WOUND CARE TODAY
2014,Vol 1, No 1
17
FOCUS ON PRESSURE ULCERS
›
For example, moist or dry,
undernourished and fragile/aged skin
is more prone to pressure damage,
so early identification of these
factors and appropriate skin care
can reduce the risk of pressure ulcer
development (Wilson, 2012).
The frequency of any subsequent
skin inspection is determined in
response to the initial skin and risk
assessment, and also to changes in
the individual’s condition. However,
patients at risk, or those with existing
pressure damage, should have a skin
assessment undertaken as per care
bundle, or at least once per shift
(NICE, 2005; Wilson, 2012).
Surface
The surface includes pressure-
reducing equipment which may be
required. This may include one or a
combination of the following:
›
Mattresses
›
Cushions
›
Redistributing equipment, such
as aids that will lift the patient’s
heel off the bed.
NICE (2005) recommends that
all patients at risk, or with a category
1 or 2 pressure ulcer should, as a
minimum, be issued with a high
specification foam mattress for their
bed. As sitting out of bed puts the
patient at the same if not higher
risk of pressure ulcer development,
NICE (2005) recommends that these
patients should be issued with a high
specification cushion. NICE (2005)
goes on to state that patients at high
risk, or with pressure damage, should
have periods of sitting in a chair
restricted to no more than two hours.
It is also important to ensure that
incorrect equipment is not used, such
as sheepskin products and water-
filled gloves (NICE, 2005). Where
possible, the use of equipment should
be discussed and agreed with the
patient. If they decline pressure-
reducing equipment, this should
be documented.
Keep moving
Keeping patients mobile is important
to reduce pressure. Where possible,
they should be encouraged to
move themselves to maintain their
independence (NICE, 2005; EPUAP/
NPUAP, 2009). However, if the
patient is immobile or has cognitive
impairment, and does not understand
the importance of keeping mobile,
they will have to be repositioned. If
possible, this should be agreed with
the patient.
Incontinence/moisture
Incontinence has been identified
as a risk factor in the development
of pressure ulcers, so good skin
care is important to prevent
pressure damage. The normal pH
of the skin is between 4.0 and
5.5. To keep the skin intact it is
essential to maintain the acidic
pH of the skin. With incontinence,
ammonia is produced as a result
of the breakdown of urinary urea
and aggravated by faecal urease,
resulting in an increase in the pH
of the skin. The skin becomes more
permeable when the pH rises, which
is exacerbated by excessive moisture
and eventually causes invisible
breaches on the skin’s surface. Once
the barrier function of the skin has
been breached, it is more vulnerable
to bacteria, which leads to the
development of moisture lesions,
increasing the risk of pressure
damage (Beldon, 2008; Costa, 2013).
Thus, it is important to remove
any urine or faeces from the skin’s
surface as soon as possible.
Washing with soap and water
can change the pH of the skin from
acidic to alkaline, which, in turn,
can lead to the skin drying out and
cracking. In the same way, washing
with soap can remove the natural
lipids which help to maintain
barrier function and also reduce the
thickness of the outer layer of the
epidermis (Best Practice Statement,
2012; Voegeli 2007).
›
Moisture, including incontinence
of urine and/or faeces, and
excessive perspiration
›
Medication
›
Sensory perception
›
Friction and shear.
The aim of any risk assessment
tool is to identify risk factors and
implement care interventions that
will correct or reduce the deficits
and help to prevent pressure ulcer
development (Guy, 2012).
PLAN OF CARE AND
CARE BUNDLES
Once identified as being at risk of
developing a pressure ulcer, patients
need to have a plan of care and care
bundle for pressure ulcer prevention
initiated. Care bundles are a popular
method of delivering structured care.
They are a small set of evidence-based
interventions/recommendations
for a defined patient population
within a specific setting. When
implemented together, the outcomes
are significantly better than when
implemented alone (Institute for
Healthcare Improvements, 2011).
The care bundle for the
prevention of pressure ulcers is the
‘SKIN or SSKIN Bundles‘ (Institute
for Healthcare Improvements, 2011).
SKIN OR SSKIN represents:
›
S
kin inspection
›
S
urface
›
K
eep moving
›
I
ncontinence/moisture
›
N
utrition and hydration.
Skin inspection (assessment)
Skin inspection is undertaken and
documented as part of the initial risk
assessment (EPUAP/NPUAP, 2009).
It is an integral part of pressure ulcer
care and should be undertaken to:
›
Identify any existing skin or
pressure damage
›
Assess the patient’s overall
skin condition
›
Devise a plan of care.
Top tip:
Pressure ulcer prevention care is
an essential component of care for
all patients.
Did you know:
The longer pressure
is exerted over a bony
prominence, the higher
it becomes and the more
likely the patient is to
develop pressure ulcers.
