Search term. ALGORITHM D - Management of pressure ulcers in adults PDF, K. ALGORITHM E - Management of pressure ulcers in neonates, infants, children and young people PDF, K.

Key priorities for implementation From the full set of recommendations, the GDG selected 10 key priorities for implementation. Carry out and document an assessment of pressure ulcer risk for adults. receiving NHS care in other settings such as primary and community care settings, and emergency departments, if they have a risk factor, for example:.

Offer adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional see recommendation 1. The assessment should take into account any pain or discomfort reported by the patient and the skin should be checked for:.

variations in heat, firmness and moisture for example, because of incontinence, oedema, dry or inflamed skin. Develop and document an individualised care plan for neonates, infants, children, young people and adults who have been assessed as being at high risk of developing a pressure ulcer, taking into account:.

Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every 6 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.

assessed as being at high risk of developing a pressure ulcer in primary and community care settings. Carry out and document an assessment of pressure ulcer risk for neonates, infants, children and young people:.

receiving NHS care in other settings such as primary and community care and emergency departments if they have a risk factor, for example:.

Provide further training to healthcare professionals who have contact with anyone who is assessed as being at high risk of developing a pressure ulcer.

Training should include:. Discuss with adults with heel pressure ulcers and if appropriate, their carers, a strategy to offload heel pressure as part of their individualised care plan.

Full list of recommendations Document the surface area of all pressure ulcers in adults. If possible, use a validated measurement technique for example, transparency tracing or a photograph.

Document an estimate of the depth of all pressure ulcers and the presence of undermining, but do not routinely measure the volume of a pressure ulcer. Document the surface area of all pressure ulcers in neonates, infants, children and young people, preferably using a validated measurement technique for example, transparency tracing or a photograph.

Document an estimate of the depth of a pressure ulcer and the presence of undermining, but do not routinely measure the volume of a pressure ulcer in neonates, infants, children and young people.

Categorise each pressure ulcer in adults using a validated classification tool such as the International NPUAP-EPUAP Pressure Ulcer Classification System. Use this to guide ongoing preventative strategies and management.

Repeat and document each time the ulcer is assessed. Categorise each pressure ulcer in neonates, infants, children and young people at onset using a validated classification tool such as the International NPUAP-EPUAP Pressure Ulcer Classification System to guide ongoing preventative and management options.

Offer adults with a pressure ulcer a nutritional assessment by a dietitian or other healthcare professional with the necessary skills and competencies.

Offer nutritional supplements to adults with a pressure ulcer who have a nutritional deficiency. Do not offer nutritional supplements to treat a pressure ulcer in adults whose nutritional intake is adequate.

Provide information and advice to adults with a pressure ulcer and where appropriate, their family or carers, on how to follow a balanced diet to maintain an adequate nutritional status, taking into account energy, protein and micronutrient requirements.

Do not offer subcutaneous or intravenous fluids to treat pressure ulcers in adults whose hydration status is adequate.

Offer an age-related nutritional assessment to neonates, infants, children and young people with a pressure ulcer. This should be performed by a paediatric dietitian or other healthcare professional with the necessary skills and competencies.

Discuss with a paediatric dietitian or other healthcare professional with the necessary skills and competencies whether to offer nutritional supplements specifically to treat pressure ulcers in neonates, infants, children and young people whose nutritinal intake is adequate.

Offer advice on a diet that provides adequate nutrition for growth and healing in neonates, infants, children and young people with pressure ulcers.

Discuss with a paediatric dietitian whether to offer nutritional supplements to correct nutritional deficiency in neonates, infants, children and young people with pressure ulcers. Preventing pressure injuries has always been a challenge, both for caregivers and for the health care industry, because the epidemiology of pressure injuries varies by clinical setting and is a potentially preventable condition.

The presence of pressure injuries is a marker of poor overall prognosis and may contribute to premature mortality in some patients. Pressure injuries are commonly seen in high-risk populations, such as the elderly and those who are very ill.

Critical care patients are at high risk for development of pressure injuries because of the increased use of devices, hemodynamic instability, and the use of vasoactive drugs.

In , the U. Centers for Medicare and Medicaid Services CMS announced it will not pay for additional costs incurred for hospital-acquired pressure injuries. The staging system also was updated and includes the following definitions:.

The injury can present as intact skin or an open ulcer and may be painful. The tolerance of soft tissue for pressure and shear also may be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue.

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin — Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin.

Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis — Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent as an intact or ruptured serum-filled blister.

Adipose fat is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.

This stage cannot be used to describe moisture-associated skin damage MASD , including incontinence-associated dermatitis IAD , intertriginous dermatitis ITD , medical adhesive-related skin injury MARSI , or traumatic wounds skin tears, burns, abrasions. Stage 3 Pressure Injury: Full-thickness skin loss — Full-thickness loss of skin, in which adipose fat is visible in the ulcer and granulation tissue and epibole rolled wound edges are often present.

The depth of tissue damage varies by anatomical locations; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. If slough or eschar obscure the extent of tissue loss, this is an unstageable pressure injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss — Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.

Depth varies by anatomical location. If slough or eschar obscure the extent of tissue loss, this is unstageable pressure injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss — Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar i.

Deep Tissue Pressure Injury : Persistent non-blanchable deep red, maroon, or purple discoloration — Intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.

Pain and temperature changes often preceded skin color changes. Discoloration may appear differently in darkly pigmented skin. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. Notice of Funding Opportunities.

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Careers Contact Us Español FAQs. Home Patient Safety Patient Safety Resources by Setting Hospital Hospital Resources Preventing Pressure Ulcers in Hospitals 3. Preventing Pressure Ulcers in Hospitals 3. Previous Page. Next Page. Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1.

Are we ready for this change? How will we manage change? What are the best practices in pressure ulcer prevention that we want to use? How do we implement best practices in our organization? How do we measure our pressure ulcer rates and practices?

How do we sustain the redesigned prevention practices? Tools and Resources. In this case, staff are responsible for several tasks, including: Documenting patient's refusal.

Trying to discover the basis for the patient's refusal. Presenting a rationale for why the intervention is important. Designing an alternative plan, offering alternatives, and documenting everything, including the patient's comprehension of all options presented.

This revised strategy needs to be described in the care plan and documented in the patient's medical record. Update the care plan to reflect any changes in the patient's risk status. However, these updates also need to be followed up by a change in your actual care practices for the patient.

Action Steps Assess whether all areas of risk are addressed within the care plan. Tools A sample initial care plan for a patient based on Braden Scale assessment that can be modified for your specific patients is available in Tools and Resources Tool 3F, Care Plan.

Practice Insights Most patients do not fit into a "routine" care plan. Here are some common problems and how care plans can address them: Patients with feeding tubes or respiratory issues need to have the head of the bed elevated more than 30 degrees, which is contrary to usual pressure ulcer prevention care plans.

Care plans and documentation in the medical record will need to address this difference. Preventing heel pressure ulcers is a common problem that must be addressed in the care plans. Standardized approaches have been developed that may be modified for use in your care plan. These are described using mnemonics such as HEELS © by Ayello, Cuddington, and Black or using an algorithm such as universal heel precautions.

Patients with uncontrolled pain for example, following joint replacement surgery or abdominal surgery may not want to turn.

Care plans must address the pain and how you will encourage them to reposition. Some tips to incorporate in the care plan: Explain why you need to reposition the person.

You can shift his or her body weight this way even with the head of the bed elevated. Sit the person in a chair. This maintains the more elevated position and allows for small shifts in weight every 15 minutes.

Try having patients turn toward their stomach at a 30 degree angle. They can be propped up or leaning on pillows. Ask the patient what his or her favorite position is.

All of us have certain positions we prefer for sleep. After surgery or injury, the favorite may not be possible. For example, after knee replacement surgery the person cannot bend that leg to curl up. Try to find an alternative that the patient will like. Frequent small repositioning shifts can help prevent pressure ulcers.

Care plans should acknowledge the need for patients to shift their weight a little each time you enter the room at least 15 to 20 degrees if possible. If they are on their side, pull the pillow out just a little. Bend or straighten the legs just a little, using care not to hyperextend the knee.

Dehydration is a common problem predisposing patients to pressure ulcers. Care plans may suggest offering a sip of a beverage each time you enter the room. Additional Information Read more about universal heel pressure relief: Cuddigan JE, Ayello EA, Black J.

Some that should be considered include: Time: Acuity of the patient population may mean the staff's time must be spent at the bedside and the development and documentation of care planning is delayed, thus increasing the chances of missed information.

Expertise: Staff may not have the needed expertise to know what interventions to include or what they can do without a health care provider's order.

Value of care plan: There may be a prevailing attitude that taking the time to write the care plan is not a priority. This is a unit or facility culture issue that needs to be addressed systemwide.

Responsibility: The plan of care should be interdisciplinary. It is not just the nursing staff that develops and implements treatment plans.

The care plan is also an active document. It needs to incorporate the patient's response to the interventions as well as any changes in his or her condition.

The care plan should indicate specific actions that should, or should not, be performed. All care planning needs to be individualized to fit the patient's needs. Any area of risk should have a corresponding plan of care regardless of the overall risk assessment scale score.

In fact, when developing the plan of care, it is important to think beyond just a risk assessment scale score to include all the patient risk factors.

To illustrate this point, consider a patient whose overall Braden Scale is 19, indicating not at-risk for pressure ulcer development. However, in examining the subscales, the nurse notes that the patient is very moist moisture subscale of 2 and there is a potential problem with friction and shear subscale score of 2.

These two subscales need to be addressed in the care plan despite the overall score. The subscales are important indicators of risk. In another scenario, a patient has an overall Braden Scale score of 19, but this patient has a history of a healed sacral pressure ulcer.

Despite the score, this patient is at particular risk for developing a pressure ulcer on the sacrum and needs a care plan that reflects this risk factor. Patients and their families should understand their pressure ulcer risk and how their proposed care plan is addressing this risk.

Specific aspects of the care plan that patients and families can help implement should be identified. If learning needs have been identified, teaching about knowledge gaps can occur.

Use of educational resources, such as appropriate-level written materials, can augment but not take the place of instruction. Patients and their significant others need to understand the consequences of not following a recommended prevention care plan as well as suggested alternatives offered and possible outcomes.

Every patient has the right to refuse the care designed in the care plan. In this case, staff are responsible for several tasks, including:. Most patients do not fit into a "routine" care plan. Here are some common problems and how care plans can address them:. Read more about universal heel pressure relief: Cuddigan JE, Ayello EA, Black J.

Saving heels in critically ill patients. World Council Enterostomal Ther J ;28 2 Documentation of care planning is essential to ensure continuity of care and staff knowledge of what they should be doing.

Most hospitals choose to have a dedicated care plan form within the medical record. Responsibility for generating the care plan and incorporating the input from multiple disciplines needs to be delineated.

The plan of care is also a communication tool. Information is then available for other staff and disciplines to see what needs to be done. The care plan also needs to be shared through discussion in all shift reports, during patient assignments, during patient handoffs, and during interdisciplinary rounds.

Sometimes, putting together all the discrete parts of the patient risk factors can be akin to putting together a puzzle. It takes time and the ability to see the whole picture, and it definitely requires patience and skill.

There are many potential barriers to accurately completing care planning. Some that should be considered include:. Planning care is essential to quality. The plan of action needs to be based on the assessment data gathered but has to be adaptable to changing needs.

The complexity and importance of integrating all the information to render appropriate care to the patient cannot be overemphasized. Read more about delays in implementing the care plan: Rich SE, Shardell M, Margolis D, et al. Pressure ulcer prevention device use among elderly patients early in the hospital stay.

Nurs Res ;58 2 Return to Contents. The sections above have outlined best practices in pressure ulcer prevention that we recommend for use in your bundle. However, your bundle may need to be individualized to your unique setting and situation. Think about which items you may want to include.

You may want to include additional items in the bundle. Some of these items can be identified through the use of additional guidelines go to the guidelines listed in section 3. Patient acuity and specific individual circumstances will require customization of the skin and pressure ulcer risk assessment protocol.

It is imperative to identify what is unique to the unit that is beyond standard care needs. These special units are often the ones that have patients whose needs fluctuate rapidly.

These include the operating room, recovery room, intensive care unit, emergency room, or other units in your hospital that have critically ill patients. In addition, infant and pediatric patients have special assessment tools, as discussed in section 3.

Skin must be observed on admission, before and after surgery, and on admission to the recovery room. In critical care units, severity of medical conditions, sedation, and poor tissue perfusion make patients high risk. Research has shown that patients with hypotension also are at high risk for pressure ulcer development.

In addition, patients with lower extremity edema or patients who have had a pressure ulcer in the past are high risk. Therefore, regardless of their Braden score, these patients need a higher level of preventive care: support surface use, dietary consults, and more frequent skin assessments.

Documentation should reflect the increased risk protocols. Read more about how critically ill patients have factors that put them at risk for developing pressure ulcers despite implementation of pressure ulcer prevention bundles: Shanks HT, Kleinhelter P, Baker J.

Skin failure: a retrospective review of patients with hospital-acquired pressure ulcers. World Council Enterostomal Ther J ;29 1 A number of guidelines have been published describing best practices for pressure ulcer prevention.

These guidelines can be important resources to use in improving pressure ulcer care. In addition, the International Pressure Ulcer Guideline released by the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel is available. A Quick Reference Guide can be downloaded from their Web site at no charge.

It aims to reduce the number of pressure ulcers in people admitted to secondary or tertiary care or receiving NHS care in other settings, such as primary and community care and emergency departments.

We checked this guideline in November We found no new evidence that affects the recommendations in this guideline. How we develop NICE guidelines.

This guideline updates and replaces NICE guideline CG29 September and NICE guideline CG7 October The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available.

When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service.

It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

The admission assessment is particularly important on arrival to the emergency room, operating room, and recovery room. It may be appropriate to have more frequent assessments on units where pressure ulcers may develop rapidly, such as in a critical care unit; or less frequently on units in which patients are more mobile, such as psychiatry.

Staff on each unit should know the frequency with which comprehensive skin assessments should be performed. Optimally, the daily comprehensive skin assessment will be performed in a standardized manner by a single individual at a dedicated time. Alternatively, it may be possible to integrate comprehensive skin assessment into routine care.

Nursing assistants can be taught to check the skin any time they are cleaning, bathing, or turning the patient. Different people may be assigned different areas of the skin to inspect during routine care.

Someone then needs to be responsible for collecting information from these different people about the skin assessment. The risk with this alternative approach is that a systematic exam may not be performed; everybody assumes someone else is doing the skin assessment.

Decide what approach works best on your units. Assess whether your staff know the frequency with which comprehensive skin assessment should be performed.

In order to be most useful, the result of the comprehensive skin assessment must be documented in the patient's medical record and communicated among staff. Everyone must know that if any changes from normal skin characteristics are found, they should be reported. Nursing assistants need to be empowered and feel comfortable reporting any suspicious areas on the skin.

Positive reinforcement will help when nursing assistants do find and report new abnormalities. In addition to the medical record, consider keeping a separate unit log that summarizes the results of all comprehensive skin assessments. This sheet would list all patients present on the unit, whether they have a pressure ulcer, the number of pressure ulcers present, and the highest stage of the deepest ulcer.

By regularly reviewing this sheet, you can easily determine whether each patient has had a comprehensive skin assessment. This log will also be critical in assessing your incidence and prevalence rates go to section 5. Nursing managers should regularly review the unit log.

A sample sheet can be found in Tools and Resources Tool 5A, Unit Log. There are many challenges to the performance of comprehensive skin assessments. Be especially concerned about the following issues:. An example of a notepad to be used for communication among nursing assistants, nurses, and managers can be found in Tools and Resources Tool 3C, Pressure Ulcer Identification Notepad.

Comprehensive skin assessment requires considerable skill and ongoing efforts are needed to enhance skin assessment skills. Take advantage of available resources to improve skills of all staff.

Encourage staff to:. This slide show illustrates how to perform a skin assessment: www. org for useful advice on evaluating erythema and the proper staging of pressure ulcers. A full-body skin inspection does not have to mean visualizing all aspects of the patient in the same time period.

As discussed above, one purpose of comprehensive skin assessment is to identify visible changes in the skin that indicate increased risk for pressure ulcer development.

However, factors other than skin changes must be assessed to identify patients at risk for pressure ulcers. This can best be accomplished through a standardized pressure ulcer risk assessment. After a comprehensive skin examination, pressure ulcer risk assessment is the next step in pressure ulcer prevention.

Pressure ulcer risk assessment is a standardized and ongoing process with the goal of identifying patients at risk for the development of a pressure ulcer so that plans for targeted preventive care to address the identified risk can be implemented. This process is multifaceted and includes many components, one of which is a validated risk assessment tool or scale.

Other risk factors not quantified in the assessment tools must be considered. Risk assessment does not identify who will develop a pressure ulcer. Instead, it determines which patients are more likely to develop a pressure ulcer, particularly if no special preventive interventions are introduced.

In addition, risk assessment may be used to identify different levels of risk. More intensive interventions may be directed to patients at greater risk. Pressure ulcer risk assessment is a standardized process that uses previously developed risk assessment tools or scales, as well as the assessment of other risk factors that are not captured in these scales.

Risk assessment tools are instruments that have been developed and validated to identify people at risk for pressure ulcers. Typically, risk assessment tools evaluate several different dimensions of risk, including mobility, nutrition, and moisture, and assigns points depending on the extent of any impairment.

Clinicians often believe that completing the risk assessment tool is all they need to do. Help staff understand that risk assessment tools are only one small piece of the risk assessment process. The risk assessment tools are not meant to replace clinical assessments and judgment but are to be used in conjunction with clinical assessments.

Many other factors might be considered as part of clinical judgment. However, many of these factors, such as having had a stroke, are captured by existing tools through the resulting immobility. Several additional specific factors should be considered as part of the risk assessment process.

However, also remember that patients who are just "not doing well" always seem to be at high risk for pressure ulcers. Comprehensive risk assessment includes both the use of a standardized scale and an assessment of other factors that may increase risk of pressure ulcer development.

Remember that risk assessment scales are only one part of a pressure ulcer risk assessment. These scales or tools serve as a standardized way to review some factors that may put a person at risk for developing a pressure ulcer. Research has suggested that these tools are especially helpful in identifying people at mild to moderate risk as nurses can identify people at high risk or no risk.

All risk assessment scales are meant to be used in conjunction with a review of a person's other risk factors and good clinical judgment. While some institutions have created their own tools, two risk assessment scales are widely used in the general adult population: the Norton Scale and the Braden Scale.

Both the Norton and Braden scales have established reliability and validity. When used correctly, they provide valuable data to help plan care. The Norton Scale is made up of five subscales physical condition, mental condition, activity, mobility, incontinence scored from 1 for low level of functioning and 4 for highest level of functioning.

The subscales are added together for a total score that ranges from 5 to A lower Norton Scale score indicates higher levels of risk for pressure ulcer development. Scores of 14 or less generally indicate at-risk status. Total scores range from 6 to A lower Braden Scale score indicates higher levels of risk for pressure ulcer development.

Scores of 18 or less generally indicate at-risk status. This threshold may need to be adjusted for the specific patient population on your unit or according to your hospital guidelines.

Other scales may be used instead of the Norton or Braden scales. What is critical is not which scale is used but just that some validated scale is used in conjunction with a consideration of other risk factors not captured by the risk assessment tool.

By validated, we mean that they have been shown in research studies to identify patients at increased risk for pressure ulcer development. Copies of the Braden and Norton scales are included in Tools and Resources Tool 3D, Braden Scale , and Tool 3E, Norton Scale.

The risk assessment tools described above are appropriate for the general adult population. However, these tools may not work as well in terms of differentiating the level of risk in special populations.

These include pediatric patients, patients with spinal cord injury, palliative care patients, and patients in the OR. Risk assessment tools exist for these special settings but they may not have been as extensively validated as the Norton and Braden scales.

Overall scale scores provide data on general pressure ulcer risk and help clinicians plan care according to the amount of risk high, moderate, low, etc. Subscale scores provide information on specific deficits such as moisture, activity, and mobility. These deficits should be specifically addressed in care plans.

Remember, even a score that indicates no risk does not guarantee that a person will not develop a pressure ulcer, especially as their condition changes. Consider performing a risk assessment in general acute care settings on admission and then daily or with a significant change in condition.

However, pressure ulcer risk may change rapidly, especially in acute care settings. Therefore, recommendations for frequency of risk assessment will vary. In settings where patients' status may change quickly, such as in critical care, risk assessment should be performed more frequently, such as every shift.

In the OR, recommendations exist to assess on admission, at discharge to the recovery room, and periodically for operations lasting longer than 4 hours. Consider the time in the holding and recovery rooms when assessing the time.

For patients with more stable conditions, such as acute rehabilitation, pressure ulcer risk assessment may be less frequent. What is important is that the frequency of pressure ulcer risk assessment be individualized to the person's unique setting and circumstances.

Documenting pressure ulcer risk is essential to ensure that all staff are aware of patients' pressure ulcer risk status. While documenting in the medical record is necessary, documentation alone may not be sufficient to ensure that all staff know the level of risk. Among the options to consider for complete documentation are:.

Remember that in documenting pressure ulcer risk, you want to incorporate not only the score and subscale scores of the standardized risk assessment tool, but also other factors placing the individual at risk.

This information is often included in narrative text. Risk status should be communicated orally at shift change or by review of the written material in the medical record or patient care worksheet.

Consider innovative approaches to conveying level of risk. For example, some facilities have color-coded the patient wristband, placed stickers on the patient chart or worksheet, or used picture magnets on the doors to indicate risk status. The accuracy of a risk assessment scale depends on the person completing it.

Experience has shown tremendous variability among staff even when evaluating the same patient. Therefore, training in how to use the scale is needed to ensure consistency.

Refer to Issue 5 under the General Assessment Series. Lindgren M, Unosson M, Krantz AM, et al. A risk assessment scale for the prediction of pressure sore development: reliability and validity. J Adv Nurs ;38 2 Internet Citation: 3.

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