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Purpose
Pressure ulcers are caused by tissue damage when the blood supply to an area of skin is impaired because of significant pressure (National Institute for Health and Care Excellence (NICE), 2014). Although most pressure ulcers are preventable, all patients are at risk (NICE, 2014). Nurses have a central role in prevention and management of pressure areas. They should be able to assess patients' risk of developing pressure ulcers using evidence-based practice, recognised risk assessment tools and by completing a holistic assessment.
Nurses must be able to identify the risk factors associated with developing pressure ulcers and implement appropriate measures to deliver harm-free care. Repositioning techniques, monitoring and ongoing care strategies are essential for pressure ulcer prevention in practice.
Pressure ulcers have become a worldwide concern for health professionals, with the cost burden of managing them and associated complications in excess of £2.1 billion annually (Dealey et al, 2012). Clinical interventions
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Assessment
Pressure area assessment
The purpose of using a risk assessment tool is to identify a patient's risk status and plan care accordingly (NICE, 2014). A comprehensive risk assessment should include intrinsic and extrinsic factors such as:
- neurological conditions
- mobility impairment
- nutritional status
- posture
- level of consciousness
- deformity
- sensory impairment
- previous pressure damage
- pain status
- psychological factors
- social factors
- cognition
- medication and continence (NICE, 2014)
Those at high risk often have multiple factors, including a history of or a current pressure ulcer.
Risk assessment tools
Risk assessment should be carried out as soon as possible and within a maximum of 8 hours of the patient being either admitted to hospital or onto a community caseload; this should be repeated as often as required based on patient acuity (European Pressure Ulcer Advisory Panel et al, 2019) and if a change occurs in the patient's condition. There are numerous validated risk assessment tools;
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Procedure
Prevention strategies
In England, the Commissioning for Quality and Innovation (CQUIN) payment framework is used as an incentive to deliver harm-free care. Once the risk of developing a pressure ulcer has been established, individual prevention strategies must be put in place. The SSKIN bundle, a five-point pressure ulcer prevention strategy (NHS, 2018; Healthcare Improvement Scotland, 2020) is designed to capture all the fundamental preventive components. The elements of the SSKIN bundle are:
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surface
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skin
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keep moving
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incontinence and moisture
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nutrition and hydration
Surface
Equipment and/or support surfaces to relieve pressure and prevent skin damage should be used and evaluated regularly to review their effectiveness.
Skin
Skin assessment is vital to prevent skin damage, manage existing pressure ulcers or prevent further breakdown, and skin fragility should be identified at each risk assessment.
Practitioners should assess all vulnerable regions such as the sacral area, bony prominences and any
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Next steps
Ongoing care and management should be agreed in conjunction with the patient, family and carer. Patients should be educated about their risk status and how they can prevent pressure damage.
Regular skin inspection should be carried out and a full reassessment completed if there has been a change in clinical status, mobility or underlying conditions (NICE, 2014). Nutritional status should be monitored continuously and additional nutritional support given if necessary.
Nurses have a responsibility to deliver evidence-based care and are professionally accountable for their practice. Pressure area care is an important part of nursing practice. Most pressure ulcers are avoidable and nurses should ensure that all appropriate measures are taken to reduce harm and risk factors and prevent pressure ulcer development whenever possible.
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages
Part 2: Procedures for the planning, provision and management of person-centred nursing care
3.3 use appropriate positioning and pressure-relieving
techniques
4. Use evidence-based, best practice approaches for meeting the needs for care and support with hygiene and the maintenance of skin integrity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
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Resources
Healthcare Improvement Scotland. Best practice statement—prevention and management of pressure ulcers. 2020. https://www.healthcareimprovementscotland.org/our_work/standards_and_guidelines/stnds/pressure_ulcer_standards.aspx (accessed 9 January 2024)
National Institute for Health and Care Excellence (NICE). Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. 2017. https://www.nice.org.uk/guidance/CG32 (accessed 9 January 2024)
National Institute for Health and Care Excellence (NICE). Pressure ulcers: prevention and management. Clinical guideline 179. London: NICE; 2014;
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