Managemen. Pressure Ulcer Prevention and Treatment. Guidance. Posture. Posture. Posture. Posture. Posture

Transcription

1 men menm Pressure Ulcer Prevention and Treatment Guidance Post ture Manag

2 The reduction of the numbers of s is a high priority for Southern Health NHS Foundation Trust Purpose of this guidance is to help: Healthcare workers to prevent, diagnose and treat damage from s Equipment prescribers select the right product for their patient or service user Definition Pressure ulcers are defined as: 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. (An action or stress resulting from applied forces which cause or tend to cause two internal parts of the body to deform in the transverse plane) Risk assessment Mattress products Equipment should be prescribed with the aim of preventing and treating s, and should be selected based upon the individual s needs, for example: Level of immobility and inactivity Need for microclimate (the environment at or near the skin surface) to maximise control and reduce shear Size, weight and flesh distribution of the individual Risk of developing new s The number, severity and location of existing s Choose a mattress which is compatible with the care setting. This could include the safe location of a pump unit and the availability of uninterrupted power supply and backup batteries (especially in rural areas). The appropriateness and function of the support surface should be reviewed and documented at each visit to confirm it is working correctly and the user is not bottomed out due to technical failure. People who are cared for on support surfaces will still require regular repositioning - the frequency of which needs to be based on their condition, level of risk, postural considerations and level of pain. Choose positioning devices and incontinence products that are compatible with the support surface. Limit the amount of linen and incontinence pads that are used on the bed. Excessive layers between the patient and the mattress are likely to adversely increase interface pressures. For assessment of risk, Southern Health use the Braden score. All staff undertaking risk assessments are required to complete a training session either with tissue viability staff or LEaD. Staff undertaking risk assessments should be: Qualified nurses Allied Health Professionals (AHPs) Associate practitioners Healthcare support workers Health professionals with an appropriate level of knowledge and training Initial risk assessment, should be undertaken on the first community visit, or within 6 hours of admission to a hospital setting. All patients under the care of Skin assessment A skin assessment should be carried out as part of the risk assessment. The baseline skin assessment should be documented on a body map, and all new skin concerns should be clearly differentiated from those already recorded by dating the changes on the body map. Consider any individuals with a category/stage I to be at risk of progressing to category/ stage II or greater s. Consider individuals with all categories of existing s to be at risk of the development of further s. A comprehensive skin assessment should be carried out: At the first visit in the community setting Within the first 6 hours of admission Southern Health require a risk assessment for pressure ulcers weekly or more frequently if the person s condition is not stable. A comprehensive skin assessment should be included as part of the risk assessment to evaluate any alterations to intact skin. This must be recorded in the persons healthcare records. If the individual assessed is at risk, a pressure ulcer prevention plan should be formulated and implemented. If the person is non-concordant with the plan despite education as to the potential consequences, this also needs to be documented. Individuals who are bed or chair fast are at risk of s. Consider the impact of limitations to the individual s mobility for the risk. As part of every risk assessment When the opportunity arises to view and report on the condition of the skin Prior to discharge On return from an acute hospital setting - treat this as a first assessment/visit. If the patient is discharged with known ation, an assessment needs to be completed within 24 hours of the referral being received. Increase the frequency of skin assessments in response to deterioration in the overall condition. Assess any localised pain as a part of every skin assessment. Types of support surfaces Static foam: High specification foam mattresses, many of which have a castellated design to immerse the user within, to provide a high contact area and thus redistribution of pressure. These mattresses have a water resistant and vapour permeable cover to manage microclimate. Pros: Comfortable for most people; very reliable. Cons: The integrity of the cover must be maintained as the foam core cannot be adequately decontaminated if contaminated by body fluids. Foam and Air systems: The person is immersed within a foam mattress; any movement they make is optimised by the movement of air within the mattress. Some foam and air systems can be used to provide static low pressure or be connected to a pump to provide alternating pressure redistribution. Pros: Comfortable for most people; reliable; good choice where the power supply is unreliable. Cons: The foam within the cells makes complete removal of pressure from areas unlikely; new to market so there has been no large scale evaluation of these products. Air Floatation Systems: Overlay mattresses which provide immersion to increase the skin contact area in order to reduce interface pressure. The systems are adjusted by removing air from the system in order to allow the patient to be immersed within the overlay, maintaining normal body shape. Pros: Reliable; adjustable to individual needs and comfort; non-powered. Cons: Requires initial adjustment by professional; education required for user/family/carers on how the system is checked for bottoming out and re-adjusted; training required in set up. Alternating Pressure Mattresses (replacements and overlays): Air cells that support the body cyclically inflate and deflate on a set programme to ensure that no part of the body that is supporting weight (and therefore subject to pressure) is ever unrelieved. Pros: Regular changes in the interface pressure between support surface and user. Cons: Reliant on mains power supply; risk of user bottoming out especially where the user requires to sit up; users can find it difficult to move themselves around on this type of system; noisy.

3 Mattress selection Heel Pressure Ulcers Consider using a high specification foam mattress or other non-powered surface for individuals with category/stage I and II s. Select a support surface that provides enhanced pressure redistribution, reduction of shear forces and microclimate control for individuals with category/ stage III and IV and s of indeterminate classification/grade. In the case of an indeterminate classification/grade of it is possible that offloading and pressure redistribution may allow reperfusion of injured tissue, however, once the has fully evolved the support surface needs to be reviewed. Consider replacing the mattress with a support surface that provides more effective pressure redistribution, shear reduction, and microclimate control for the individual if they: Are unable to be positioned off the existing Have s on two or more turning surfaces (e.g. the sacrum and trochanter) that limit turning options Have an ulcer that fails to heal or deteriorates despite appropriate and comprehensive care Are at high risk of developing additional pressure ulcer The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. The heels should be inspected regularly at each visit and this information recorded. For individuals who have reduced ability to reposition themselves aim to reduce the risk of s developing by using pillows to elevate and offload the heels completely. Assess if the knee break of a profiling bed (if in use) assists in the leg and heel positioning. Position the pillow/s in such a way as distribute the weight of the leg along the calf without placing excessive pressure on the Achilles tendon. Slight flexion of the knee (5 or 10) will avoid popliteal vein compression and reduce risk of DVT. When seated ensure the height and angle of chair and the position of the feet resting on floor are not adversely loading heels. When treating individuals with existing category I or II s on their heels complete offloading is recommended using pillows. Where the pressure ulcers are category/stage III or IV the use of specific devices is recommended as pillows may not be enough. Seating support surfaces Nutrition The patient s pelvis should be in neutral position, where possible, with their feet supported. The use of any pressure reducing cushion should not affect this, but if it does, the resultant seating posture could be detrimental. The choice of cushion should be made in the context of the chair on which it is used and take account of: The dimensions of the cushion and surface it will be used on The dynamic seating ability of the person seated Their ability to return to the midline The amount of time they are able to safely sit (without slumping, sliding forward or leaning sideways) The amount of time the individual wants to sit, and the purpose of sitting (e.g. for activity or mobility in a powered wheelchair) Correct seating can reduce the risk of s from sitting, but the provision of pressure relief devices may not, if done in isolation. Use a pressure redistributing seat cushion for individuals sitting in a chair whose mobility is reduced as long as it does not adversely affect posture and resultant pressure. Encourage mobility, for example, standing for 5 minutes every hour. Pressure cushions should not be used in a riser/recliner chair unless risk assessed. It may be necessary for the riser to be disenabled. Consult with MDT when appropriate The selection of a seating support surface should be in consultation with the user, and the clinician must have an understanding of the basic requirements of good seating. The selection of seating needs to give consideration to: Body size and configuration, flesh distribution Effects of posture and deformity on pressure redistribution Mobility and lifestyle requirements Ensure the cushion has a stretchable / breathable cover that fits loosely on the cushion that allows conforming to body contours. A tight non-stretch cover will adversely affect the cushion s performance. Provide the user with training on correct use, set up and maintenance of the equipment, including the replacement process for worn or damaged equipment. For users who are at risk, or have existing pressure ulcers, ensure the involvement of the MDT or specialist seating professional. Cushions should be selected to redistribute pressure away from the. Minimise sitting time and consult a seating specialist if s deteriorate on a seating surface. Use alternating seat cushions judiciously for individuals with existing s. Evidence demonstrates the link between poor nutrition and an individual s susceptibility to development, particularly in people with a low body mass index or recent weight loss. The MUST assessment of nutritional status is also required if this risk factor identified by the PU risk assessment tool. Preventative skin care When positioning a patient known to have existing areas of category 1 damage; try not to position them on these areas if possible. Where there are multiple pressure areas this may not be possible. Basic principles for preventative skin care are: Keep the individual s skin clean and dry Use a skin moisturiser to hydrate dry skin as this is weaker and more prone to damage Do not massage or rub areas of skin which are at risk Develop an individualised continence care plan Cleanse skin promptly following episodes of incontinence, in order to remove excess moisture and chemical irritants in urine and faeces Prophylactic dressings Protect the skin from excessive moisture as this increases the risk of development of pressure ulceration. Excess moisture increases the friction coefficient between skin and the support surface that enhances the risk of shear damage Use silk-like fabrics to reduce friction and shear Ensure correct provision and use of moving and handling equipment, e.g. slide sheets, transfer devices and slings Re-position regularly and review if the frequency is sufficient and acceptable to the individual There is controversy about the use of prophylactic dressings as the products are not pressure relief and also prevent regular inspection of the at risk area. There is limited evidence to suggest that the application of polyurethane foam dressings to bony prominences will reduce friction and shear and should be considered in some cases. The EPUAP guidelines (2014) state that if these dressings are used, the areas they cover will still require daily inspection, and that foam dressings with silicone adhesive should be used to facilitate this.

4 management Photography management needs are critical in considering the patients needs for prevention and treatment. Consider the other forces, which may be contributing to risk apart from pressure such as shear and friction. For people with complex posture management requirements then joint assessment by the MDT is recommended to ensure that holistic needs are met, to include function and prevention. The MDT may involve the specialist postural advisor for complex case advice. Summary of Southern Health expectations for prevention of s Southern Health require s to be photographed as part of the recording of the wound; in addition to measurements or tracing. Consent for photography should be sought from the client or family if possible, but need not be in writing. The digital images should only be recorded on Trust digital cameras and not mobile phones. Specific guidance about the recording and use of pressure images: Digital photographs should only be taken for the purpose of clinical evaluation and record keeping Reporting Images taken should include a patient identifier, the date and an index measure to give scale to the wound The image should be downloaded as soon as possible to RiO to prevent a breach of information governance (should a camera be lost) The image quality should be adequate for a clinical record (e.g. in focus) the use of the macro setting (close up) will help with this. Patient or service user identified as being at risk of s Required actions: Assessment of risk using Braden Scale Formulation of a care plan for risk Patient (or carer) education and explanation of risks identified using Southern Health leaflet, results of this must be clearly documented in the healthcare record Assessment of mental capacity (documented) Screening of nutritional status using MUST Holistic assessment to include recording of past medical history and existing conditions (Co-morbidities) Baseline observations A baseline comprehensive skin inspection Identify appropriate and acceptable equipment and order this, document the equipment received and verify that it is set up and is being used and is working correctly Review of the patient and equipment (if prescribed) and reassessment when required Consideration of patient positioning to include posture and associated risks Additional actions in the event of being present Devise a care plan for wound Progress charted for wound (at each dressing change) minimum of weekly Classification of wound using EPUAP tool after peer review within 24 hours (this will assist with the selection of equipment interventions) Report the on Ulysses Safeguard system if Grade 2 or above Follow Trust guidance on reporting of Grades III and IV s to CQC and Adult services in the case of a nursing home or private provider Consider and document any safeguarding concerns if the patient is considered vulnerable Regular and transparent schedule for re-assessment Documentation of all actions Discharge duty of candour responsibilities Any discovered on a person must be reported after the grade of the damage has been assessed (or estimated in the case of suspected deep tissue injury with unbroken skin) at category/grade II or above. This must be undertaken by two members of Southern Health staff with appropriate knowledge of the EPUAP classification tool. The Trust s expectation is that this review will occur within 24 hours. The assessment also gives the opportunity to review previous assessments and prevention strategies, and to initiate them if they are not in place. Use and review of devices As with all medical devices, you should record the product being used by the patient, and ensure that you are familiar with its application, set up and use. The product should be supplied with user instructions, and is incomplete without them. In the event of a fault being detected, ensure the user or carer knows where to report this. It is good practice to document the correct use and function of any pressure relieving device in use. The use of pressure redistribution devices should be reviewed periodically as the patient s condition changes. Patient assessment for provision of equipment The selection of equipment as well as the assessment of risk should be undertaken by a person who is suitably trained to recognise changes in skin condition and recognise any damage including possible causative factors. Ask the question, is the wound associated with a bony prominence or contact with equipment?

5 Serious incident investigation Pressure ulcers of Category/Grade III and IV require investigation with the analysis of the patient s context and journey. A full root cause analysis presented at a SIRI Panel may be required. If the is thought to be unavoidable this may only require the presentation of information to describe the context and what happened at a pre-panel. The investigation needs to be completed by the team to whom the patient is open as a referral. Formal action plans will be formulated to ensure that the learning from the incident has been both captured and the likelihood of the situation developing again reduced, this may include training or performance management. The following criteria are applied to differentiate between a incident which is avoidable (could have been avoided) or Unavoidable (there was nothing that could have been done which would have made a difference to the outcome). Avoidable The person receiving care developed a pressure ulcer and the provider of care did not do one of the following: evaluate the person s clinical condition evaluate the person s risk factors plan and implement interventions that are consistent with the persons needs and goals and recognised standards of practice monitor and evaluate the impact of the interventions or revise the interventions as appropriate Unavoidable The person receiving care developed a pressure ulcer even though the provider of the care had: evaluated the person s clinical condition and risk factors planned and implemented interventions; consistent with the persons needs and goals monitored and evaluated the impact of the interventions revised the approaches documented the persons refusal to adhere to prevention strategies documented the persons mental capacity status if there is non-concordance Southern southernhealth.nhs.uk Become a member of our Trust. membership@southernhealth.nhs.uk or call Southern Health NHS Foundation Trust SH00xxx_1 Communications and Engagement Team Acknowledgements to Southern Health Tissue Viability Team and Gill Grist, Postural Facilitator & Tissue Viability AHP