AT RISK PATIENT

Harms – New or Existing

Pressure Ulcers, CAUTIs, VTEs, Falls

Pressure Ulcer

TISSUE VIABILITY
Localised injury to the skin and/or
underlying tissue usually over a bony
prominence, as a result of pressure,
or pressure in combination with shear
– European Pressure Ulcer
Advisory Panel / National
Pressure Ulcer Advisory Panel
(2014)

Prevention is better (and less costly) than

cure
Maintain skin integrity – intact skin will
protect against infection

ASSKING S – Skin Assessment

Skin inspection should:
• be completed within 6
A Assess Pressure Ulcer Risk (Waterlow for adults) and hours of admission to
other risks hospital/ward/unit
including transfers
S Skin assessment and skin care between wards. ALL
dressings removed and
S Surfaces /Equipment wounds assessed
• occur regularly and the
K Keep moving/ Reposition frequency determined
as a response to
changes in the
I Incontinence individuals condition.
• Include assessment of
N Nutrition vulnerable areas

G Giving information Document findings: Body map

wounds/pressure/moisture
damage.
Medical photography X64139
Handover.

WATERLOW Skin Assessment

Start ICP if Waterlow is

• Health care professionals should be aware of the following
10 or more
Persistent erythema
OR patient has existing Non-blanching hyperaemia
Blisters
pressure ulcers Discolouration
Feel for:
OR patient has a history Localised heat
of pressure ulcers Localised oedema
Localised induration
Reassess Weekly or
following change in Note: on darker pigmented skin
patients condition and visually damage may appear
more purple in colour.
on transferring to other
units

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 Grade / Category 1 Grade / Category 2

Category 2: Partial thickness

skin loss involving epidermis,
dermis or both. The ulcer is
Category 1: Non-blanching erythema of
superficial and presents clinically
intact skin. Discolouration of the skin,
as an abrasion or blister.
warmth, oedema, induration or hardness
may also be used as indicators particularly
on individuals with darker skin.

Grade / Category 3 Grade / Category 4

Category 4: Full thickness

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

A grade 4 Pressure ulcer

will not become a grade
3, 2, or 1.
It will become a healing
grade 4 pressure ulcer.
Why?

Category 3: Full thickness skin loss Because you don’t replace

the damage to the muscle,
involving damage to or necrosis of subcutaneous fat and
dermis prior to
subcutaneous tissue that may extend down epithelialisation.
to, but not through underlying fascia.

Unstageable Suspected Deep Tissue Injury (SDTI)

Suspected deep tissue injury – depth unknown

This is purple or maroon localised area of discoloured
intact skin or blood-filled blister due to damage of the
Unstageable/unclassified: Full thickness skin
underlying soft tissue from pressure and/or shear.
loss – depth unknown
Depth completely obscured by slough and/or
eschar. The true depth cannot be determined
until enough slough and/or eschar are removed
to expose the base of the wound, but it will be
either a category 3 or 4. Eschar on the heel
serves as “the Body’s natural (biological) cover”
and should not be removed.

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 Mucus Membrane Tissue Damage (MPrU) Medical Device Related Pressure Ulcers

• Moist lining of body cavities communicating with exterior especially

vulnerable especially related to medical devices
• Pressure can cause ischemic with ulcer formation
• These ulcers are not graded using the current system but reported as
mucosal pressure ulcer damage.
Related devices:- Other things to consider:

Oxygen tubing
Endotracheal tubes
Bite blocks
Nasogastric tubes
Urinary catheters
Faecal containment devices

Skin Assessment and Skin Care PRESSURE ULCERS vs MOISTURE LESIONS

Moisture Associated Skin Damage

PRESSURE ULCERS MOISTURE LESIONS
(MASD)
Often mistaken for pressure damage. • Circular/ Regular shape • Diffuse shape, may have
Treatment: Good skin hygiene several skin breaks
• Distinct edges
• Pressure / shear present • May have irregular or jagged
• Anal cleft • Localised over Bony edges
prominence, site of mucous • Moisture: urine, faeces, sweat,
membrane cavity or evidence exudate
of medical device • Sites associated with moisture
• Can be deep - Sacrum, skin folds, wound
• Necrotic tissue can be present margins
• Kissing Ulcer • Shallow
• Necrotic tissue not present
Stop the Pressure:
Moisture + Pressure = Accelerated skin
• Diffuse Spots
damage
Combination Ulcer.

Skin Care SURFACES- EQUIPMENT

• Keep skin clean and supple Mattresses.

Pressure reduction – Static Mattresses
Pressure relief – Dynamic Mattresses

• Use wipes to cleanse the skin

• Pat dry with a towel if required
• Apply a moisturiser for general skin care or barrier product
if the patient has continence issues

Derma S Cream Derma S Sticks or Spray

Protection from
incontinence & dry areas Broken Skin

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 K – Keep Moving I – Incontinence

• Encourage mobility and self repositioning. Get patients up and out – good
for mood, address any pain needs. Increased moisture on skin, accelerates skin breakdown
• Slide sheets or Hoist into chair – consider correct surface. and breeds bacteria. Urine and faeces burn the skin.

• Reposition as risk assessment guides e.g. 2, 4hourly - document • Commence protecting skin with barrier cream before damage when
patient is incontinent.
• Off loading of patients pressure areas with damage.
• Regular pad checks and repositions – correct sizing of pad. Only 1 pad is
• Liaise with other specialities /discharge planning required

• Time spent in bed, off loading of pressure to • Cleanse skin with aqueous cream dissolved in water.
vulnerable/ damaged areas.
• Complete documentation

N – Nutrition G – Giving information

Nutrition is key in wound healing and skin integrity. • Communicating concerns with patient, relatives and MDT.
• Encourage good diet and fluids. • Does the patient have capacity?
• Is the patient and relatives aware of the risks of
• If poor intake/ patient at risk commence nutritional supplements.
pressure/tissue damage?
• Ensure MUST assessment completed. • Are they aware of the importance of the advised
interventions?
• Are there safeguarding concerns?
• Escalate and document non concordance/ variations in
care.
• Mental capacity assessment if non-concordant
• Pressure ulcer leaflet.

When to Report pressure ulcers on ULYSSES WOUND ASSESSMENT - TIME

All pressure ulcers and moisture damage must be reported
• Wound assessment chart to document assessment of the wound
NB Check wound with senior nurse before instigating incident if and plan of care.
uncertain of Category. (NB Only Pressure ulcers are categorised)

1. NEW pressure ulcers TIME

2. Deterioration of a pressure ulcer – e.g. – category 2 increases to • T - Tissue
Category 3. • I - Infection /Inflammation
3. Existing pressure ulcers • M - Moisture balance
• E - Edges
. • Other considerations – e.g. Pain
Known and previously reported pressure ulcers/ wounds do NOT
need to be re-reported on admission to your area.

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 IPC/TV Team Contact Details SOME SUGGESTIONS FOR FURTHER READING / INFORMATION

• MFT eLearning packages on the hub for IPC & TV

• Oxford Road Campus • EPUAP/NPIAP websites
0161 276 4042 • Wounds UK website “Made Easy” Guides
• STOP THE PRESSURE website – Red dots
[email protected] • React to red campaign
• Legs matter campaign
• WOUND CARE TODAY website
• Nursing Times & other journal websites
• Wound care product websites e.g. Convatec for information re dressings
• 3M Health Care Academy: Provided free to MFT staff To register, staff just
need to put in email and Trust code which is LEARN132.
• Principles of best practice: Wound infection in Clinical practice 2016
consensus document
• NHS Improvement

Any Questions?