The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [130]
(EPUAP 2003)
Identifying at-risk patients
The European Pressure Ulcer Advisory Panel (EPUAP 2003) recommends that assessment of at-risk patients should be ongoing and frequency of reassessment should be dependent on changes in the patient’s condition or environment.
Many predisposing factors are involved in the development of pressure ulcers. An individual’s potential to develop pressure ulcers may be influenced by the following intrinsic factors.
Reduced mobility or immobility.
Acute illness.
Level of consciousness.
Extremes of age.
Vascular disease.
Severe, chronic or terminal illness.
Previous history of pressure damage.
Malnutrition and dehydration.
Neurologically compromised.
Obesity.
Poor posture.
Use of equipment such as seating or beds which do not provide appropriate pressure relief (NHS Institute for Innovation and Improvement 2010, RCN 2005).
Older people and pregnant women are also at risk, as are people from black and minority ethnic backgrounds whose skin colour may mean that early signs of pressure ulcers are not as readily identifiable (NHS Institute for Innovation and Improvement 2010).
Grades of pressure ulcers
If a pressure ulcer develops then classification of the wound may assist in determining the most appropriate treatment. These classifications are valuable in describing the state of the ulcer and the most pertinent care required by the patient (see Box 4.3).
Preprocedural considerations
Equipment
A wide variety of devices are available to help relieve pressure over susceptible areas, for example cushions, static/dynamic mattresses and replacement beds. These devices differ in function, complexity and costs and the choice must be based on meeting the patient’s individual need, sound criteria for decision making and effective use of available resources (Table 4.2). The data currently available to evaluate the clinical effectiveness of pressure-relieving devices are variable but the following are supported by some data.
Table 4.2 A selection of mechanical methods for relieving pressure
Patients with pressure ulcers should have access to pressure-relieving support surfaces and strategies, for example mattresses and cushions, 24 hours a day and this applies to all support surfaces.
All individuals assessed as having a grade 1–2 pressure ulcer should, as a minimum provision, be placed on a high-specification foam mattress or cushion with pressure-reducing properties. Observation of skin changes, documentation of positioning and repositioning schemes must be combined in the patient’s care.
If there is any potential or actual deterioration of affected areas or further pressure ulcer development, an alternating pressure (AP) (replacement or overlay) or sophisticated continuous low pressure (CLP) system (e.g. low air loss, air fluidized, air flotation, viscous fluid) should be used.
Depending on the location of ulcer, individuals assessed as having grade 3–4 pressure ulcers (including intact eschar where depth and therefore grade cannot be assessed) should be, as a minimum provision, placed on an AP mattress or sophisticated CLP system.
If AP equipment is required, the first choice should be an overlay system. However, circumstances such as patient weight or patient safety indicate the need for a replacement system.
In 2005, NICE in collaboration with the RCN created a clinical guideline in pressure ulcer management (NICE 2005, RCN 2005). This included data looking at evidence-based practice, cost-effectiveness and economic evaluations of the different devices, drugs and procedures, amongst others, in the management of pressure ulcers (see Table 4.2). In 2009 the Nursing Executive Centre in the US also looked at the prevention of pressure ulcers and their approach is linked to ward organization, spot audits of assessment and pressure-relieving devices (Nursing Executive Centre 2009).
Assessment tools
There are several risk assessment tools in pressure ulcer development such as those developed by Norton, Braden and Waterlow (Braden and Bergstrom