Guidelines on Prevention and Management of Pressure Ulcers

Original Editor - Sibylle Daymon as part of the Wheelchair Service Provision course'

Top Contributors - Mariam Hashem and Lauren Lopez  

Introduction

The purpose of these guidelines is to ensure that persons with a pressure ulcer, or who are at risk of developing pressure ulcers when using their wheelchairs, are appropriately assessed by the physiotherapist (or other appropriated health care professional) and are prescribed the most suitable equipment.

These guidelines should be read in conjunction with external guidelines produced by the National Institute for Health and Clinical Excellence[1] and the European Pressure Ulcer Advisory Panel[2].

Definition of Pressure Ulcer

A pressure ulcer is ‘a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear’[2].

Whilst pressure ulcers are more likely to affect older people, it is now accepted that people of all ages may be affected, therefore the principles of these guidelines apply to beneficiaries of all age groups.

Classification

According to the European Pressure Advisory Panel system[2], pressure ulcers are classified as following:

Stage I

Nonblanchable Erythema

The skin is intact, but shows a red or dark mark, often over bony areas. The skin marking does not fade when pressure is removed, although this might be difficult to see in people with darker skin. This stage could indicate people at risk of pressure ulcers.

Stage II

Partial thickness skin loss

There is a dry, shallow, red pink wound without any dead tissue. Skin blistering (closed or open) would also fall in this category.

Stage III

Full thickness skin loss

At this stage there is a deep wound that may expose subcutaneous fat (depending on location), but not tendons or muscles. There may be dead tissue present, but the deep wound is clearly visible.

Stage IV

Full thickness tissue loss

There is a very deep wound that goes through to the muscle or tendon and might expose the bone, or the bone can be felt. Depending on location, this wound may be shallower, as there may not be any subcutaneous issue (such as on the ear or the ankle).

Unstageable: Depth Unknown

There is a deep wound but it cannot be determined, as there is a lot of dead tissue or a scab present.

Suspected Deep Tissue Injury: Depth Unknown

The skin area is intact but discoloured (purple or maroon), or there is a blood filled blister as a result from pressure or shear damage to underlying soft tissue. The area may feel painful to touch, different temperature or consistency to surrounding skin. Can be difficult to detect in people with dark skin.

Risk Assessment

Risk assessment is an essential part of preventing pressure ulcers. Although the use of published pressure ulcer risk assessment scales has been incorporated into these guidelines, it is vital that these assessments are used only as a prompt and should not replace clinical judgement. It is critical that risk factors coming from the user themselves (intrinsic) and those that are out of the users’ control (extrinsic) are identified.

The screening of pressure ulcer risk factors must be incorporated into the holistic seating assessment completed by the physiotherapist (or other appropriated health care professional). For all beneficiaries considered to be at risk, or for those who already have an existing pressure ulcer, the appropriate section on the [[[Images/e/ec/Intermediate Wheelchair Assessment Form.pdf|Intermediate Wheelchair Assessment Form]] - section: Presence, risk of or history of pressure sores] must be completed. Where required to aid a more precise assessment, an additional pressure ulcer risk assessment tool should be completed. The appropriate assessment score must be calculated and documented within the clinical assessment / notes and results will be interpreted not in isolation, but in conjunction with clinical judgement.

For all children aged between 0 to 18 years old considered to be at risk of pressure ulcers, physiotherapist (or other appropriated health care professional) will use the Modified Braden Q Risk Assessment Scale.

The Braden Risk Assessment Scale will be used for all young people and adults aged from 18 years and above.

Staff working with partner organisations will also have to complete any documentation as used / required under local arrangements.

Pressure Ulcer Management

Beneficiaries(or where appropriate and required their parents / guardians / carers) will be informed of their individual level of risk and advised on measures for prevention of further tissue damage. Where appropriate, relevant information leaflets will be provided to support verbal information (e.g.,RISE: Prevention of Pressure Ulcers – Information for Carers, EPUAP:How can you help to stop pressure ulcers?, or NHS Improvement: Stop the Pressure).

Beneficiaries identified to be at high risk of developing pressure ulcers, or who already have a pressure ulcer, must be referred to the appropriate health care professional such as Tissue Viability specialist for specialist assessment, if not already known to the service.The referring physiotherapist should include a request to be kept updated on the beneficiary’s treatment and / or any implications on the provision of mobility equipment.

Reassessment of the risk, utilizing the appropriate risk assessment tool and the physiotherapist clinical judgement, must be undertaken throughout the episode of care and documented in the clinical notes.

For beneficiaries with sensory impairments, or whose first language is not English, the physiotherapist should involve link workers or interpreters and consider to communicate the information in alternative forms, such as audio-visual.

For beneficiaries with identified pressure ulcers, and those who are categorized as being at high risk of developing pressure ulcers, the appropriate pressure relieving cushion must be ordered within 48 hours from time of assessment. Whilst new equipment is on order, the most suitable available alternative will be provided.

Upon receipt of equipment, a handover certificate will be completed and signed by the physiotherapist (or other appropriate health care professional) and the beneficiary (or where appropriate and required by the parent / guardian / carer), to indicate that they understand the instructions given.

Regular reviews are crucial to reassess the beneficiary’s needs and the suitability of the equipment; the frequency of reviews depends on the level of risk, recommendations of the Tissue Viability specialist, clinical judgement and individually assessed beneficiary needs and preferences. If requested and assessed as appropriate by a Tissue Viability specialist, the responsible health care provider will provide alternative pressure relieving equipment to manage the changing needs of the user.

The benefits of a pressure relieving cushion should not be undermined by prolonged sitting within the wheelchair. the physiotherapist will highlight the importance of 24 hour postural management and regular change of position during the handover of chairs / seating equipment, but cannot take responsibility for the ongoing management.

Training

Training will be provided to any healthcare professional working in the health care provider facility on the following topics:

  • Risk factors for pressure ulcers
  • Recognizing pressure ulcers
  • How to complete a risk assessment
  • Prevention of pressure ulcers and basic management strategies
  • Relevant information material for beneficiaries and carers
  • Sources of advice and support

Responsibilities

The following responsibilities apply to services directly provided by healthcare facilities. Local variations will have to be respected / incorporated where the healthcare facility is delivering a service on behalf of / in collaboration with a partner organisation.

Responsibility of the physiotherapist:

  • Identify beneficiaries at risk of pressure ulcers and undertake risk assessments using the Modified Braden Q Risk Assessment Scale or the Braden Risk Assessment Scale (as required) and their clinical judgement.
  • Seek advice of / contact the Tissue Viability specialist/service where appropriate, whilst maintaining the ongoing responsibility for the beneficiary’s wheelchair seating needs.
  • Liaise with beneficiaries, their families, carers and the relevant multidisciplinary professionals to contribute to 24 hour postural management in order to reduce the risk of tissue damage.
  • Ensure that all clinical assessments and interventions are recorded and any details around tissue viability are accurately documented.
  • Ensure that mobility assessment outcomes and tissue viability care plans are communicated to the appropriate healthcare agencies, with the agreement of the beneficiary and / or their carer or guardian.
  • Order the most suitable pressure relieving cushion according to the risk identified and ensure safe handover of this equipment.
  • Maintain their knowledge and competence in prevention and treatment of pressure ulcers related to mobility equipment
  • Report any new pressure ulcers classified as Grade 3 or Grade 4 and occurring during an episode of care / contact as an incident, following the health care facility/organization guidance.

Responsibility of Line Managers:

  • Implement these guidelines in their clinical area.
  • Ensure that staff understand their accountability and responsibility and comply with these guidelines.
  • Ensure that staff have the knowledge, skills and competence appropriate for their role and responsibilities to manage the risk of new / existing pressure ulcers as part of the assessment and equipment provision through the healthcare facility.
  • Ensure that all staff have access to copies of references and resources referred to within this guidelines.
  • Monitor the occurrence of new pressure ulcers classified as Grade 3 or Grade 4 and investigate possible reasons and outcomes.

Resources


References

  1. National Institute for Health and Care Excellence (NICE), Pressure ulcers: prevention and management, [CG179]. Available from: https://www.nice.org.uk/guidance/cg179 [Accessed 29th October 2018].
  2. 2.0 2.1 2.2 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan PacificPressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. EmilyHaesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014.Available from: http://www.epuap.org/wp-content/uploads/2016/10/quick-reference-guide-digital-npuap-epuap-pppia-jan2016.pdf [Accessed 29th October 2018]