PRESSURE ULCERS – WHAT YOU NEED TO KNOW! BEWARE Disturbing Photos! provided for WhereIsTheCare

THIS ARTICLE INCLUDES:

  • What are they?
  • What causes them?
  • Additional factors that increase the risk of developing them.
  • What to expect when you or a relative is admitted into hospital or another health care setting
  • Risk assessments
  • Care plans
  • Essential documentation to support the provision of care
  • Evaluating care and re-assessments
  • Classifications and grades
  • Photos
  • Moisture Lesions
  • Pressure ulcer prevention
  • How bowel and bladder continence impacts on tissue viability
  • Most commonly used Pressure Ulcer Risk Assessment Tool (Waterlow)

 

INTRODUCTION

Pressure ulcers are wounds that are caused by constant, unrelieved pressure, or a combination of pressure, shear (twisting of tissue in opposite directions) and/or friction.  They are also known as bed sores, pressure sores, pressure damage or decibitus ulcers.  They can occur on any part of the body, but are seen most commonly over bony prominences such as the back of the head, sacrum, elbows, heels, hips and the ischial tuberosities (i.e. the bones we sit on over the buttocks area). Any person who is unable to move themselves without assistance will be at immediate risk of pressure ulcers.  Any person who has any loss of sensation will not be able to respond to the effects of pressure (i.e. the numbness we all feel on our bottoms with prolonged sitting for example, which forces us to move).  Sensory loss may occur when a person has had a stroke, had a spinal injury, if they have dementia and sometimes if they have learning disabilities. Most, if not all of us have had a pressure sore at some point in our lifetime; a blister from a rubbing shoe; on our hands from digging the garden; over our ears or on the bridge of the nose from spectacles are just some examples of common pressure sores, although most people do not recognize these blisters (which are actually wounds) as pressure damage.

WHAT CAUSES PRESSURE ULCERS?

Pressure damage is predominantly caused by prolonged and unrelieved pressure from any external object pressing against the skin (e.g. bed, chair, clothing, footwear, medical devices, hearing aids, spectacles). The pressure applied squashes the blood vessels in the skin and underlying tissues, starving them of essential oxygen and nutrients causing the tissues to die.  It is similar to a boulder being placed on a hose pipe that feeds a garden; failure to remove the hose pipe to allow water through will result in the garden drying up and dying.  People who are immobile or have difficulty responding independently to pressure, or those who have a neurological deficit and can’t feel the effects of pressure, will be at immediate risk of developing pressure damage, unless they are reminded to move, or are physically moved if they are incapable of moving themselves.  

 

Additional factors that increases an individual’s risk of developing pressure ulcers

There are many factors that affect an individual’s likelihood of developing pressure ulcers, and the more factors involved the greater the risk will be, and the faster a pressure ulcer is likely to develop.   For example, the aging process, circulatory problems, diabetes, heart disease, obesity, very thin, malnourishment, scar tissue (e.g. from previous pressure ulcers), incontinence or moisture from sweating or wound leakage, certain medications (e.g. steroids) and breathing problems/difficulties such as chronic obstructive pulmonary disease, asthma, emphysema.  The following are the main factors that apart from pressure/shear/friction will contribute to pressure damage if these are not appropriately addressed by care/nursing staff. The pressure ulcer risk assessment is only one part of a full holistic assessment that must be carried out in accordance with legislation, national and local guidelines, which considers the patient/resident’s daily activities of living (e.g. eating, drinking, breathing, mobility, nutrition, elimination to name but a few).

Incontinence, moisture and sweating

Moisture that is in constant or regular contact with the skin will cause maceration (i.e. water logging) or excoriation (i.e. burning) that will make the skin much more vulnerable to pressure.  Skin damage from moisture will in effect give pressure damage a head start.

Poor Nutrition

After immobility, reduced nutritional intake is the next main cause of pressure damage;  poor nutrition leads to lethargy, reduced cell regeneration, and poor healing rates.  It is therefore essential the patient is encouraged to take adequate nutrition and fluids in order to reduce the risk of developing pressure ulcers and to improve healing rates in cases where they exist.   The

recommended daily intake for a male is around 2000kcals and for females is around 1600kcals per day.  These calories are required for daily activities and normal cell regeneration.  If a wound exists the patient will require a higher intake of nutrients, particularly of protein, in order to improve wound healing rates.

Underlying Co-morbidities 

There are many medical conditions that make an individual more likely to develop pressure damage compared to the risk level of a healthy individual.  For example, diabetes, peripheral vascular disease, other vascular diseases (e.g. vascular dementia) and coronary artery disease each have an effect on the circulation, so can affect the circulation to the skin also.  When pressure is applied, the (probably) already reduced blood supply will be reduced even further, making pressure damage occur more quickly. In conditions such as malignancy, organ failure or in general malaise, the metabolic rate (i.e. tissue breakdown rate) is faster than in a health individual, which means that there is a need for increased nutrition, yet these patients usually do not feel like eating, so will be at very high risk of developing pressure damage.

Medications

Certain medications are known to impact on the tissue viability of a patient; for example, steroids and cytotoxic drugs and these patients will be at increased risk of developing pressure ulcers if they are not regularly moving or are repositioned.

What to expect when you or a relative is admitted into hospital or another health care setting

When an individual is admitted to any care setting (e.g. a hospital, a care home, nursing home, or onto a district nursing service) the nursing and/or care staff are obligated by legislation (the Health & Social Care Act 2008 and the Regulated Activities 2010) to undertake a pressure ulcer risk assessment within a reasonable timeframe (i.e. 6 hours) and to devise and implement a plan of care (a formal Care Plan) that instructs staff on how to minimize that risk.   This care plan must be implemented immediately and without undue delay as pressure damage can occur as quickly as within 20 minutes in the most vulnerable. Legislation and the National Institute of Clinical Excellence (NICE) thereafter determine the minimum re-assessment and care plan review times.

The following steps must be evidenced in the nursing records; without this documentation it will be virtually impossible for nursing/care staff to claim that the care they have provided was delivered to an acceptable standard if a pressure ulcer actually exists:

Risk Assessments: The risk assessment must be carried out on you or your relative by a trained member of staff.  In the residential setting this will be a basic assessment that may simply ask the question about whether or not the resident can move themselves independently or not.  If the answer is no, then the care staff must write a care plan to mitigate the risk, and where necessary request that a registered nurse (e.g. the district nurse) attends to carry out a more in-depth risk assessment. When assessing any individual the trained nurse must utilize an acceptable risk assessment tool that considers a variety of risk factors.  There are many of these tools available and in use, the most commonly used ones are the Waterlow and the Braden tools.  Using such tools will determine the level of risk that will determine the level of care required.  However, as these tools are not 100% reliable, the trained nurse must also utilize his/her own clinical judgment.  For example, a young spinal injury patient who is otherwise fit and well may have a low score meaning that they are not at any risk of pressure damage according to the risk tool, however by virtue of their total immobility they are clearly at risk of pressure damage; whereas an older person who achieves a very high risk score may not be at any risk because they are fully mobile and able to respond independently to pressure, at least until such time they too become immobile. The risk assessment must also include observation of the resident/patient’s skin in order to identify any existing pressure damage or any skin conditions that could increase their risk of pressure damage.  Any skin damage or pressure ulcers identified must be documented on a Body Map.

Care Plans: Care plans must be devised for each and every identified problem/need/risk noted during the assessment process.

Any patient/resident who is deemed to be at risk of developing pressure damage must have a care plan devised and implemented without delay for Pressure Ulcer Prevention.  As a minimum this care plan should include a regular repositioning regime (a common regime is between 2 and 4 hourly) and the installation of appropriate pressure relieving devices (e.g. mattress/cushion or heel protectors), which are selected based on the resident/patient’s risk level.

As a minimum the type of mattress/cushion to be utilized on anyone deemed to be at risk is a high specification high density foam mattress (e.g. memory foam).  This type of device is suitable for anyone with an existing pressure ulcer up to a Grade 2 severity (discussed later).  Any patient/resident that has a Grade 3 or 4 pressure ulcer MUST be nursed on a dynamic air mattress, irrespective of their risk score.  NICE do however warn against the efficacy of such mattresses as they suggest that it is the frequency of repositioning that is of utmost importance in preventing pressure ulcers, so nursing and care staff should not assume the use of this type of equipment alone will prevent pressure damage, as it won’t; pressure will still be applied to the body, and these devices will simply mean that the onset of pressure damage will be delayed compared to when these devices are not used.

Even when on these devices patients/residents will require repositioning at intervals that are determined by any skin changes noted when the patient/resident is turned.  As previously stated, a common starting point for a repositioning regime is 2 – 4 hourly.  However this frequency should be increased in the event that the patient/resident develops any redness or skin discolouration, which will probably indicate the onset of pressure damage (discussed later).

Care Plans must then be devised for each and every other identified risk that increases the patient/resident’s potential for pressure ulcers; for example, for continence care; nutritional and fluid intake; diabetes management; moving and handling to name but a few.  Each care plan must be cross-referenced to the Pressure Ulcer Prevention care plan, so that all factors that contribute to risk is adequately addressed.  In the event that a patient/resident has or develops pressure damage, a Wound Management care plan must be devised that instructs nursing staff on the management of the wound.

Essential documentation to support the provision of care: As stated previously; without documentary evidence to prove the care has been provided, the presence of a pressure ulcer will nearly always be indefensible in a Court.  It is therefore essential that the following evidence is provided to show that appropriate care has been given to you or your relative:

  • Risk assessments, which includes a full holistic assessment, and separate assessments for aspects of care such as pressure ulcer risk & body map, falls risk, nutritional risk and mobility;
  • A care plan for each and every identified health and social care problem, need or risk;
  • Evidence the care plans are being implemented (there are many charts available but the following are essential for pressure ulcer prevention:
  • Turn / Repositioning Charts
  • Skin observation charts
  • Food and Fluid intake/output charts
  • Toileting opportunities / episodes of incontinence
  • Daily evaluations that determines from the above how effective the care plan is
  • Wound Assessment Charts for any existing wound

Evaluating Care & Re-assessments

The care provided must be evaluation on at least a daily basis in order to determine whether or not the care is appropriate (e.g. the frequency of turns, toileting, equipment etc).  If the patient/resident develops any change in their skin condition (or they develop pressure damage or if existing ulcers deteriorate), the care plan must be amended to reflect a more appropriate level of care.  For example if a patient/resident develops a red area on 4-hourly turns, then this frequency needs to be increased and monitored until the correct frequency is established (i.e. when the ulcer stops deteriorating then begins to heal).

A similar process must be applied to each and every care plan that has been devised. Re-assessments must be carried out at intervals determined by legislation, including local and national policy.  In terms of pressure ulcer risk, common practice is to repeat the assessment on at least a weekly basis, and sooner than this if a pressure ulcer develops or an existing ulcer deteriorates.  If on reassessment additional problems/needs/risks are identified, then the direction in the care plan must be amended to reflect these changes so that appropriate care is continually being provided.  If extensive changes are required then the care plan must be re-written. I

n cases where patients/residents are in long-term care, it is rare that no changes will have occurred within a 6-month period, which is why it is best practice to write complete new care plans every 6 months following holistic assessment.

It is unacceptable for a care plan to remain in use for longer than this and could indicate lack of monitoring of the identified problem/need/risk.  

Classification of Pressure Ulcers

Pressure ulcers are classified in the UK using the European Pressure Ulcer Advisory Panel (EPUAP) severity scale, which uses a scale of 1 to 4, with grade or category 4 being the most severe pressure ulcer.  In the USA they use an additional two classifications that are increasingly being adopted in the UK by tissue viability nurses.  The definition of each grade/category is as follows:

Grade / Category I (Fig.1) – Intact skin with non-blanching redness (i.e. does not go white when pressed). This grade may be difficult to detect in darker skin tones.

Wyn Grade 1

Category/Stage II (Fig.2)-  A partial thickness loss of dermis presenting as a blister or a shallow open ulcer with a red or pink wound bed. No slough or necrosis is present.  It may also present as an intact or a ruptured blister.

Wyn Grade 2(1)Wyn Grade 2(3)Wyn Grade 2(2)

 

 

CategoryStage III (Fig.3) Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed.  Slough may be present but does not obscure the depth of tissue loss.  It may include undermining and/or tunnelling.   The depth will vary depending on the anatomical site of the ulcer, and is dependent on the depth of adipose (fat) tissue.

Wyn Grade 3(1)Wyn Grade 3(2)

Category/Stage IV (Fig. 4) – Full thickness tissue loss with exposed bone, tendon or muscle.  Slough, eschar (scab) or necrosis may be present.  There is often undermining and tunnelling. The depth varies by anatomical location.  

Wyn Grade 4(1)Wyn Grade 4(2)Wyn Grade 4(3)

 

USA Classifications: Unstageable/ Unclassified (Fig. 5) – Full thickness tissue loss, in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) on the wound bed.  This ulcer will be classified as a Grade III or IV in the UK.   

Wyn Grade 5(1)Wyn Grade 5(2)

 

Suspected Deep Tissue Injury (Fig. 6)– depth unknown – Purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.  The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones.   This ulcer will be classified as a Grade III in the UK.

Wyn Grade 6

 

Moisture Lesions (Fig. 7) – These are not pressure ulcers and are wounds that are caused by prolonged contact with moisture.  These are often incorrectly categorised as grade 2 ulcers due to the dermal loss that occurs with maceration and/or excoriation.  This damage can however increase the speed at which a pressure ulcer will develop if not appropriately managed.

Wyn Moisture Lesion 1

 

Pressure Ulcer Prevention

In recent years most NHS Trusts have adopted a model of care known as SSKIN, which when adopted in patient care has been proven to reduce the incidence of pressure ulcers.  It has also been proven to increase the healing rates of existing pressure damage.  However, it is important to assess and address all other influencing factors noted on pressure ulcer risk assessment as well as implementing care in accordance with the following SSKIN care bundle:

S – Skin –the skin is observed on admission and any pressure damage is recorded on a Body Map.  The Body Map is repeated each time a re-assessment of risk is carried out.  Additionally, the patient’s skin should be observed for signs of pressure damage at each position change, and at least once on every shift.  The findings should be recorded on the care plan evaluation.

S – Surface – following assessment of risk, the correct pressure relieving devices (e.g. cushions and mattresses) must be installed under the patient.  The choice of equipment used will be determined by the holistic and risk assessment result and the specific device used must be recorded in the patient’s notes (discussed in the next chapter).

K – Keep Moving – NICE recommend that no patient should be left in the same position for longer than 4 hours when in bed, and no longer than 2 hours when sitting in a chair, providing the patient is on adequate pressure relieving surfaces.  Those at greater risk will require more frequent repositioning than this, as will those who are awaiting pressure relieving surfaces.  It is vital that every position change is recorded on a Turn/Repositioning Chart to enable continuity of care and to alert others to when repositioning is required.  In the event that pressure damage occurs or an existing ulcer deteriorates, the frequency of repositioning must be increased without delay following re-assessment.

I – Incontinence – this section must not be limited to urine and faecal incontinence, but consider must also be given to any moisture that may be in contact with the skin for prolonged periods; for example sweat, wound exudates, or leakage from catheters or stoma bags and drink spillages.  Adopting a regular toileting regime will prevent incontinence, whilst providing repositioning and therefore regular pressure relief for the patient.  When there is a risk that moisture will get onto the skin it is essential that good skin care is provided using appropriate wash creams and moisture barriers.

N – Nutrition – As stated in the previous chapter, reduced nutrition is the second highest reason why an individual will develop pressure ulcers.  It is therefore vital that a nutrition assessment is completed as soon as possible after admission to the care setting, and diet and fluids are monitored to ensure adequate nutrients are taken by the patient.  NICE recommend the use of the Malnutrition Universal Screening Tool (MUST) on admission and at weekly intervals along with weekly weights (or monthly if on a district nurse workload).  Re-assessments must be carried out in the event that a patient fails to take sufficient diet and fluids, or if they demonstrate any weight loss.  In these instances food supplements must be provided and a referral to a GP or a dietician must be made without delay.  Further, if a patient has or develops a grade 3 or 4 pressure ulcer, it is also advisable to refer the patient to the dietician due to the need for increased nutrition to aid healing.

How Bladder and Bowel Incontinence Impacts on Tissue Viability

Incontinence is the inability to control bladder and/or bowel functions.  It affects people of all ages however females are twice as likely as men to develop incontinence.  When such a problem exists it can impact not only on the quality of the individuals life and ones dignity, but on the quality of the skin unless adequate steps are taken.  The purpose of this article however, is not to go into detail on the causes or indeed into great detail regarding management and treatments of incontinence, but to discuss the probable consequences on the skin if this problem is not adequately managed.  Once we have identified skin problems related to incontinence we will be better placed to discuss ways in which skin problems can be prevented in the first instance and managed in the second, by using simple techniques that will maintain skin integrity. The skin is the largest organ of the body, weighing an average of 5-7llbs.  It is the most vulnerable organ of all as it is in constant contact with insults from the external world so is often breached by trauma, burning and even by excess moisture.  When skin is intact it is your first line of defence against bacterial invasion that could result in infection.   It is therefore essential that we maintain good skin integrity.

Skin integrity is also known as tissue viability; this is when the skin is healthy and intact with no obvious breaks, abrasions or rashes.  As we age our skin integrity reduces due to the reduced production of collagen and elastin, each of which gives the skin its strength and elasticity.  In order to maintain healthy skin with good integrity it is essential that a good daily nutritional intake and sufficient hydration is maintained. However, many people with urinary incontinence will restrict their fluids believing this will better control the problem.  Unfortunately this will inevitably lead to dehydrated skin that will be weaker than it would be if it was well hydrated and so will experience damage easier than it would do otherwise.  Additionally, a dry skin will absorb moisture from incontinence (and sweating often associated with infection) and will become macerated (i.e. water logged) or excoriated (i.e. burned due to the acids in the faecal matter or urine).  Maceration presents as white wrinkly skin, whilst excoriation appears as red, burning skin.  This means that the skin has been breached and will lead to the invasion of bacteria.

Dehydration can also lead to urinary tract infections that in turns results in worsened urinary incontinence (and sweating).  As the bacteria within the urine produces waste products this alters the Ph balance in the urine, which when in contact with the skin can cause excoriation, this then breaches the surface area of the skin. The invasion of bacteria into the skin via breaches results in cellulitis (i.e. the name for a skin infection).  This can cause severe pain and/or severe itching, resulting in scratching, further skin damage and additional bacterial invasion.  This cycle often negates the efficacy of antibiotics and so the infection does not resolve.

If the infection is not eradicated by appropriate skin care and antibiotics, there is a possibility the infection will spread to wider areas of the skin and deeper into underlying tissues.  In the worst case scenario the infection could invade the bloodstream causing the patient to be extremely ill, requiring hospitalisation.

In the world of tissue viability, skin damage caused by incontinence is known as ‘moisture lesions’ or ‘continence dermatitis’.

In Fig.1.  You can see how the skin damage is spread over the buttock areas where you can see the moisture. The extend of the damage is wide, but superficial in depth.  You can see that this area is not directly over the coccyx or the sacral bone, unlike the pressure ulcer (Grade 4) in Fig. 3.

Fig. 2 demonstrates a moisture lesion where the skin goes from red/pink to white underneath (blanching)

Fig. 3 demonstrates a non-blanching erythema (redness) (Grade 1 pressure ulcer) sited over the right side of the sacrum.

Fig. 4 demonstrates a Grade 4 pressure ulcer sited directly over the coccyx.  Note the surrounding moisture.  This wound most probably developed from the pre-existing moisture lesion.          

Fig. 1 Moisture Lesion                                                                Fig. 2  Blanching Moisture Lesion    

 

Wyn Moisture Lesion 1                            Wyn Moisture Lesion 2

    

Fig. 3 Non-blanching Grade 1 and a                                          Fig. 4 Grade 4 pressure ulcer                   

tiny Grade 2 ulcer directly over the bone    

Pressure ulcer (i.e. the small break in the skin)  

 

Wyn Non-Blaching                    Wyn Grade 4 Pressure Ulcer

 

Very often moisture lesions are often mistaken for pressure ulcers, particularly early onset pressure ulcers (i.e. Grades 1 or 2).  The clinical differences between pressure ulcers and continence lesions are detailed below:

Pressure Ulcer Moisture Lesions
Usually occur over a bony prominence such as over the sacrum, or under anything that applies constant pressure to the skin e.g. under the tight elastic on underwear Occurs where there is excess moisture against the skin.  The area may be extensive and over areas where there are no bones immediately underneath the skin e.g. the buttocks, groins.
Usually round in shape to begin with and confined to the area directly over the bone Appears initially as a rash or a tiny grazes(s) that are sporadic over the area of moisture
The onset of pressure damage appears red (when it is a Grade 1).  When pressed it is non-blanching (this is it remains red when pressed) Appear red, and when pressed the red area blanches (i.e. it goes white)
The skin surrounding the ulcer is usually dry The skin around the lesions appear ‘wet’
The depth of damage can go deep down to muscle, bones and tendons Are usually superficial, although if pressure is applied on these areas, the damage can go deep as with pressure ulcers.  These ulcers will be categorised as pressure ulcers, with a moisture lesion onset
Can become infected, although this is unusual with good wound management.  Therefore any infection will be delayed, if at all. Can usually become infected very quickly due to the presence of bodily fluids and matter that harbours bacterial growth.
Usually hot or lumpy to touch Usually cool to touch, unless infected
The patient complains of pain The patient usually complains of a stinging sensation

 

 

As always, prevention is better than cure.  Therefore, to begin with, as far as possible, it is vital to address the cause of the incontinence (or sweating, or both).  This may include instigating a regular toileting regime (e.g. 2 – 3 hourly) and excellence in skin care in the event that incontinence occurs.  In any event it is essential that expert advice is sought from a Continence Specialist Nurse who will be able to assess, treat and manage the cause of your incontinence. In the meantime, as well as the above it is crucial that the following care is taken in order to avoid moisture lesions:

  1. The application of appropriate sized continence pads; these must be fitted to the conformity of the body and should not be placed as a sheet under the patient. Modern pads have indicator when they need changing (e.g. a line that appears on the outer pad). Choosing the right sized pad will mean that maximum wear time and costs will be achieved, whilst the pad will be changed before it reaches its maximum absorbency, after which the moisture will then sit against the skin. It is therefore important to observe for the indicator line. However, this method of capturing moisture must not be substitute for toilet opportunities;
  2. The use of an appropriate moisture barrier cream, that will assist in preventing moisture sitting next to the skin. It is important to be aware of the variety of products on the market thereby following expert advice. Many barrier products are difficult to spread onto the skin due to its consistency, and by applying and washing off the barrier cream this can cause skin trauma. Furthermore, some barrier creams (e.g. Sudocrem) is contra-indicated for use with continence pads as this product (as well as others) can ‘clog’ the pores of the pad, thereby preventing moisture soaking into the pad. This results in moisture sitting against the skin which will eventually penetrate the cream, causing moisture damage. It is therefore advisable to use tissue viability recommended barrier creams such as Cavilon Cream.
  3. Once there are breaks in the skin caused by moisture (and/or pressure ulcers), it is advisable to stop the use of creams and use a Barrier Spray instead (e.g. Cavilon spray). This creates a ‘protective film’ that moisture is unable to penetrate. Applying creams to moisture lesions will simply add to the moisture levels, which will encourage further bacterial growth, thereby increasing the risk of cellulitis.
  4. Keep skin clean and dry, using a moisturising barrier cream (e.g. Cavilon Cream) as already stated. Avoid the use of alcohol wipes and soaps to wash the skin; use wash creams instead (e.g. Tena wash cream). Soaps containing alcohol causes the skin to dry and crack, so when urine or faecal matter get on to the skin this will cause a stinging sensation and increase the risk of infection.
  5. Ensure adequate nutrition and hydration. A good well-balanced diet and around 2 litres of fluids daily will maintain maximum skin integrity.
  6. Refer the patient to the GP or district nurse for further advise if any moisture lesions increase in depth and surface dimensions.
  7. If the patient is unable to reposition themselves independently in response to pressure, it is vital that care is provided to ensure regular repositioning is carried out in order to prevent pressure ulcers occurring; as moisture lesions will give pressure damage a ‘head start’ and they can quickly deteriorate to deeper tissue damage.

Urinary or bowel incontinence requires expert advice in order to address the cause and to implement appropriate measures that eliminates, or appropriately manages the condition to an acceptable level for the patient, in order to maintain dignity and skin integrity. It is vital that regular toilet opportunities are offered and that appropriate skin care is provided in order to reduce the incidence of incontinence and to avoid the presence of moisture against the skin. This can be achieved by appropriate assessment of needs and the use of appropriate skin care products, water barrier products, and continence pads. The failure to adhere to these standards will result in the development of avoidable continence lesions that could result in cellulitis, infection of deeper tissues and wide spread infections.  Furthermore, once such lesions occur, the immobile patient will be at increased likelihood of developing pressure ulcers, all of which could be avoided with good and appropriate care.

 

Most Commonly Used Pressure Ulcer Risk Tool (the Waterlow Pressure Ulcer Risk Assessment tool)

 

A number of things must be considered when assessing someone’s risk.  However, clinical judgment (i.e. common sense) must be used, as you may get a young male with a spinal injury who is unable to move himself, who  achieves a ‘no risk’ score, but clearly will be at risk by virtue of his immobility – nurses don’t always get this.

On the other hand, you may get an elderly person who has lots of medical issues who achieves a very high risk score, but by virtue of the fact they are independently mobile and able to respond to the effects of pressure, they are not at any risk (once they become immobile they will develop pressure ulcers faster than the young otherwise fit male who has a lower score). Therefore, the greater the score the faster a person will develop pressure damage if extra vigilance is not provided by more frequent repositioning and the use of better pressure relieving equipment.

There are lots of other tools out there but the Waterlow Pressure Ulcer Risk Assessment Tool is the most commonly used tool and is the one that considers the patient’s health problems – many of the others don’t.  However, a tool is only as reliable as the common sense I mentioned, and after all common sense is not so common, hence the reason why so many people suffer needlessly.

See Waterlow Risk Pressure Risk Assessment Tool  at ‘Useful Documents’ on this site.

 

Wyn@gms-medicolegal.co.uk

01536 648011

07841 054352