Smith & Nephew How to Guide on Pressure Ulcer Management
How to Guide: Pressure Ulcer Management
(Other situations include where patients have capacity but refuse care, do not have mental capacity and are unable to co-operate, where patients cannot be turned for medical reasons or where an acute/critical event occurs affecting the person’s ability to reposition (eg following a fall due to an unexpected collapse).
WHO IS AT RISK OF A PRESSURE ULCERPressure ulcers can affect patients in every health care setting and are seen in all age groups (Wilson, 2007). Intrinsic factors include extreme age, limited mobility, vascular disease, sensory impairment, malnutrition, dehydration and a previous history of pressure damage. Even fit, healthy people who are limited to bed rest or restricted patterns of chair sitting can develop pressure ulcers. This is because damage can occur at any point where the tissues are subjected to pressure, shearing or frictional forces (extrinsic factors, see Box 1). This may be high pressure over a short period of time or low pressure applied continually over a long period of time (Int Review, 2010).
- Other factors
The temperature and moisture levels of the environment at or near the skin surface – the micro climate – may also affect the risk of pressure ulcer development (Clark and Black, 2011). In addition, medications that induce sedation and/or anesthesia and medical/surgical interventions that prevent or reduce the ability of the patient to move increase the risk of tissue damage.
- When are pressure ulcers unavoidable?
Pressure ulcers are often seen in end-of-life patients and may be unavoidable due to skin changes and the inability to maintain nutrition and hydration (Wilson, 2012). Care often focuses on comfort measures.
WHERE DO PRESSURE ULCERS OCCUR?Most pressure ulcers appear over the major weight-bearing parts of the body. The sacrum and the heels are the two most common sites of ulcer development (Wilson, 2007). This is because the thin layer of subcutaneous tissue between the skin and the bone provides minimal protection from the applied forces of pressure, shear and friction. Also there is often a reduced blood supply to the extremity due to co-morbidities that compromise the vascular system (eg diabetes). Pressure ulcers may also occur where devices such as tubes, masks and catheters press into the body.
- PRINCIPLES OF MANAGEMENT
When a pressure ulcer occurs, it is important to accurately assess the individual and the wound. Initial assessment should take place within six hours of the first episode of care and include assessment and documentation of:
- Size and shape
- Wound bed condition
- Exudate level and consistency
- Pain and mal odour
- Signs of infection.
When assessing the pressure ulcer it is important to use a pressure ulcer grading tool to measure the severity of the injury objectively. The European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) recommend the use of a basic classification system comprising four categories or stages based on the severity of tissue damage (EPUAP/NPUAP, 2009).Pressure ulcers can have a negative impact on wellbeing and quality of life. It is essential to involve the patient and his/her family in ensuring that individual problems and concerns are addressed (Int Consensus, 2012). Pressure ulcers remain a common problem and affect the quality of life of many patients. The majority of pressure ulcers are avoidable and successful prevention will depend on removing or modifying the cause. This “how to” guide looks at how to identify and manage pressure ulcers correctly in any health care setting and the importance of education to improve outcomes. The ultimate goal of pressure ulcer management is prevention.
PRESSURE, FRICTION AND SHEAR
Pressure is the amount of force applied at right angles to the tissues between the bone or a hard object such as a catheter and the supporting surface. Patients at highest risk from pressure damage are those who are not able to move in a bed or chair unaided.Friction is a force that is created whenever two surfaces move or try to move across one another. This may be when a person moves or is moved across the bed or cushion, causing the outer layers of the skin to be subject to abrasion.Shear is an internal force caused when two adjacent surfaces slide across each other, which results in twisting and tearing of the underlying blood vessels and leads to a restricted blood supply to the tissues.