report?

Element to be monitored Lead Tool Frequency Reporting arrangements

1. All pressure ulcer Tissue Viability lead Whittington Health Essence of Monitoring - Every 3 months Report to Director of Nursing
prevention strategy as community and Whittington Care monitoring tool, Report - Quarterly
outlined within Essence Hospital will co-ordinate and
of Care key elements provide monitoring tools.

Ward managers will undertake

the audits
2. Pressure relieving Mattress audit tool
equipment and devises Tissue Viability leads Monitoring - Yearly for foam Secondary care Health and
are available, effective mattresses and beds Safety committee
in working order

Pressure relieving Tissue Viability Secondary care Key performance indicator Monitoring Quarterly
equipment contract and Steven Packer within contract
Secondary care

3. All grade 2 4 Deputy director of Nursing and Safety thermometer, Pressure Monitoring Monthly Monthly - Director of Nursing
pressure ulcers are Pressure ulcer SI Panel ulcer log. Report Quarterly Quarterly - Quality committee
reported and committee (PUSIP)
investigated

4. Education and training Tissue Viability Lead. Attendance lists and ESR Twice yearly To be included in twice yearly in
Education department report to Quality committee
administrator to provide data.
A full report will be provided
yearly to the quality committee
on all elements of the policy.

26
Pressure Ulcer policy - December 2012
Plan for Dissemination and implementation plan of new Procedural Documents

To be completed and attached to any document which guides practice when submitted
to the appropriate committee for consideration and approval.

Acknowledgement: University Hospitals of Leicester NHS Trust

Title of document: Pressure ulcer prevention and management

Date finalised: Dissemination lead: Jane Preece and
Print name and Claire Davies
Previous Yes contact details
document already Jane.preece@nh
being used? (Please delete as s.net
appropriate)
Claire.davies1@
nhs.net

If yes, in what Single documents for community and Hospital intranet general
format and where? guidelines. Tissue Viability web page. Hard copies on Whittington
Hospital site
Proposed action to Lead will collect from all clinical areas.
retrieve out-of-date
copies of the Lead will remove from Tissue Viability webpage
document:
To be How will it be Paper Comments
disseminated to: disseminated/implem or
ented, who will do it Electroni
and when? c
All clinical staff On the intranet Electroni Launch at Stop Pressure
c ulcer day
Distributed and
communicated at link nurse
meetings

Is a training No Training all ready in place on

programme Pressure ulcer prevention
required?
Who is responsible Tissue Viability
for the training Service
programme?

Pressure Ulcer policy - December 2012

27
Appendix I

Equality Impact Assessment Tool

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Impact (= relevance) Evidence for impact assessment Evidential gaps (what info do Action to take to fill Other issues
(monitoring, statistics, consultation, you need but dont have) evidential gap
1 Low research, etc
2 Medium
3 High
Race 1

Disability 1

Gender 1

Age 1

Sexual Orientation 1

Religion and belief 1

Once the initial screening has been completed, a full assessment is only required if:

The impact is potentially discriminatory under equality or anti-discrimination legislation

Any of the key equality groups are identified as being potentially disadvantaged or negatively impacted by the policy or service
The impact is assessed to be of high significance.

If you have identified a potential discriminatory impact of this procedural document, please refer it to relevant Head of Department, together with any
suggestions as to the action required to avoid/reduce this impact.

28
Pressure Ulcer policy - December 2012