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Nursing and Midwifery Policy

Pressure Ulcer Prevention and Care for Adults

in the Community

Policy Manager Sue Mackie :

Policy Group : Tayside Tissue Viability Network Sub-Group

Policy Established June 2012 Review Date June 2013

This Document does not Apply to Medical/ Dental staff

UNCONTROLLED WHEN PRINTED

Signed: Executive Lead

(Authorised Signatory)

NHS TAYSIDE

ITEM 5.3

APPENDIX

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Policy Development, Review and Control Policy

Version Control Version Number

Purpose/Change

Author

Date

1

Sue Mackie

June 2012

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CONTENTS Page No. 1. Purpose Scope and Definition 3 2. Policy Statements 4 2.1 Person Centered Care and Patient Involvement 4 2.2 Assessment 4 2.3 Prevention 5 2.3.1 Skin Inspection and Grading of Pressure Ulcers 5 2.3.2 Bed and Foam Mattresses Allocation 5 2.3.3 Re-Positioning 6 2.3.4 Seating 6 - 7 2.3.5 Prevention of Heel Ulcers 7 2.4 Skin and wound care 8 2.5 Discharge/transfers 8 - 9 2.6 Education and Training 9 3. Responsibility and Organisation Arrangement 9 4. Evidence Base for Policy Statements 10 - 12 5. Contributors 12 6. References 13 - 14 APPENDICES Appendix I EPUAP Grading Tool (REVSIED BY NATVNS) 15 Appendix II NATVNS, Scotland Skin Excoriation Tool For Incontinent 16 Patients Appendix III NATVNS, Scotland, Dark Pigmented Skin 17 Appendix IV Semi Fowler Position -30 degree Tilt 18 Appendix V NHST Guidelines for the use of heel elevators 19 - 21 Appendix VI NHST Continence guidelines 22 - 23 Appendix VII Rapid Impact Check List 27 24 - 25 Appendix VII Policy/Strategy Approval Checklist 29 26 - 27

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1. PURPOSE, SCOPE AND DEFINITION The aim of this policy is to: • Ensure patients are provided with optimum person centred evidence based

pressure ulcer prevention • Ensure each patient has the correct bed and mattress to meet their clinical needs • Standardise the assessment and care of patients with/or at risk of developing

pressure ulcers • Set the minimum standard for the maintenance of knowledge and skills related to

pressure area care

This policy is based on the best available evidence at the time of development and applies to all Community healthcare staff within NHS Tayside. However, if the Registered Nurse with their professional clinical judgement overrides the policy, the rationale for the decision must be clearly documented in the record. If the patient/carers view of the care required differs from the policy, this is to be respected, however, the Registered Nurse will document clearly in the nursing record, what advice they have given the patient/carer and the potential risks associated with their decision. This policy does not provide guidance on specific wound care. Practitioners should refer to NHS Tayside Wound Care Formulary; (http://www.nhstaysideadtc.scot.nhs.uk/TAPG%20html/MAIN/Front%20page.htm) for such advice. Definition Pressure ulcers are also known as bed sores, decubitus ulcers and pressure sores. For the purpose of this document the term pressure ulcer will be used. A pressure ulcer is an area of localised damage to the skin and underlying tissues caused by pressure, shear and friction or a combination of these. The above is a working definition. New theories are being developed but further work is required before they can be included in an accepted definition. The goals of prevention are: • To identify individuals at risk of pressure ulcer development • Identify and implement interventions related to the specific risk factors • Protect against the adverse effects of pressure, shear and friction • Improve the outcomes for patients at risk of pressure damage through timely

evaluation of nursing interventions and educational programmes to healthcare providers, patients and carers.

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2. POLICY STATEMENTS 2.1 Person Centred Care and Patient Involvement All patients at risk of pressure ulcer development will be informed (when possible) of their risks and given practical information on how they can help themselves to reduce these. Health Professionals are advised to respect and incorporate the knowledge and experience of people who have or have had a pressure ulcer. This advice will be given verbally and supported by the provision of relevant leaflets. 2.2 ASSESSMENT All patients on admission to the District Nursing caseload will have a Preliminary Pressure Ulcer Risk Assessment (PPURA) carried out. If there are any risks identified the following will be carried out • Full Waterlow risk assessment (NATVNS adapted) carried out at the time of

admission using NHST Pressure Ulcer Prevention Treatment Plan (THB 620) · • Ensure a complete skin assessment is carried out as part of the risk assessment.

Skin assessment should include assessment of local heat, oedema, indurations (hardness) especially in individuals with darkly pigmented skin (EPUAP, NPUAP 2009)

• The Registered Nurse has a duty to review all relevant risk factors at each visit. If

there is a change in circumstances/condition or treatment, the risk score will be re-assessed and interventions reviewed and adjusted accordingly

• Risk assessments should be used to determine the plan of care to alleviate

factors that cause pressure ulcers, i.e. poor mobility, incontinence, poor nutrition, not as a tool to determine the pressure relieving device

• The EPUAP (European Pressure Ulcer Advisory Panel) NATVNS revised grading

tool will be used to assess and document pressure ulcers (see Appendix I) • The NATVN Scotland Skin excoriation tool for incontinent patients (see Appendix

II) will be used to assess and document skin damage due to moisture Care plans will be in place for each relevant risk factor by the second DN visit • Risk factors identified from the Waterlow risk assessment and all interventions

will be reviewed at each visit and appropriate changes made to the planned care taking into account the patient’s individual home environment

• Informal reassessment using the PPURA will be carried out at each visit. The

Waterlow risk assessment will be carried out monthly unless the patient’s condition changes and the scale will be re-calculated.

2.3 PREVENTION 2.3.1 Skin Inspection and Grading of Pressure Ulcer s • Skin inspection should be based on an assessment of the most vulnerable areas

of risk for each patient; typically heels, sacrum and ishial tuberosities are the areas most affected by friction, pressure or shearing and other invasive devices such as catheters and Naso Gastric tubes

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• Skin inspection and the grading of any pressure ulcers will be undertaken during

the District Nurse visit for those at high risk. This will be documented on the pressure ulcer assessment and treatment plan. The site, condition and possible cause of the ulcer will be documented and treated in accordance with NHS Tayside Wound Management Formulary. Skin inspection will be used to assist deciding repositioning schedules

• Individuals/carers who are willing and able should be encouraged, following

education to inspect their own skin and report any concerns to their healthcare provider. The use of a mirror is recommended

• It may be difficult to assess erythema in patients with darkly pigmented skin,

therefore other signs such as heat, oedema, discolouration and indurations might be observed (see Appendix III)

2.3.2 Bed and Mattresses Allocation • Do not base the selection of support surface solely on the perceived level of risk

(EPUAP, NPUAP 2009) • All patients at risk of developing pressure ulcers or have grade 1-2 pressure

ulcers will have as a minimum a high specification mattress and/or cushion with pressure reducing properties (see 2.3.4) (patient to be advised, however, their individual choice may override this)

• Dynamic mattresses, which are either alternating pressure mattresses,

continuous low-pressure mattresses or a combination, will be used in the following circumstances and according to NHS Tayside Treatment Plan THB 620.

Patients with grade 3 or 4 pressure ulcer

Patients who cannot/will not be re-positioned/turned regularly Patients with severe impaired muscle tone, neuro muscular disorders vascular/arterial disease, diabetes, flaccid paralysis, sensory impairment

Patients with a history of pressure ulcer development and who remains a high risk

In the community setting, patients on treatment plan C (RED) will receive the appropriate resources, i.e. bed and or dynamic mattress within 24 hours of admission to the service. Patients who require treatment plan B (AMBER) will receive the appropriate resources within 72 hours of admission to the service. There will be a mechanism for exception reporting within each CHP to identify circumstances where this has not been achieved. Improvement plans will be developed within each CHP to ensure patients receive the right resources at the right time. Equipment stores will ensure that there are local processes in place to cover for patients on treatment plan C for weekend and PH cover. • The need for any dynamic mattress must be re-assessed as soon as the patient’s

risk factors decrease to ensure the effective use of resources and availability of resources for other patients when required

• The bed linen must be loosely fitted to prevent a hammock effect that would

negate the pressure relieving properties of the mattress

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2.3.3. Re-Positioning • All individuals at risk of pressure ulcer development will be re-positioned regularly

(EPUAP, NPUAP 2009). This will be negotiated and agreed with carers (paid and unpaid) and documented in care plan

• Self Care patients who are at risk will be given advice from the NHST pressure

ulcer advice leaflet on actions they can take to reduce the risks. In partnership and agreement with the patient, they will be afforded the opportunity to check and record their own skin integrity and re-position themselves. The nurses are responsible for documenting this agreement in the nursing care plan. Ask patient to report any pain that may prevent them from re-positioning themselves

• In some circumstances it may be beneficial for carers to use the NHST SKIN

bundle (THB MR 608) to record all the pressure ulcer prevention strategies • Avoid subjecting the skin to shear and friction forces • Avoid postures that increase shear and friction such as 90 degree side lying or

semi recumbent position which increases pressure and shear on the sacrum and heels

• Specific advise to patients and carers should be documented in the care plan and

evidence that an NHS Tayside Pressure Ulcer information booklet (Staffnet) has been issued

• To avoid positioning patients on bony prominences and maximising weight

distribution, the semi fowler position and 30 degree tilt will be used. See illustrations (Appendix IV)

• Whenever possible, do not position patients onto a body surface that is still

reddened from a previous episode of pressure loading (EPUAP, NPUAP 2009) • Repositioning frequency will be determined by the individual’s tissue tolerance;

his/her level of activity and mobility, general medical condition, treatment objectives (healing may not be the goal for patients on the Liverpool pathway for example, and comfort needs may supersede a re-positioning regime, if all other methods of pain/nausea relief have been exhausted)

• Assessment of the skin condition and need for increased interventions should be

made at each re-position event. If the individual’s skin is not responding to the regime, consider increasing the frequency and method of repositioning or pressure relieving surface.. There should be close liaison with carers – formal/informal to progress this out with District nursing visits

2.3.4 Seating • Limit the time an individual is seated in a chair without pressure relief. Patients at

risk of pressure ulcers should be advised not to be seated for more than 2 hours at any one time without being re-positioned utilising strategies to relieve pressure such as frequent standing or mobilising

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• Sitting in a chair increases the risk of pressure ulcer development/deterioration, as pressure is concentrated on one area

• The ideal seating position maximises weight distribution: The back and head

support should maintain maximum contact to fully support the patients back and head. The patient’s feet must be supported to attain maximum load distribution. If a height adjustable chair is not available a footstool can be used (assess risks of patient falling or tripping during transfer before use). The ideal sitting position is where the hips, knees and feet are at 90 degree angles. This can be achieved with an adjustable chair or the use of high specification foam cushions. Thighs must be fully supported along their length

• Patients with grade 1 or 2 pressure ulcers on their sacrum will have a pressure

reducing/relieving cushion • It is not advised for patients with grade 3/4 ulcer on the sacral area to sit in a

chair as the patient’s weight cannot be distributed and the focus of pressure is on the pressure ulcer. If possible, patients remain on a profiling bed and the chair position of the bed utilised. Mobilisation regimes are to be actively encouraged. However, patient’s choice, their clinical condition and professional judgement need to be exercised to ensure that care is patient focussed. If it is not possible or the patient does nor wish this, advise the patient/carer to limit the time to less than one hour and no longer than three times a day where possible. Document the advice given

• If pressure areas deteriorate despite the above, seek advise from the TORT

centre 2.3.5 Prevention of Foot Ulcers Patients at particular risk of developing ulcers will have one or a combination of:- Neuropathy Vascular Insufficiency Diabetes Immobility during surgery and at home. Critically ill If a patient triggers a risk using the PPURA and has any of the above, consider the following:- • Raising the knee section of a profiling bed when possible, reduces pressure on

the heels and should where possible be utilised. • The NHST heel protection guidelines (see Appendix V) are considered when

deciding on pressure relief for heels • Elevate heels completely in such a way as to distribute weight of the leg along

the calf without putting all the pressure on the Achilles tendon. The knee should be in slight flexion. A soft pillow along the length of the calf (not under the Achilles tendon) has been shown to be effective (EPUAP 2009)

• Educate the patient and or carer to Inspect their heels when bathing and, ask the

patient to report redness, blisters, or bruises to the District nurse or healthcare provider

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• If the patient is wearing compression stockings, patient/carer/nurse should remove them at least once a day for inspection the use a mirror may be useful to see the heels

• The best heel pressure-reducing products reduce pressure, friction and shear;

separate and protect the ankles; maintain heel suspension; prevent footdrop. They should also be comfortable for the patient, easy for you to use and permit re-positioning without increasing pressure in other areas. The care plan (pressure ulcer treatment plan and wound care plan) will ensure that a regular skin inspection regime is prescribed and documented to ensure that boots or braces are removed and the skin inspected for pressure damage

• Prevent heel ulcers from abrasion with moisturisers or transparent film dressings.

These nursing interventions reduce friction from shearing and rubbing • Bed linen must be loosely fitting on the pressure-relieving mattress • District nurse should ensure that the Diabetic Handbook is followed for patients

with diabetes and patients with vascular disease are regularly monitored to ensure optimum condition of the lower limbs

2.4. SKIN AND WOUND CARE Moisture: • The NHSQIS excoriation tool will be used to assess the level of skin damage

caused by moisture (see Appendix II) • The NHS Tayside continence skin care and product guidelines (2011) appendix

VI available on the Intranet will be used to treat excoriated areas • The NHS Tayside continence product guide (2009) available on the Intranet will

be used to determine the correct absorbency aid. • The nursing record will contain evidence that the advice of a continence advisor

was sought where continence management products are compromised by pressure ulcer prevention strategies

• Soap and water should not be used on patients with or at risk of excoriation. A

skin cleansing agent will be used following episodes of incontinence. Skin cleansers that are PH neutral are acceptable. This needs to be discussed with carers

Dry Skin : • Non-perfumed moisturisers are used at least twice daily on individuals with dry

skin, apply sparingly to prevent clogging, as dry skin is a significant and independent risk factor for pressure ulcer development (EPUAP, NPUAP 2009). The NHS Tayside continence skin care guideline (2009) suggests suitable moisturisers to be used to treat dry areas. Skin care should be discussed with carers

Wound Care: • The NHS Tayside Wound Care Formulary will be utilised to decide the most

appropriate dressing

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• District nurses will use the NHST wound chart (THB MR 609) to document wound

assessment and interventions • Products that promote a moist wound environment are used for all skin damage

unless contraindicated by the individual’s condition • Nursing records contain the site, condition and dressing utilised and will

demonstrate evidence of ongoing assessment and skin and wound care 2.5 DISCHARGE –TRANSFER The nurse responsible for arranging the discharge/transfer of patients with a pressure ulcer or at risk of developing an ulcer will ensure that the receiving nurse/hospital/area has written (or verbal in an emergency) information on: • Patient’s risk score • Whether the ulcer was present on admission or to caseload or community

acquired • Grade, condition and site of ulcer • Nursing intervention such as dressings and turning regimes

• Complex cases will be discussed with the GP and if appropriate seek advice or

arrange a hospital visit to plastics/dermatology 2.6 EDUCATION AND TRAINING Each Registered Nurse will: • Have read the NHST policy (community) for pressure ulcer prevention • Ensure they are updated in pressure ulcer prevention and wound management

and evidence this in their KSF annually by completing one of the following:-

• NES Education Resource Pack • Learn Pro module • Study day pressure ulcer prevention

3. RESPONSIBILITY AND ORGANISATIONAL ARRANGEMENTS Responsibility • It is the responsibility of the individual nurse//health professional to be familiar

with and practice in accordance with this policy • Maintain accurate records of assessment intervention and evaluation in

accordance with NMC standards for record keeping. Accountability • Each individual nurse is accountable for making evidence based assessment and

decisions in accordance with this policy

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• Each Nurse will ensure that when delegating care to Health Care Assistants, they

comply with NMC Guideline on Delegation (2008) • Each Nurse is accountable for documenting in the care plan, any non-

concordance or patient preference where aspects of this policy cannot be implemented in relation to prevention of pressure ulcers

• Maintain accurate records in accordance with NMC standards for record keeping • The Team Leader will keep a record of nurses who have read the policy and

updated their knowledge yearly • Grade 2 pressure ulcers and above will be reported through the Clinical Incident

reporting System. (A.I.M.) 4. EVIDENCE BASE FOR POLICY STATEMENTS

Rationale for statement 2.1 – Person Centred Care a nd Patient Involvement

• Individuals or their carers who are willing and able should be educated on

assessment and prevention strategies (NICE 2005) • Where patients cannot self-care, they will be informed and consulted on their

care needs and provision. Patient dignity will be preserved at all times • Patients and carers will be involved in shared decision making about the

management of pressure ulcers (NICE 2005) • Information, support, education and training will be provided to significant others

and will be done in accordance with Data Protection Act and Adults with Incapacity Act (Scottish Parliament 2000)

Rationale for statement 2.2 - Assessment

• Risk assessment is used to identify factors that contribute to the development of

pressure ulcers, not as a tool to determine the pressure-relieving device (NICE Guidelines 2005, Journal of Tissue Viability Vol 14 No.1 January 2004)

• A comparison of Braden and Norton, both scales predict equally well (or badly).

In both scales if nurses used preventative strategies according to risk assessment scales 80% would receive unnecessary pressure prevention and only 20% would develop pressure ulcers if they did not have prevention strategy (NICE 2005)

• Norton, Braden and Waterlow were compared. The Waterlow scale was the most

sensitive of the three (Wellard & Lo 2000)

Rationale for statement 2.3.1 - Skin Inspection and Grading of Pressure Ulcers

• NHS QIS Best Practice Statement (BPS) 2005

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• Healy (1996) tested the inter-rater reliability of three classification systems -Stirling, Torrance and Surrey. The Kappa’s measured were very low and varied between 0.15 and 0.37, indicating a low degree of agreement, however, Ware Bours et al (1999) studied the inter-rater reliability using the EPUAP classification and reported the Kappa to be 0.81-0.97 which is interpreted as excellent agreement. The EPUAP grading tool also describes some warning signs that may be evident in an individual with pigmented skin, which has not previously been addressed

Rationale for statement 2.3.2-Bed and Mattresses Al location

• Patients at risk should not be placed on a standard hospital mattress. High

specification foam mattresses reduce incidence in high-risk patients (Cochrane Wounds Group 2005)

• The use of electric profiling beds can reduce the prevalence of pressure ulcers,

pain and hospital stay Purvis &.Pearman 2005 • There is little evidence to support the use of risk assessment to make decisions

about the allocation of pressure relieving devices (NICE 2005) • Merits of CLP continuous low pressure and AP alternating pressure are unclear.

Professional consensus agrees that patients with grade 3 or 4 ulcer should be nursed on a dynamic mattress (Cochrane Library 2005)

Rationale for statement 2.3.3 - Re-Positioning

• 30 degree lateral inclined position maintained normal oxygenation of the

trochanter and sacral bony prominences (Seiler et al 1986) • Dramatic impairment in oxygen supply to the skin in the 90 degree lateral inclined

position but not in the 30 degree inclined position (Colin et al 1996) • 90 degree side lying position should be avoided, 30 degree Semi Fowler position

and prone position resulted in the lowest interface pressures (Defloor2000) • Patients who are able and willing should be informed and educated about risk

assessment and resulting prevention strategies. The strategy should include carers where appropriate (RCN 2001)

• A written record of positioning schedule agreed with the individual should be

established for each person at risk (RCN 2001)

Rationale for statement 2.3.4 -Seating • Insufficient evidence of the value of seat cushions (Cochrane 2005) • The use of pressure-relieving devices (beds, mattresses and overlays) for the

prevention of pressure ulcers in primary and secondary care (McInnes 2004) • The management of a patient in a sitting position is also important. Even with

appropriate pressure relief it may be necessary to restrict sitting time to less than 2 hours until the risk factors improve (RCN 2005)

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Rationale for statement 2.3.5 - Prevention of Heel Ulcers • Because of its thin layer of subcutaneous tissue between the skin and bone, the

heel is the second most common site for pressure ulcer development (after the sacrum)

The following groups of patients are at greatest risk for heel pressure ulcers: • Patients with immobile legs due to health problems such as fractured hips, joint

replacement surgery, spinal cord injury, Guillain-Barré syndrome, stroke, or those who do not move their legs because of paralysis, weakness, or pain

• Patients with vascular disease and diabetes may have peripheral neuropathy,

which may prevent them from feeling pressure or injury to the feet. Immobile patients with diabetes also may have trouble moving their legs. Carefully monitor these patients and assess their heels at each visit

• Patients with leg spasms, those in pain and those who are confused may rub

their heels on the bed and abrade the heel. Patients may also dig their heels into the mattress to keep from sliding down in bed causing further pressure injury (Preventing heel pressure ulcers Black 2004)

• Dekeyser et al 1994 - examined the pressure-reducing effects of 13 different

heel-protecting devices. An ordinary head pillow was shown to be the most effective pressure-reducing device, followed by heel protectors based on siliconized hollow fibres

• Gilcreast, et al 2005 - stated there are implications for further investigation into

the use of pillows as pressure-relief devices for the heels, and although excellent studies have been done by Tymec et al it is likely that there is great variability in how pillows could be applied. The investigators believe that the most effective way is with the long dimension of the pillow oriented to the length of the leg, with the heel suspended. This method distributes the weight over a greater surface area and reduces the weight per square inch on the heel. Softer, conformable pillows would provide superior relief compared to firmer pillows with less deformability; however, the pillow must not be so soft that it allows the heel to rest on the mattress surface

Rationale for statement 2.4 - Skin Care and Wound C are

• Incontinence can increase an individual’s risk of pressure ulcer development due

to chemical irritation and/or the inappropriate cleansing regime adopted (Cooper and Gray, 2001). Cleansing with soap and water can contribute to the development of pressure ulcers (Cooper and Gray, 2001)

• There is evidence that cleansers, as opposed to soap and water, are used to

cleanse the skin of those individuals who are incontinent (Cooper & Gray 2001, Whittingham & May, 1998)

• Evidence suggests modern wound dressings are preferable to traditional

(Heyneman, Beele, Vanderwee, & Defloor 2008)

• Incontinence can change the ph of the skin causing maceration. Barrier creams are found to be helpful in preventing further skin breakdown when used after skin cleansing (White& Cutting 2003)

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5. KEY CONTRIBUTORS • Sue Mackie, Senior Nurse Practice Development/leadership • Kaye Wiseman Clinical Team Manger Community Nursing Services Angus • Ann Skelly, Community Nurse Manager, Dundee • Elaine Grant, Community Nurse for Dundee

• Pam Perry, Community Nurse for Dundee • Wilma Latham, Senior Nurse, Clinical Education and General Practise Nursing • Anne Elliot, Senior Charge Nurse, Community Nurse for Dundee • Catherine Davidson, Associate Practitioner Nurse • Emma Milne Specialist podiatrist Perth and Kinross CHP • Sarah Kelly Team leader Perth and Kinross • Anne Paterson DN Kinloch Rannoch • Kay Gray DN Angus CHP

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6. REFERENCES Black J, 2004. Preventing Heel Pressure Ulcers. Nursing, 34 (11) p p. 17. Lippincott Williams & Wilkins, Inc. Bours G J J, Halfens R, Lubbers M, Haalboom JR, 1999. The development of a national registration form to measure the prevalence of a pressure ulcer in the Netherlands. Ostomy Wound Management, 45 p p.28-40. The Cochrane Database of Systemic Reviews, 2005. Support Surfaces for Pressure Ulcer Prevention. Cochrane Library. Vol 2 updated Feb. Colin D, Abraham P, Preault L, Bregeon C, Saumet J, 1996. Comparison of 90-degree laterally inclined positions in the prevention of pressure ulcers using transcutaneous oxygen and carbon dioxide pressures. Advances in Wound Care. The Journal of Prevention and Healing ,9(3)p p 35-38 Cooper P, Gray D. 2001. Nursing & Residential Care. 3,(7), p p 335 -344 European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and Treatment of pressure: quick reference guide. Washington DC. : National Pressure Ulcer Advisory Panel; 2009. Heyneman A, Beele H, Vanderwee K, Dehloor T, 2008. A Systematic Review of the use of Hydrocolloids in the Treatment of Pressure Ulcers. Journal of Clinical Nursing, 17( 9) p p. 11641173(10). Blackwell Publishing De Keyser G, Dejaeger E, De Meyst H, Eders G C, 1994. Pressure-Reducing Effects of Heel Protectors. Advances in Wound Care, 7 (4 )p p 30-2, 34 Gilcreast D M, Warren J B, Yoder L H, Clark J J, Wilson J A, Mays M Z. Section Editor(s): Doughty D. 2005.Research Comparing Three Heel Ulcer-Prevention Devices . Journal of Wound, Ostomy and Continence Nursing, 32 (2 ), p p 112–120. Buss IC, Halfens J G, Saad. H H ,. 2002. Rehabilitation Nursing .Glenview 27,(2) pp 59. McInnes E. 2004. The Use of Pressure-Relieving Devices (Beds Mattresses and Overlays) for the Prevention of Pressure Ulcers in Primary and Secondary Care. Journal of Tissue Viability 14 (1), p p 4-6, 8, 10. NATVNS Scotland. 2008 Tissue Viability Toolkit. NHS QIS Best Practice Statement 2005. The Treatment/Management of Pressure Ulcers. www.nhshealthquality.org NHS QIS Best Practice Statement 2005 and Revised Statement 2009 Pressure Ulcer Prevention http://www.nhshealthquality.org/ NHS Education for Scotland . The Prevention & Management of Pressure Ulcers –An Educational Workbook for Healthcare Staff 2009.Edinburgh NICE Guidelines 2005. Pressure Ulcer Risk Assessment and Prevention of Pressure Ulcers (Beds, Mattresses and Support Surfaces). http://www.nice.org.uk/guidance/index.jsp?action=download&o=29885

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Purvis K. Pearman A. How the Use of Electric Profiling Beds can reduce the Prevalence of Pressure Ulcers Professional Nurse. 2005 Apr; 20 (8) 46-8 Royal College of Nursing and National Institute for Clinical Excellence 2005. The Management of Pressure Ulcers in Primary and Secondary Care. A Clinical Practice Guideline. http://www.rcn.org.uk/ Royal College of Nursing 2001. Pressure Ulcer Risk Assessment and Prevention. April RCN Publishing Royal College of Nursing 2005, The Use of Pressure Relieving Devices (Beds, Mattresses and Overlays) for the Prevention of Pressure Ulcers in Primary and Secondary Care -guidelines commissioned by the National Institute for Clinical Excellence. January 2005 RCN publishing Schoonhoven, Lissette Deflloor. Incidence of Pressure Ulcers Due to Surgery. Journal of Clinical Nursing, 11(4) July 2002 Blackwell Science Ltd Scottish Parliament 2000 Adults with Incapacity (Scotland) Act. Edinburgh: .HMSO Seiler WO, Allen S, Stahelin H. B, 1986. Influence of the 30-Degree Laterally Inclined Position and the ‘Supersoft’ 2 piece Mattress on Skin Oxygen Tension on Areas of Maximum Pressure – Implications for Pressure Sore Prevention. Gerontology, 32 158-166 White RJ, Cutting KF (2003). Interventions to avoid Maceration of the Skin and Wound Bed. British Journal Of Nursing,12 (20): pp1186-1203 Whittingham K, May S, 1998. Cleansing Regimens for Continence Care. Professional Nurse,14(3) p p167-72

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Tendon

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What is Darkly Pigmented Skin? An individual’s skin colour is determined by the amount and type of pigmentation (Melanin) in the skin. Individuals with darkly pigmented skin have more melanin in their skin than individuals with lightly pigmented skin.

Key Principles of Assessing Darkly Pigmented Skin

Darkly pigmented skin does not blanch

• Depending on skin tone, the skin may appear blue or purple compared to the surrounding area of skin. It is important to compare the section of the body you are concerned about with other areas of skin to look for differences in skin tone.

• Assess skin in a good light in order to see slight variances in colour

• Touch the skin and ask yourself if the skin feels boggy, stiff, warm or cool?

• Observe if the skin has changed since the last time you inspected it.

• Listen to the individual and any complaint of itchiness or pain.

A Grade 4 Pressure ulcer clearly illustrating darker skin tones around the ulcer site

Appendix III

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Semi Fowler Position

30-degree lateral tilt: gently turn patient, place a pillow support under shoulder and one corner of pillow at base of spine. Patient to rest back on the pillow, to a 30-degree tilt. Place another pillow between the patients’ legs ens uring the heel is off the pillow. The nurse will check that the tailbone and shoulder bla des are not touching the bed. The buttocks should be taking the weight not the tail b one, shoulder blade or touching the bed.

30 degree Tilt Illustration Courtesy of MSS Dolby

Appendix IV

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NHST Guidelines for the use of heel elevators There is a paucity of clinical evidence; about the selection of an optimal device for preventing heel PU, however as heel ulcers are the second most common pressure ulcer in NHS Tayside, some guidelines based on a combination of existing evidence and clinical experience are required to ensure a consistent approach to the reduction in heel ulcer development While pressure redistribution devices may reduce tissue interface pressures at the heels, expert opinion and clinical experience concur that elevation of the heel is indicated to both reduce pressure and prevent shear and friction caused by frequent movement of the heel due to restlessness, reflex movements of the legs, or voluntary movement. A variety of heel protection devices are available that are designed to both relieve tissue interface pressure and protect the heel from shear and friction. Considerations for selecting an optimal heel protection device include its ability to elevate the heel off the underlying support surface while preventing foot-drop and rotation of the leg, the boot's ability to wick away temperature, its ability to be cleaned, whether it allows patient ambulation, its ability to remain in place despite patient movement, and its ability to remain in place without causing pressure to other surfaces of the foot. J Wound Ostomy Continence Nurse. 2009 Nov-Dec; 36(6):602-8. The following table is a guideline only. When c hoosing a device for heel elevation consider the ob jectives of care for the individual and the following:- Comfort Mobility in bed/theatre. Are the patient’s legs likely to stay in one position in the bed? Are they at risk of friction and shear forces? Length of time of immobility Co-morbidities such as diabetes, vascular impairment, neuropathy, stroke Safety - is the patient at any further risk of falls if they mobilise with a secured device on the foot Existing heel ulcers and location of heel ulcer Registered nurses can supply the undernoted equipme nt for the prevention of heel ulcers however for co mplex issues Refer to the following Orthotics Podiatry Diabetic nurse Refer to physio for mobility/drop foot issues when required Refer to Pressure Ulcer prevention policy NHST for further guidance

Appendix V

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PRODUCT Advantages Contraindications ORDER DETAILS PILLOWS Patients who are bed or chair bound and have immobile legs Except for those: • At risk of foot

drop/have sensory loss/stroke

• Other co-

morbidities Diabetes, ischemia • Any heel or foot

damage • Restless, and at risk

from friction injury

Multiple patient use Available on the ward and to commence at any time Good for short term use on people who do not move their leg/heel position too much in bed or chair Elevate heels completely in such a way as to distribute weight of the leg along the calf without putting all the pressure on the Achilles tendon. The knee should be in slight flexion. A soft pillow along the length of the calf (not under the Achilles tendon) has been shown to be effective (EPUAP 2009).

Not suitable for long term use as pillows do not provide protection from footdrop

Please ensure the covers are not used interchangeably with pillows used for the head without cleaning and changing the covers

LEG TROUGH Short term use i.e 24-48 hours for patients who have or need to have limited movement i.e pre and post op care Remove the trough every one two hours to facilitate movement

Completely elevates the heel off the bed Multiple use - readily available on ward or theatres Short term use-i.e in theatre/post op/epidural/blocks Follow manufacturers cleaning guidance

No protection against foot drop-short term use 24 – 48 hrs only

Park House Medical PLO32S 5” Cost: £20.27 each

PRODUCT Advantages Contraindications ORDER DETAILS REPOSE Can be used for multiple . Available on contract

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Bed/chairbound With or without existing heel ulcers N.B. • Those at risk of

footdrop or rotation of the ankle should have a PODUS boot

patients – ensure manufacturers cleaning guidance is adhered to Can held as stock for high risk people Can be secured to the patient, loosely with a light tubular bandage - do not secure on any patient who may be confused or disorientated as they may try to walk with the Repose in situ. Education video available http://reposedirect.com/

Patient should not be mobilised with the Repose in position Ensure the knee is slightly bent and supported May not protect from foot drop associated with stroke/spasticity/existing footdrop Not as suitable if the heel ulcer is at the medial or lateral side of the heel, use the PODUS

One pair Foot protector and pump Frontier medical group Code 650110 Warranty period one year Cost: £64 per pair excl. VAT

PODUS Expected to be immobile for more than a week and/or At risk of foot drop or rotation of foot Existing heel ulcer Co-morbidities PVD Diabetes Sensory loss

Single patient use Lining can we washed or purchased for a single patient use For prevention/relief of ulcer in high risk patients For any patient with an existing ulcer

Not suitable for ambulation, transfer only

Request through TORT centre ext 36292 Or hold a ward stock for high risk areas Standard size ORT 6657 fits most legs Ex large ORT 6658 for very obese/oedematous leg Cost: Approx £27 each

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Guidelines for the Product Management of Urinary and Faecal Incontinence Continence Assessment If following a comprehensive continence assessment, the need for continence management products has been identified follow the guidance detailed in Boxes A,B & C (NHS QIS Best Practice Statement, Continence –adults with urinary dysfunction) In addition regular skin assessment and interventions as per Skin Excoriation Tool for Incontinent Patients (NATVNS Scotland) to be implemented Disposable procedure pads should not be used routinely as a continence aid ( recommended use Box D) Box A Management of Urinary Incontinence Re-usable products Helps maintain self esteem

Needs laundering facilities, not suitable for most short stay wards unless relatives take home laundry

P&S range: body worn & under pad

Disposable products

Close fitting ensures quicker-better absorption of urine. Super absorbents in products minimise likelihood of skin wetness. Ensure pads are worn with close fitting pants

Adhesive backing : Tena Comfort Extra (stretch/net pants not appropriate for use with these pads as they require a wider gusset on which to adhere) Shaped: - Tena Comfort range All-in one : (Diaper /nappy style) Tenaslip range

Box B Management of faecal incontinence Disposable Does not require the use of super absorbent pads Shaped – Tena Comfort Normal

Box C Management of both urinary and faecal incontinence Disposable The degree of urinary incontinence guides the

absorbency level of product required. Shaped : Tena Comfort range All-in one : ( diaper /nappy style) Tenaslip range

Box D Recommended use of under/procedure pads • For bowel care –suppositories/enema • Following discussion with Dermatology staff where body worn pads would be more detrimental to patient needs • To alleviate frequent moving and handling whilst undertaking end of life care Review date June 2013 For further information or advice contact your local Continence Advisory & Treatment Service (C.A.T.S.)

Appendix VI

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June 2012 Skin Care Guidelines in the management of urinary and faecal incontinenc e Recommended first choice products. For further choi ces and information see Tayside Prescribing Guide a nd Tayside Wound Formulary Review date June 2013 Acknowledgement. NHS Lothian Skin Care Guidelines *For further information or advice on management of incontinence contact your local Continence Advisor y & Treatment Service (C.A.T.S.)

Appendix VII

Each patient should have a continence assessment an d if required appropriate continence aids supplied (NHS QIS Best Practice Statement, Continence –adults with urinary dysfunction) Assess skin condition regularly using excoriation Tool (NATVNS Scotland) and use guidance below Document assessment and decisions in the health record U Use a soap substitute to cleanse skin or if bathing use a bath/shower emollient (Box 1) –Routine cleansing Ensure water is at 370C, Do not use bubble bath or bath salts Usual cleansing for rest of body,

Excoriation Tool Score Score 0 - Use emollient cream or gel after cleansing if skin dry/fragile (Box 1) Score 1 - Use barrier cream ,( in addition to routine cleansing), if : (Box 2) Incontinent of urine ≤ 3times per day- apply 24hrly Incontinent of urine ≥ 4times per day -apply 8hrly Use barrier film , (in addition to routine cleansing), if: (Box 2) Incontinent of urine and faeces -apply 24hrly Score 2 - Use barrier film , (in addition to routine cleansing), if: (Box2) Incontinent of urine and/or faeces apply -every 12hrs Score 3 - As for score 2, may require a dressing as per wound formulary (and if required *)

Box 1. - Emollients/moisturisers/cleansers (Test patch on good skin and check at 48hours before using) Apply as directed. Over application can create a restriction to the urine being absorbed by the pad For use in bath Oilatum® For use in Shower Dermol 200 Soap substitute Senset Cleansing Foam (through supplies order via fast aid service) Dermol® 500 For dry skin Diprobase® cream Doublebase® gel Ordering Information Hospital: via Pharmacy Community: via GP10

Box 2. Barrier products Barrier creams Conotrane, Cavilon® Cream, Drapolene Barrier film - Cavilon® No Sting Barrier Film Ordering information Hospital: via Pharmacy Community: via GP10 Various sizes available - Check Pharmacist/Formulary If problems with these products contact Dermatology for advice

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Section 8: Rapid Impact Checklist (RIC) (Page 1of 2) EACH POLICY MUST INCLUDE A COMPLETED AND SIGNED TEMPLATE OF ASSESSMENT

Which groups of the population do you think will be affected by this proposal? • minority ethnic people (incl. gypsy/travellers, refugees & asylum seekers) • women and men • people in religious/faith groups • disabled people • older people, children and young people • lesbian, gay, bisexual and transgender people

• people of low income Other Groups: • people with mental health problems • homeless people • people involved in criminal justice system • staff

N.B. The word proposal is used below as shorthand for any policy, procedure, strategy or proposal that might be assessed.

What positive and negative impacts do you think there may be? See Page 2 Which groups will be affected by these impacts? ALL

What impact will the proposal have on lifestyles? For example, will the changes affect: • Diet and nutrition? • Exercise and physical activity? • Substance use: tobacco, alcohol or drugs? • Risk taking behaviour? • Education and learning, or skills?

Diet & nutrition and other risk factors will be assessed with potential for change required Mobility and re-positioning will be required Patient and/or carer education regarding self-care and rationale for nursing interventions

Will the proposal have any impact on the social environment? Things that might be affected include • Social status • Employment (paid or unpaid) • Social/family support • Stress • Income

No

Will the proposal have any impact on

• Discrimination? • Equality of opportunity? • Relations between groups?

No

Will the proposal have an impact on the physical environment? For example, will there be impacts on: • Living conditions? • Working conditions? • Accidental injuries or public safety? • Transmission of infectious disease?

Improvement for patient outcomes

Will the proposal affect access to and experience of services? For example, • Health care • Transport • Social services • Housing services • Education

No

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Rapid Impact Checklist (RIC): Summary Sheet (Page 2 of 2)

Each policy must include a completed and signed tem plate of assessment

1. POSITIVE IMPACTS (NOTE THE GROUPS AFFECTED)

Use of high specification foam mattresses and profiling beds will provide patients with pressure-redistributing properties. Ongoing purchases of equipment will provide high standard of pressure relief as standard to reduce pressure ulcer incidence. Compliance with policy and Clinical Quality Indicator (CQI) will result in anticipated improvements in pressure ulcer incidence. CQI and policy will standardise practice within NHS Tayside.

2. NEGATIVE IMPACTS (NOTE THE GROUPS AFFECTED)

None

3. ADDITIONAL INFO RMATION AND EVIDENCE REQUIRED

Evidence supports use of electric profiling beds, high specification foam mattresses and compliance with Best Practice Guidelines in pressure ulcer prevention improves patient outcomes

4. RECOMMENDATIONS

Risk assessment/management strategies should be employed to minimise negative impacts.

5. FROM THE OUTCOME OF THE RIC, HAVE NEGATIVE IMPACTS BEEN IDENTIFIED FOR RACE OR OTHER EQUALITY GROUPS? HAS A FULL EQIA PROCESS BEEN RECOMMENDED? IF NOT, WHY NOT?

No MANAGER’S SIGNATURE: ___S. MACKIE____________ D ATE: JUNE 2012

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Appendix l V: NHS Tayside – Policy/Strategy Approva l Checklist This checklist must be completed and forwarded with policy to the appropriate forum/committee for approval. POLICY/STRATEGY AREA: CLINICAL POLICY/STRATEGY TITLE: Pressure Ulcer Prevention an d Care for Adults in the Community LEAD OFFICER: Why has this policy/strategy been developed?

To ensure that all pressure ulcer prevention and care in NHS Tayside is consistent with national guidelines and evidenced based practice

Has the policy/strategy been developed in accordance with or related to legislation? – Please give details of applicable legislation.

N/A

Has a risk control plan been developed? Who is the owner of the risk?

No

Who has been involved/consulted in the development of the policy/strategy?

Policy development group with representation from across NHS Tayside.

Has the policy/strategy been assessed for Equality and Diversity in relation to:-

Has the policy/str ategy been assessed For Equality and Diversity not to disadvantage the following groups:-

Race/Ethnicity Gender Age Religion/Faith Disability Sexual Orientation

Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes

Minority Ethnic Communities (includes Gypsy/Travellers, Refugees & Asylum Seekers) Women and Men Religious & Faith Groups Disabled People Children and Young People Lesbian, Gay, Bisexual & Transgender Community

Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes Yes

Does the policy/strategy contain evidence

of the Equality & Diversity Impact

Assessment Process?

Yes

Is there an implementation plan? Yes

Appendix VIII

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Which officers are responsible for implementation?

Associate Nurse Directors and Lead Nurses CHPs

When will the policy/strategy take effect? July 2012 Who must comply with the policy/strategy?

All nursing and AHP staff

How will they be informed of their responsibilities?

Policy emailed to Clinical leads Cascade training at ward/team level

Is any training required? Yes

Education on the Policy and associated documentation and care

If yes, has any been arranged? Each CHP developed an implementing plan Are there any cost implications? No If yes, please detail costs and note source of funding

N/A

Who is responsible for auditing the implementation of the policy/strategy?

CHP leads

What is the audit interval? Weekly with the implementation of national nursing quality indicators

Who will receive the audit reports? Nursing & Midwifery Directorate NHS Scotland

When will the policy/strategy be reviewed and by whom? (please give designation)

Annually, Nursing & Midwifery Directorate

Name: S.Mackie Date: June. 2012