Pressure ulcer Resources

Osteomyelitis is a complex and frequently less recognised complication of pressure ulcers, particularly those associated with deep tissue loss and exposed bone. For community nurses, early recognition is challenging because clinical presentation is often subtle, diagnostic certainty is limited in the early stages, and the evidence base specific to pressure ulcers above the ankle remains underdeveloped. This first article in a two-part series focuses on the clinical foundations required for early identification, integrating epidemiology, pathophysiology, and key risk factors, alongside a structured and holistic approach to history-taking and clinical examination. It emphasises the role of community nurses as first assessors, highlighting the importance of recognising high-risk presentations such as category 4 pressure ulcers, exposed or palpable bone, delayed healing, and recurrent local inflammation. By strengthening clinical suspicion and supporting timely escalation, this article aims to improve early recognition and reduce missed or delayed diagnosis of osteomyelitis in primary and community care.

Pressure ulcers are often preventable and highlight the broader challenges of maintaining high standards of care, especially in vulnerable patient populations, such as those with psychiatric conditions. This article highlights the difficulties pressure ulcers pose for healthcare organisations, healthcare professionals and patients, while also exploring strategies to address these challenges in clinical practice.

As the UK population ages and greater numbers of people are living with long-term conditions (Office for National Statistics [ONS], 2014), increasing numbers of people are subsequently at risk of developing pressure ulcers (PUs). PUs are painful, costly and can negatively affect patient quality of life. They are particularly prevalent in the community setting, leading to high-costs in treatments, especially in those suffering from a chronic condition (Jaul et al, 2018). The prevention of PUs is therefore a key global care quality indicator, which is the focus of considerable quality improvements in primary care. Identifying a patient at risk of developing PUs is an action that should be undertaken at the first community visit. Nursing care to prevent PUs needs to be systematically planned, implemented and evaluated, following assessment of the patient and their
circumstances. As demonstrated by Clarkson et al (2019), integrating an interprofessional approach can reduce the severity of PUs in the community. There are a wide range of resources required to help prevent PUs, including nursing time, ensuring effective patient repositioning and risk assessment, as well as delivering the most appropriate pressure-relieving surfaces (Dealey et al, 2012).

The second part in our series on pressure ulcer prevention and management looks at
risk assessment tools or scales which can be used across all clinical settings in primary
and secondary care. It presents the case of Mrs Smith and how the different tools can assess her risk of pressure ulcer development. The scores and risk levels  vary according to the scale used so an explanation of how her risk level was assessed
is given.

This article, the first in a series on pressure ulcer prevention and management, looks
at undertaking risk assessment as the first step in preventing pressure damage. It
discusses the most popular tools in clinical practice, as well as how reliable they are in
predicting patient risk. Legal aspects of pressure ulcer risk assessment documentation
are also explored, together with future developments in producing a risk assessment
tool which can be used across all clinical settings in primary and secondary care.

As healthcare professionals, our purpose is to deliver treatments and interventions to patients to aid recovery and prevent deterioration in health. But what does that look like when patients do not wish to follow advice, do not want treatment or interventions, even if that means significant consequences such as loss of limbs, sepsis or death — where do we legally stand in these situations and how do we work with patients to achieve the best possible outcomes for them? Over years of clinical experience, the authors have found that working with those who self-neglect can be complex. This is due
to a range of factors, such as risks to the individual and sometimes others. Other issues involved include healthcare professionals’ views and moral conflict between respecting patient autonomy and their duty of care, challenges in trying to engage patients who may not want services involved, attempting to assess and being clear on the patient’s mental capacity, working within task-orientated systems which may not always be conducive to building rapport, and working with the patient’s socio-economic factors which impact upon their health (Research in Practice, 2020). 

Pressure injuries are sometimes considered to be due to a lack of good nursing care. However, it has been debated as to whether the development of some pressure injuries at the end of life is inevitable. More recently, the term ‘skin failure’, which occurs in dying patients, has been introduced in the wound care literature, and it is proposed that the presence of skin failure may make pressure injury inevitable. This article defines the theories around skin failure and presents the different terminologies used to describe skin damage typically found in the dying patient, such as the Kennedy ulcer and Trombley- Brennan terminal tissue injury (TB-TTI). It also discusses the importance of healthcare professionals being able to recognise that skin changes, which appear to be pressure injuries, are due to skin failure at the end of life and be able to differentiate between these and usual pressure injuries when planning and delivering care for these patients.

With pressure ulcers remaining a challenge to the healthcare system across all care settings, this 12-week pilot study aimed to evaluate implementation of the SEM Scanner as an adjunct to standard of care (SoC) in pressure ulcer (PU) prevention. Two district nursing bases enrolled 17 palliative care patients, who received SoC and preventive interventions. Patients with Waterlow scores 10–19 who were able to be scanned for three consecutive days were included. Broken skin was not scanned, and visual skin checks were documented after SEM scans. Patients with SEM delta ≥0.6 were considered at high risk and preventive interventions were escalated using a clinical decision matrix aligning with SoC. The study found that implementing the SEM Scanner in an existing PU prevention pathway resulted in a reduction in community-acquired PU (CAPU) incidence by 26.7% from 16.1% to 11.8%; 88% (n=15) of patients remained PU free. Furthermore, clinical judgement informed by SEM deltas resulted in 82% (n=14/17) of nurses reporting that the SEM delta had changed their clinical decision-making.

With pressure ulcers remaining a challenge to the healthcare system across all care settings, this 12-week pilot study aimed to evaluate implementation of the SEM Scanner as an adjunct to standard of care (SoC) in pressure ulcer (PU) prevention. Two district nursing bases enrolled 17 palliative care patients, who received SoC and preventive interventions. Patients with Waterlow scores 10–19 who were able to be scanned for three consecutive days were included. Broken skin was not scanned, and visual skin checks were documented after SEM scans. Patients with SEM delta ≥0.6 were considered at high risk and preventive interventions were escalated using a clinical decision matrix aligning with SoC. The study found that implementing the SEM Scanner in an existing PU prevention pathway resulted in a reduction in community-acquired PU (CAPU) incidence by 26.7% from 16.1% to 11.8%; 88% (n=15) of patients remained PU free. Furthermore, clinical judgement informed by SEM deltas resulted in 82% (n=14/17) of nurses reporting that the SEM delta had changed their clinical decision-making.

A pressure ulcer is localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful (NHS Improvement, 2018a). The consequences of pressure ulcers are increased length of hospital stays for the patient, estimated at 4.31 days (National Institute for Health and Care Excellence [NICE], 2005), but also an increase in cost to the NHS, which is identified at around £14-21 billion annually (Nutritional Pressure Ulcer Advisory Panel et al, 2014). Poor nutrition has been recognised as one of the risk factors in the development of pressure ulcers. Improving nutritional intake of patients is thus paramount in reducing patient harm and unnecessary cost. This article looks at the role nutrition plays in the prevention and treatment of pressure ulcers, provides practical advice and signposts readers to the resources produced by the Nutrition and Pressure Ulcer Task and Finish Group.