MANAGEMENT OF PRESSURE ULCERS/INJURIES

The underlying pathology of a pressure ulcer/injury must be treated, pressure must be relieved or removed by appropriate measures to prevent further injury, ensure the patient is receiving adequate nutrition and that wound care is optimised. The key concepts of pressure ulcer/injury management is discussed below.

Ensuring that pressure ulcers/injuries are prevented through the use of a risk assessment, early detection through regular skin inspection and appropriate prophylaxis is essential.

The following preventative care interventions are recommended in the case of pressure ulcers/injuries:-

• Skin inspection
• Repositioning
• Use of relieving /reducing equipment
• Skin care, clean, dry and hydrated
• Management of incontinence and excess moisture
• Maintaining adequate dietary and fluid intake
  (Wilson, 2012)

Successful pressure ulcer management requires a comprehensive approach that includes prevention, relieving pressure, restoring circulation, managing the wound and minimising related disorders.

Dressing Selection

NICE (2014) guidelines recommend that the use of dressings used to treat category 2, 3 and 4 pressure ulcers/injuries should promote a moist wound healing environment taking into account pain and tolerance levels, position of the ulcer, the amount of exudate and the frequency of dressing changes.

Suitable wound dressing for pressure ulcers/injuries are moist wound healing dressings with good absorption and exudate management properties.

Please see Module Five Dressing Selection.

The treatment needs of a pressure ulcer/injury change over time. Treatment strategies should be continuously re-evaluated based on the current status of the ulcer.

Nutrition

Good nutrition is essential for pressure ulcer/injury prevention and management. Patients should be screened and nutritional status assessed. It is important to encourage liquid intake, as hydration is as important as nutrition.

Patients with pressure ulcers/injuries may require a greater proportion of protein in their diet to help ensure a positive nitrogen balance and replace protein lost through their ulcers. They may also need vitamin and trace element supplementation (Hess, 2002). (Also see patient assessment section, module 3).

Reassessment of Risk and Grading

Risk monitoring and grading of pressure ulcers/injuries should be reassessed at regular intervals to make sure that patient management plans (equipment selection) are appropriate.

Patient Education

The goal of patient education is to improve the possibility of pressure ulcer/injury prevention. Patients should be involved in the assessment, prevention and treatment of their condition/wound. Knowledge and understanding can play a major part in patients’ compliance with their treatment regimes. Patients who are willing and able, should be taught how to relieve their own pressure areas to aid pressure ulcer/injury prevention and management (Vuolo, 2009).

The information to the patient/carer should include:

• The cause of a pressure ulcer/injury
• The early signs of a pressure ulcer/injury
• Ways to prevent a pressure ulcer/injury
• Implications of having a pressure ulcer/injury (for general health, treatment, options and future development risks)
• Techniques and equipment

If patients refuse to allow a change in position it may be necessary to consider their mental capacity which must be officially assessed and documented. Also, patients must be made aware that their choice may have a direct impact on pressure ulcer development. This must be clearly documented in the individual’s medical and nursing notes.

Moisture

Prolonged exposure to moisture can water log the skin, leaving it macerated. This softens the connective tissue and may lead to an increased risk of pressure ulcer development (Wilson, 2012). Factors of excessive perspiration, oedema and incontinence may place the patient at risk of skin damage from excess moisture.

Incontinence

In urinary incontinence the urea contained in urine decomposes the skin resulting in the formation of ammonium hydroxide which will raise the pH level of skin encouraging bacterial proliferation (Errsser et al, 2005). In faecal incontinence enzymes such as proteases and lipases degrade the barrier function of the skin which allows microorganisms to proliferate and facilitates bacterial and fungal growth (Wilson, 2012).

End of Life

Skin changes at the end of life may be an inevitable event that will not be avoided despite all preventative measure being implemented (Galvin, 2002). The skin is an organ, like the heart, and is subject to failure. This is most likely to occur at the end of life and may result in unavoidable skin damage (Bedfordshire & Hertfordshire TVN Forum, 2010).

The information given in this section is a guide and practitioners must ensure they refer to both local and national guidelines when treating patients who have pressure ulcers/injuries or those at risk of pressure ulcer/injury development.

Documentation

aSSKINg Bundles, Care Pathways, Wound Care Assessment/Wound care Plans and are all part of the patient’s medical records. It is important to assess the patient regularly and to record any observations within these records. All pressure ulcers should be documented and all pressure ulcers Category 2 and above should be reported according to local reporting procedures; also, pressure ulcers/injuries should not be re-graded as they heal.
All practitioners must ensure that they are aware of local and national guidelines when treating patients with pressure ulcers/injuries or of those at risk of developing pressure ulcers/injuries.

The importance of accurate, timely and legible record keeping is highlighted by the Nursing and Midwifery Council (NMC) Guidelines for Record Keeping and the fundamentals are as follows:

• Help to improve accountability
• Show how decisions related to patient care were made
• Support the delivery of services
• Supporting effective clinical judgements and decisions
• Supporting patients care and communications
• Making continuity of care easier
• Providing documentary evidence of services delivered
• Promoting better communication and sharing of information between members of multidisciplinary healthcare team
• Helping to identify risks, and enabling early detection of complications
• Helping to address complaints or legal processes (NMC, 2014).

Also, documentation must be completed for all pressure ulcers/injuries, to comply with the NICE guidelines for pressure ulcer management (NICE, 2014). These guidelines state that all pressure ulcers categorised/staged at 2 and above must be reported as a clinical incident which would result in a clinical incident form being completed.

The DoH (2009) have stated that there would be safer care for patients, who then could be confident that they would be protected from avoidable harm. Following on from this, the DoH identified pressure ulcers/injuries as an area to tackle. In 2010, the National Patient Safety Agency (NPSA) urged the NHS to take a zero tolerance approach to the development of pressure ulcers/injuries. All NHS organisations now have a statutory duty to report serious patient safety incidents to the NPSA. This has since been made mandatory in April 2010. The development of a category 3 or 4 pressure ulcer is to be classified as a patient safety issue and will be recorded as a clinical incident (NPSA, 2010).

This section has shown the importance of assessment and classification in the prevention and management of pressure ulcers/injuries.