The Management and Prevention of Pressure Ulcers. A Teaching Pack For Health Care Support Workers

Transcription

1 The Management and Prevention of Pressure Ulcers A Teaching Pack For Health Care Support Workers Menna Lloyd Jones Senior Nurse Tissue Viability North West Wales NHS Trust Trudie Young Lecturer in Tissue Viability Conwy and Denbighshire NHS Trust

2 Introduction Pressure ulcers are not a new phenomenon in fact they were discovered on an ancient Egyptian priestess mummy. It was found that the mummy had pieces of leather on her sacrum and buttocks. Although for years pressure ulcers have been seen as a nursing problem, things are changing, and today pressure ulcers are used as a quality of care indicator. However we also need to consider the cost of treating and preventing pressure ulcers. Depending on which study you read the cost of treating pressure ulcers varies between 60 and 300 million per year. What we must also understand is that it is very difficult to put a price on the cost to the person that develops the pressure ulcer. What is important, however, is that we all have a responsibility when it comes to pressure ulcer prevention and we need to have the appropriate knowledge in order to be able to prevent pressure ulcers and to recognise the early signs of their development. The Aim of this teaching pack is to give health care support workers the knowledge and understanding to enable them to manage and prevent pressure ulcers. The Objectives are: After completing this pack you will be able to: Define a pressure ulcer Understand the factors that contribute to the development of pressure ulcers Recognise the first signs of pressure ulcer development Understand the care a patient requires in order to minimise the risk of developing pressure ulcers Who is the teaching pack for? This pack has been developed for health care support workers caring for people that are at risk of developing pressure ulcers. Contents The pack contains a teaching pack and an accompanying workbook. 2

3 How to use the package? There are 2 parts to this package including: the information with regards to pressure ulcer prevention included in this part of the package a workbook for you to work through on your own or in a group and the package can be used by the home manager to work through with the carers, either individually or in a group The pack is split into units, which can be worked through at your own pace. Each activity is clearly marked using the owl symbol. Each activity should be completed before moving on to the next part of the unit. Where to get help? Should you require any assistance you can get help from your tissue viability link nurse or you may contact me Tissue Viability. That is the introduction. Let s start with unit 1 and work through the package at your own speed. Have fun!! 3

4 Unit 1 Definition Of A Pressure Ulcer And The Skin 4

5 Unit 1 In order to minimise the risk of developing pressure ulcers, it is important that you understand what a pressure ulcer is and how to care for the skin. In this unit we will look at the definition of a pressure ulcer and at the anatomy, function and care of the skin. The objectives are that at the end of this unit you will be able to describe the anatomy and function of the skin. Enabled by your ability to: Define a pressure ulcer Describe the anatomy of the skin Explain how the function of the skin protects against the development of pressure ulcers Describe the skin changes in the elderly Describe how to care for the skin Define a pressure ulcer Let us start with a definition of a pressure ulcer (pressure ulcers have also been called "bed sores or pressure sores"). So what is a pressure ulcer? Activity 1 In your workbook write in your own words what you understand by the term pressure ulcer. Now look at my definition and compare. Is your definition similar to mine? A pressure ulcer is an area of localised damage to the skin following disruption to the blood supply due to pressure, shear or friction or any combination of these. (Dealey 1994) Don't worry about pressure, shear and friction as we will discuss these later in Unit 2. Ok we have defined a pressure ulcer now let's move on and discuss the skin. Describe the anatomy of the skin Believe it or not but the skin is an organ. In fact it s the largest organ in the body. It weighs around 6lbs and covers an area, which is equivalent to 3000 Square inches or 2 meters. Just out of interest 1 square centimetre of skin contains: 15 sebaceous glands 0.9 meters of blood vessels 100 sweat glands 3000 sensory nerve cells at the end of nerve fibres 3.7 meters of nerves 25 pressure apparatus for the reception of tactile stimuli 200 nerve endings to record pain 2 sensory apparatus for cold 12 sensory apparatus for heat epidermal cells 10 hairs 5

6 Activity 2 Right let s have another activity. In your workbook can you fill in the blanks in the short passage. Answer How did you get on? Don't worry if you did not get them all. Below you will find the completed passage. The skin is the largest vital organ in the body in terms of surface area. In the average adult the skin occupies a surface area of approximately 2sq metres. It consists of two principle parts, the outer layer composed of a thin, avascular layer of epithelial cells called the epidermis which is cemented to the inner thicker, connective tissue layer called the dermis. Beneath this layer is the subcutaneous layer, which acts as a cushion. The middle layer of the skin (the dermis) supports and anchors the upper layer (the epidermis). Complex protein fibres called collagen fibres provide strength and elasticity to this layer which carries: blood vessels, nerves, hair follicles, sweat glands, sebaceous glands and the lymphatic drainage vessels. These vessels remove and transport excess fluid and toxins that are found outside the circulatory system e.g. sitting in between the cells. The dermis cannot regenerate if destroyed. It heals by the formation of granulation tissue which is then replaced by scar tissue. Explain how the function of the skin protects against the development of pressure ulcers What about the function of the skin? Well the skin has 5 main functions: it protects, it helps to regulate body temperature, it registers external stimulation, it metabolises vitamin D and melanin, and it helps us to communicate with each other. However from the point of pressure ulcer prevention I would like to focus on 2 of the functions: protection and sensation. Protection The skin protects the body from bacteria and infection, therefore, any break in the skin will put the individual at risk of developing an infection by providing a passage and route of entry for bacteria. The skin protects the body from chemicals; therefore you should be aware that when applying cream to a broken area of skin the components of the cream will be absorbed into the body much sooner than when the skin is intact. The skin protects the body from mechanical damage. That is, the skin will protect the body from damage caused by things like pressure, shear and friction. Mechanical damage 6

7 can be likened to wearing shoes that may be a bit tight. We can wear them for a short period of time with no real damage occurring, however if we wear them to go shopping for the day we develop a blister that becomes very painful and will take a few days to heal. The skin can no longer protect us from that mechanical damage. Sensation It is the sensation properties of the skin which allow us to feel. We can feel the heat and the cold. We can feel pain and discomfort. However people may lose this sensation. Loss of sensation means that you don't feel pain and discomfort. There is no way you will sit in a chair for more than a few minutes without feeling discomfort and it is this discomfort which makes you readjust your position. Can you imagine what it would be like if we had to sit still in a chair all day without moving? Well I can tell you that you would be uncomfortable. People who have lost the sensation don't feel the pain so they don't move away from it. People who are paralysed, diabetics, those with multiple sclerosis or those people who have suffered a stroke cannot feel the discomfort and therefore cannot move away from that discomfort. It is important therefore that you are their sensors and that you are aware of the discomfort they may feel; so for example, make sure that they are not left in the same position for a long time. It is like the tight shoe that has caused a blister; we would not wear those shoes the following day because it would be too painful. If we could not feel that pain and we did wear those shoes can you imagine what state your feet would be in if you wore them for a week. Just a word of warning a pressure ulcer can develop in as little as 2 hours. Activity 3 Ok! Just to re-cap on what we have just done. In your workbook see how many of the questions you can answer. Your answers should have been: 1. Protection 2. It registers external stimulation 3. It helps to regulate body temperature 4. It metabolises vitamin D and melanin 5. It t helps us to communicate with each other 7

8 1 Protection 2 Sensation Describe the Skin changes in the elderly As we get older our skin changes also we slow down and we get prone to knocks and bumps. Therefore with age there is an increased chance of injury, along with poor response to repair. Barrier function reduced There is increased risk of irritation or damage. Reduced vitamin D production with an increased risk of brittle bones. Temperature control There is a decrease in the number of sweat glands, subcutaneous fat and blood supply, which increases the tendency to feel the cold and for the skin to become dry. Elasticity and tensile strength of the skin is reduced The skin does not retain its original shape after stretching and distortion. Sensitivity of the skin can alter increasing incidence of allergic contact-dermatitis. Describe how to care for the skin The skin produces lipids, sebum and sweat from the glands; these provide the skin with a barrier which is relatively impermeable to water. Removal of this barrier can cause dryness and make the skin more vulnerable to friction damage. Excessive washing and in particular the use of soap can remove this barrier. Soap can change the ph of the skin, which is normally acid to alkaline. It is this factor that causes the dryness. Constant washing of the skin should be avoided, however, it is important to keep the skin socially clean. To achieve this, clean the skin with an unfragranced soap or a non-soap cleanser. If you have to wash an area of the body several times a day it will become sore, in the same way that your nose becomes sore when you have a cold. In these cases consider a non-soap cleanser and the use of a barrier cream such as Zinc and castor oil ( sudocrem has a variety of unwanted additives which can cause an allergic reaction especially in the elderly). Once it has been washed the skin should be dried thoroughly using a patting motion. Years ago it was common practice to dry the skin using a rubbing motion. However Dyson (1978) examined the effects of rubbing vulnerable areas of the skin. She reported that there 8

9 was a 38% reduction in the development of pressure ulcers in a control group whose skin was not rubbed compared with a group of patients whose skin was rubbed. Because of these findings rubbing has become outdated. The practice of rubbing a reddened area is also dubious. It is not advisable to use talcum powder as it tends to soak up the natural oils in the skin and dry it out. Talc can also irritate the skin if it cakes in skin creases. If the skin is very dry the use of bubble bath etc in the bath can also increase the dryness. Instead try using an emollient to moisturise the skin. Some of these emollients can be used in the bath in place of some other additives and some will even lather. Diprobase can be used as a soap substitute and as a moisturiser after bathing. Activity 4 We have discussed emollients and barrier creams. In your workbook complete activity 4 and then have a look at what I had to say about emollients and barrier creams. Emollients Emollients soothe and hydrate the skin and are indicated for all dry and scaling disorders. Their effects are short-lived and therefore they should be applied frequently even after improvements occur. (MacFarlane & Hughes1998) Emollients include: White soft paraffin White soft paraffin and liquid paraffin in equal parts Epaderm Diprobase ointment and cream Aqueous cream Barrier creams Barrier creams are not emollients but instead they are used to stop water and irritants e.g. sweat, urine and faeces coming into contact with the skin. They are used around stoma sites, sacrum or buttocks. However it should be noted that they do not prevent the development of pressure ulcers and unless the patient has a problem with continence their use is of little value. Before applying any cream or ointment stop and consider, why am I using this product will it benefit the patient? And is it the most appropriate product to use? Barrier creams include: 9

10 Zinc -and- castor oil. That is the end of the first unit! I hope you have enjoyed completing this unit and that you have learnt something new. If you are ready you can move on to unit 2. If you feel that you are not happy about any aspect of unit 1 don't worry take your time and have another go. 10

11 Unit 2 The Aetiology of Pressure Ulcers 11

12 Before you can look at pressure ulcer prevention strategies, it is essential that you understand the causes of pressure ulcers. In this unit you are going to look at the factors that contribute to the development of pressure ulcers. Objectives: You will be able to identify the potential risk factors involved with the development of pressure ulcers, and the groups in which they occur. Enabled by your ability to: List the 3 main causes of pressure ulcers Identify factors that contribute to the development of pressure ulcers List the importance of nutrition and identify factors that can contribute to a poor nutritional intake Explain how to improve the nutritional intake of patients in your care Activity 5 In your workbook see if you can you list the three main causes of pressure ulcer development? The Answer should have included pressure, shear and friction. We are always happy to use these terms but do we really understand what they mean? Well let's have a look at pressure, shear and friction. Pressure is the force applied vertically to a surface (Bennett and Lee 1985). In other words, it is force from above. If sufficient pressure is exerted on tissue, the capillaries collapse and the blood flow is occluded. The cells are deprived of oxygen and nutrients, and the waste products of the metabolism are not removed, and therefore the cells supplied by the capillaries die. Shear is a distorting force, and this distortion and subsequent stretching of the skin causes damage to the blood vessels. That is the skeleton moves and the skin stays where it is therefore damaging the small blood vessels in the skin. Activity 6 In your workbook give an example of how shear can occur. 12

13 The Answer: a patient sliding down the bed or off a chair. Friction can be described as the force generated when two surfaces move across one another (Krouskop 1978). An example can be seen in incorrect lifting where a patient is pulled or dragged up the bed, or when there is excess rubbing of the skin. Activity 7 In your workbook list as many factors as you can think of that can make a person prone to develop pressure ulcers. If you have known a person with a pressure ulcer what do you think may have caused the ulcer? Did you think of a few answers? If you only got one or two don't worry have a look at my list. Reduced mobility Previous history of pressure damage or immobility conditions which cause immobility such as osteoarthritis, Parkinson's disease or a stroke. Nutrition Food is important because once the resident/patient stops eating even for a day or so their risk of developing pressure ulcers increases. Physical condition The patient's general condition is important. For instance a bout of flu or when they become suddenly unwell puts them at risk. Also other conditions such as those that interfere with blood flow and the ability to provide oxygen to the skin are also important factors e.g. cardiac, circulatory, vascular or respiratory disease. Underweight/overweight Underweight people are at risk because of malnutrition. Overweight people are at risk because their weight can make walking and moving difficult. Mental State and altered levels of consciousness Depression can put people off their food and they can also become immobile preferring to sit in one place rather than walk about. Age The majority of people that develop pressure ulcers are over the age of 70. The higher the age of the patient, the increased risk of disease such as heart disease which will put them at an even greater risk. Reduced circulation If the blood flow to the skin is poor it places them at risk Smoking reduces the available oxygen thus lessening the supply to the skin. Medications Medication such as steroids can cause the skin to become thin and fragile. Pain Patients with pain may make themselves comfortable, and then they will often prefer to stay in the same position, which thereby increases the risk of developing pressure ulcers. Pain can also put them off their food and prevent them from mobilising. 13

14 Diabetes Patients with diabetes may develop a poor blood supply especially to the legs and feet. They also loose sensation and therefore may not move away from discomfort or trauma as they are unable to feel the external pressure. Neurological deficit Patients with Multiple Sclerosis, and those that have suffered a stroke, or patients with Parkinson s disease have mobility problems as well as other complications which increase their risk factors. The surface the patient is nursed on i.e. beds and chairs If a patient is left sitting in the same chair all day, or lying in one position in bed, they become at risk of developing pressure ulcers. External influences on the skin Such as moist skin from urine or faeces and excess use of talcum powder. Listed above are some of the factors that can put a patient at risk. However you need to be aware that any patient who develops an acute illness such as pneumonia or a urinary infection will be at risk, as the illness could put them in bed. In addition increased immobility may prevent them from eating and drinking. They may also have a temperature and they may even become incontinent. Do you have any factors that I had not considered? Nutrition As previously mentioned, one of the factors that can predispose the development of pressure ulcers is poor nutrition. Activity 8 In your workbook list as many factors as you can think of that can contribute to a poor nutritional intake. Answers: Did your list include any of the following? Acute illness often results in a loss of appetite, although in fact nutritional requirements may be increased. Chronic illness and disease combined with the drug therapy may affect appetite or result in malabsorption. Pain may result in loss of appetite. Age increases the risk of disease. Physical disability may cause difficulties in shopping, cooking or feeding. Mental disorder Patients with a mental disorder are less likely to be aware of the need for a good diet. 14

15 Poor fitting dentures or no teeth Such patients may be unable to eat a full range of foodstuffs. Alcoholism is often associated with poor diet and can cause thiamine deficiency. Poverty often results in a poor intake of protein and vitamins. Lack of care Food may be placed out of reach. Ok why do we need to monitor nutritional intake? Well there are several reasons. Here are some of mine: In order to be able to determine the nutritional input of the patient. To identify any need to refer to a specialist e.g. dietician. To be able to address problems that we have just identified such as ill fitting dentures. So how can you monitor nutritional intake? Well there are a few ways these could include the following: Ask the patient how much they eat. Serve and collect the dishes and note what food is being left. We have identified factors that can contribute to poor nutritional intake, and we have discussed how and why, we need to monitor nutritional intake. What we need to do now is discuss how we can improve nutritional intake. Activity 9 a patient. In your workbook list ways in which you could improve the nutritional intake of Compare your list with mine. Are their similarities? Prepare the patient before a meal. Sit the resident/patient up in bed or out in a chair ready for their meal. Offer them the opportunity to use the toilet and to wash their hands before their meal. Make sure that the patient has his/her dentures in (preferably their own!). Make sure that the surface you serve the food on is clean and uncluttered (no urinals, dirty tissues, newspapers or vases of flowers). 15

16 Serving Food Put the food within easy reach of the patient. Make sure that the implements are appropriate. Remove any covering from the food. Ask if they would like their food cut or mashed etc. Other Assist the patient with selecting food. Encourage the patient to drink fluids and take any supplements they may be given. Ask the patient why they have left certain foods. Well done another unit completed! By now your understanding of pressure ulcer development should be much improved. If you are having problems with any aspect of the unit don't worry, have another go, or ask for help, don't struggle on your own when we are here to help you. Once you are ready move on to unit 3. 16

17 Unit 3 Equipment 17

18 In this unit, we will be continuing with pressure ulcer prevention and treatment. We are going to be looking at the role of pressure relieving equipment and alternative methods of relieving pressure. There are several different types of mattresses to meet the needs of individual residents/patients and the cost of theses mattresses can vary from around 60 to around 4,000. It is therefore very important that the mattress provided is the most appropriate for that particular patient. Objectives: At the end of this module you will be able to select the correct method or equipment for the prevention and treatment of pressure ulcers. Enabled by your ability to: List the important features of support surfaces. Describe the difference between low tech pressure relieving and high tech pressure relieving mattresses. and cushions. Identify the different types of pressure reducing/relieving equipment available. Describe the care of the seated resident/patient. Activity 10 In your workbook list some of the factors you consider to be important features when choosing a mattress. Did your answer include any of the following? To be acceptable to and comfortable for the resident/patient To relieve or redistribute pressure To reduce the effects of shear and friction To allow moisture evaporation To be reliable and durable To conform with health & safety standards including fire regulations To facilitate patient management and nursing procedures To be inexpensive and easy to clean, maintain and transport To facilitate cardiac compressions Pressure-relieving equipment falls into two main categories: low tech and high tech Let us consider the properties of the different categories. 18

19 Low Tech The pressure reducing surface increases the area of the body in contact with the surface therefore allowing the patient to sink into the high quality foam by having a 2 way stretch cover, thereby spreading the load and reducing the effect of pressure. This category includes: Fibre filled mattresses/overlays (for example Spenco) Foam mattresses/overlays Visco mattresses/overlays Gel, fluid or air filled mattresses/overlays Fibre filled mattresses/overlays These have been around for a long time and today they are used mainly for comfort. They should not be used for patients that are at high risk of developing pressure ulcers or for patients that have developed pressure ulcers. One of the main problems with fibre filled overlays was the washing and drying process which resulted in the fibres becoming matted and this made them hard and uncomfortable. Foam Mattresses/Overlays In hospital the old standard foam mattress (those with a marble cover) have been replaced, and the mattresses we use today are suitable for patients at risk of developing pressure ulcers. Some of these mattresses will need to be rotated and any instructions are clearly written on the mattress. The overlays are mainly used in a community setting and are placed on top of the patient s own mattress. Visco Mattresses/Overlays The use of visco mattresses/overlays is a fairly new concept. These mattresses/overlays are suitable for patients at high, to very high risk, of developing pressure ulcers. These mattresses do not need to be rotated. They work by moulding to the shape of the patient, therefore very lightweight patients need to be nursed on a mattress that is suitable for lightweight people. High Tech The pressure relieving mattress moves under the patient thus reducing the amount of pressure being applied to any one point at regular intervals. 19

20 There are several different makes of pressure relieving mattresses on the market. They can be in the form of an overlay, which is placed on the top of the existing mattress, or a full replacement mattress, which is placed directly on the bed base. The choice of mattress is made depending on the patient's condition, however they should mainly be used for patients at high risk or with existing pressure ulcers. E.g. - alternating pressure mattresses/overlays - air fluidised beds/mattresses/overlays - low air loss beds/mattresses/overlays - turning beds/frames All mattresses should be thoroughly cleaned between patients again following manufacturer s instructions. Let us recap on the different types of mattress. Activity 11 In your workbook see if you can work out if the following statements are true or false. 1. Fibre filled overlays are mainly used as comfort aids. 2. Foam mattresses are low tech mattresses. 3. Visco mattresses are suitable for individuals at elevated risk of developing pressure ulcers. 4. Visco overlays are placed on top of the existing mattress. 5. Pressure relieving mattresses should be used for patients at elevated risk of developing pressure ulcers. 6. All mattresses should be thoroughly cleaned between patients. Remember the equipment does not take away the need to reposition a patient. The need to reposition will be dependent on the following factors: The state of the patient s skin. Presence of pain on repositioning. Patient's ability to alter position (they may be restricted e.g. if on traction). Patient's day to day activities e.g. meal times, visits to other areas, visiting times. 20

21 Patient's need for rest. Type of equipment utilised. Level of risk. Patient s general health state and care needs. The Seated Individual It is important to remember that if the patient is vulnerable to or at elevated risk of developing pressure ulcers, then sitting them out of bed will not reduce the risk, if anything the risk is increased. If they are in need of a specialist mattress they will also need to be sat out on a cushion or a specialist chair with a pressure-relieving cushion. When positioning individuals who spend substantial periods of time in a chair or wheelchair you should take into account: distribution of their weight, postural alignment and the support of their feet. If the patient is able, they should be advised and encouraged to change their position every 10 to 15 minutes. If they are unable to reposition themselves, they should be repositioned at least every 2 hours. If they are at elevated risk of developing pressure ulcers they should not be sat out for more than 2 hours at a time. Did you ever consider that putting a patient in the wrong sized chair could cause so many problems? Next time you see a seated patient or even a member of your own family, have a good look at their seating position and see if you can identify any problems with their position. That s another unit completed! How did you get on? If you feel ready you can move on to the final unit. If you are unsure of any aspect of this unit, have another go or get some help, don't struggle on your own. 21

22 Unit 4 Prevention And Treatment Of Pressure Ulcers. 22

23 Unit 4 In this unit, we are going to pull all the other units together in order to demonstrate how we can use our knowledge to identify those individuals vulnerable to or at elevated risk of developing pressure ulcers and how we can minimise that risk. Objective: On completion of this unit you will be able to identify and address factors that can lead to the development and /or to the delay in the healing of pressure ulcers. Enabled by your ability to: 1. Identify individuals vulnerable to or at elevated risk of developing pressure ulcers. 2. Recognise the areas most at risk. 3. Describe how risk factors can be eliminated or minimised. Identify individuals at risk of developing pressure ulcers Let us start be recapping on some of the work we have already covered. Activity 12 In your workbook write a list of factors that put individuals at risk of developing pressure ulcers. Answers Your list should include some of the following: Age Respiratory disease Acute, chronic or terminal illness Incontinence Loss of appetite or no appetite Diabetic Overweight/underweight Heart disease Some medication (i.e. steroids) Immobility/reduced mobility Previous pressure damage Loss of sensation Vascular disease Acute illness (i.e. Urinary infection) Loss of consciousness How did you get on? It is important that you remember these risk factors, as they will help to alert you to individuals that are likely to develop pressure ulcers. Remember the more factors they have the more vulnerable they are to developing a pressure ulcer. 23

24 The next step is to identify areas of the body that are at risk. A pressure ulcer can develop on any area of the body but they are more likely to develop over a bony prominence. The patient s skin must be inspected on a regular basis. Activity 13 Now see if you can complete activity 13 in your workbook. 24

25 Ok! Now we know where to look the next step is what to look for? Well you look for a reddened area that does not change colour (normally goes white) when you press on it lightly with your fingertip. This is called non blanching hyperaemia/erythema. The area may be hard to the touch and there may be some warmth and slight swelling. Although the skin is still intact this is a pressure ulcer as damage has already occurred. This needs immediate attention to prevent further damage. If you are working in the community you need to contact one of the community nurses in your area. If you are working in a hospital you need to report your findings to one of the registered nurses. What happens if you can't get help immediately? Well there are a few things you can do: If you can find the cause of the damage you may be able to remove it e.g. trapped catheter tubing, or if not you can reposition the individual. If you have any specialist equipment such as a mattress or cushion these may help. If you have nothing, you may need to reposition the patient at frequent intervals 2hourly, 3hourly or hourly depending on the individual s condition. What is important is that you relieve the pressure. Don't use any aids such as water filled rubber gloves, sheepskin rugs or rubber rings (NICE 2003). Barrier creams or dressings will not aid healing and should only be applied if you have a valid reason for using them. If the individual is not eating try and encourage nutritional fluids such as milk, Complan, custard or soups etc. What do you do if the skin is broken? You should follow the same procedure as above. Registered nurses should advise on the most appropriate dressings. Right you have had a lot of reading to do so let's have an activity for a change. 25

26 Activity 14 In your workbook list when you would have the opportunity to inspect the resident s/patient s skin for signs of damage. Did your answers include any of the following? It is important not to disturb the patient all the time and there are several opportunities for you to inspect the skin. For instance: When you get them up in the morning. Putting them back to bed or settling them down in the evening. Toileting is always a good opportunity. Always check them on admission. If they complain of discomfort. These are only a few examples. Did you consider any others? Finally! Let us recap on all the units by completing Activity 15 in your workbook. But look out there are no answers this time, so you will have to get the activity marked by your tissue viability link nurse. That s it all completed! I hope you enjoyed completing this workbook and that your understanding of pressure ulcers has improved and hopefully your patients will be the ultimate beneficiaries. Remember to have a read through every now and then just to keep yourself updated. Many thanks 26