Title of Guideline (must include the word “Guideline” (not protocol,
policy, procedure etc)
Author: Contact Name and Job Title
Pressure Ulcer Prevention Guideline
Directorate & Speciality
Stuart Thompson-Mchale, Tissue
Viability Matron, 07812268737
Dawn Woolley, Tissue Viability Nurse
Specialist
Tissue Viability Team
Date of submission
15/07/2014
Explicit definition of patient group to which it applies (e.g. inclusion
and exclusion criteria, diagnosis)
Version
Version 1
If this version supersedes another clinical guideline please be
explicit about which guideline it replaces including version number.
Statement of the evidence base of the guideline – has the
guideline been peer reviewed by colleagues?
Evidence base: (1-6)
1
NICE Guidance, Royal College Guideline, SIGN
(please state which source).
2a
meta analysis of randomised controlled trials
2b
at least one randomised controlled trial
3a
at least one well-designed controlled study without
randomisation
3b
at least one other type of well-designed quasiexperimental study
4
well –designed non-experimental descriptive
studies (ie comparative / correlation and case
studies)
5
expert committee reports or opinions and / or
clinical experiences of respected authorities
6
recommended best practise based on the clinical
experience of the guideline developer
Consultation Process
This guideline has been peer
reviewed by the Tissue Viability
Team.
The following guideline by NICE has
been sourced and referred to in this
document
NICE (2014) Pressure ulcers:
prevention and management of
pressure ulcers. London: NICE.
This guideline has been adapted
from, and replaces the following
document
Nottingham City NHS (2009) Nursing
practice guidelines: pressure ulcer
prevention and treatment policy.
Nottingham: Nottingham City NHS.
Ratified by: Matrons’ Forum
rd
Date:23 of September 2014
Target audience
All clinical staff involved in patient care
Review Date: (to be applied by the Integrated Governance Team)
A review date of 5 years will be applied by the Trust. Directorates
can choose to apply a shorter review date, however this must be
managed through Directorate Governance processes.
This guideline has been registered with the trust. However, clinical guidelines are guidelines only.
The interpretation and application of clinical guidelines will remain the responsibility of the
individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using
guidelines after the review date.
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1
GUIDELINES
Contents
Page
Guideline summary
3
Introduction
9
Pressure ulcer risk assessment
10
Skin inspection and identifying pressure 14
damage
Equipment and devices used for the
20
redistribution of pressure
Mobilisation and repositioning
23
References
30
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2
Nottingham University Hospitals NHS Trust
CLINICAL GUIDELINES
Pressure Ulcer Prevention Guideline
This document has been developed from the National Institute for Health and
Clinical Excellence Clinical Guidelines (NICE, 2014) and best practice evidence
from the European Pressure Ulcer Advisory Panel and National Pressure Ulcer
Advisory Panel (NPUAP, 2009). Below summarises some of the key
statements in these documents.
Risk assessment
1
All patients must be risk assessed using a valid and reliable risk
assessment tool. This tool should be completed accurately in the
clinical area.
2
All patients will be risk assessed within two hours of admission to
hospital.
3
Risk assessment is the responsibility of a registered nurse, although
preventing pressure ulceration is the responsibility of anyone involved
in patient care.
4
Risk assessment will be undertaken by a registered nurse who has
undergone training in the use and implementation of a risk assessment
tool.
5
Re-assessment will occur weekly. Re-assessment should be more
frequent if a patient is having surgery or if critically ill.
6
All risk assessments must be fully completed, timed, dated, signed and
be made accessible to all members of the multi-disciplinary team.
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7
Risk assessments are only to be used as an aide memoire and should
not replace clinical judgement.
8
Anyone found to be at risk or to have pre-existing pressure damage
should be commenced on a SSKIN-bundle.
9
Every inpatient will have a pressure ulcer careplan commenced which
is appropriate to their level of identified risk.
10
The pressure ulcer care-plan will be evaluated according to the date
set and/or change in the patient’s condition
Skin inspection and documentation
1
A full initial skin inspection should take place using a risk assessment
chart. Full attention should be focussed on examining bony prominences
and the potential for possible device related pressure ulcer damage.
2
If a patient is found to have a pressure ulcer, it should be staged according
to the European Pressure Ulcer Advisory Panel and the National Pressure
Ulcer Advisory Panel grading system (EPUAP and NPUAP, 2009).
3
There should be a recorded statement of the patient’s skin condition both
on admission and discharge from hospital, and on transfer to other
departments/wards in the hospital.
4
If skin damage is encountered on inspection of the skin, a photograph
should be taken and a wound assessment commenced(NUH, 2011).
5
For patients identified at risk, frequency of skin inspection will be
determined by whether the patient is on a red or amber sskin bundle.
6
During inspection of the patient’s skin, the skin tolerance test (commonly
known as the ‘blanche test’) will be carried out on all visible red and purple
areas of skin.
7
Where a patient has heavily pigmented skin, the skin tolerance test is not
as reliable. Extra care should be taken to ensure that skin damage has
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not developed.
8
Patient and carers must be provided with education on skin care and the
prevention of pressure ulcer damage. Leaflets are available on the
intranet for patients and carers.
http://nuhnet/Communications_Marketing/Coporate%20Leaflets/0335v2_P
ressure%20ulcers.pdf
9
Appropriate skin care should be provided for patients that develop
moisture lesions.
Equipment used for the redistribution of pressure
1
The provision of equipment should be based both on a holistic
assessment of the patient, and on clinical judgement. Reference to the
risk assessment tool and to the equipment flow chart should be used when
deciding on what equipment is required.
2
Factors determining the type of equipment ordered may be dictated by the
following
 Level of movement and mobility
 Nutritional status
 Condition of the skin
 Level of pressure ulcer risk
 General health status
 Patient comfort and concordance
 Patient lifestyle
 Ability for the patient to reposition or be positioned
 Bariatric patients
3
Pressure relieving aids may be used for specific parts of the body to
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prevent pressure ulceration and medical device related skin damage. The
types of aids that can be used are
 Heel pads
 Pressure redistribution cushions, wedges and heel boots.
 Non-adhesive tapes that prevent friction damage.
4
Patients who require the use of a long term wheelchair, will need input
from Occupational Therapy and also possibly the Mobility Centre.
5
If a patient is to be sent home and needs pressure relieving equipment
ordering for home you will need to liaise with the Occupational Therapist
who will organise this if they are involved in the patients care. If the OT is
not involved or further advice needed you will need to contact the Tissue
Viability Team.
6
It is crucial that any equipment ordered from the Equipment Library is used
safely. Staff should have an understanding of how the equipment works
and how to spot faults and damage to equipment (NUH, 2013)
Mobilisation and repositioning
1
All patients should be assessed within two hours of admission or transfer
to another ward or unit. All patients identified at risk will be prescribed a
repositioning regime on a SSKIN bundle. The prescribed repositioning
regime will be recorded in the pressure ulcer prevention care plan. There
should also be a daily documented summary of the care given in the
nursing evaluation in relation to what pressure relief has been provided to
the patient.
2
For patients who are acutely ill, at high risk of pressure ulcer development,
or have existing tissue damage to the sacral area or ischial tuberosities, it
is advisable that patients remain on ‘bed-rest’. Whilst on ‘bed-rest’, it is
still possible for rehabilitation to take place if a physiotherapist wants to
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help mobilise the patient. In this situation it is acceptable to help a patient
to stand, walk or to sit on the edge of the bed.
3
The 30 degree tilt is considered good practice when repositioning a patient
in bed.
4
Patients that are sat out in a chair or wheelchair should have a cushion
provided that provides adequate pressure redistribution for that individual
Consideration should be given to postural alignment, feet support, and
heel, elbow protection when a patient is sat out
5
Referral to Occupational Therapy should be considered for advice on
seating and positioning.
6
Referral to Physiotherapy should be considered for advice on passive limb
movements for those patients that are on ‘bed-rest’
7
Correct manual handing equipment should be used to prevent the
possibility of pressure ulcers through friction and shear. Refer to the
manual handling policy for further advice (NUH, 2012).
8
Repositioning regimes should be negotiated and agreed with the patient to
gain concordance.
9
The frequency at which a patient is turned should be reviewed individually
and regularly for that patient in order to determine the effectiveness and
appropriateness of any prescribed repositioning regime.
10
Attention should be made to the skin damage medical devices can cause.
When repositioning a patient, any tubes, wires or drains, should not be
resting against the skin or left to hang free. If any medical devices are in
contact with the skin, a dressing, or non-adhesive tape can be used to
protect the skin underneath.
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Education for staff and patients
1
All healthcare professionals should attend regular training on the
prevention of pressure ulcers.
2
The training and education of healthcare professionals will be organised
and facilitated by the Tissue Viability Service.
3
The Tissue Viability Service will cascade information and updates through
various sources. This will be through the link-nurses, Pressure Ulcer
Podcast , newsletters, nursing induction, ward visits etc.
4
Patients and carers will be provided with information regarding the
importance of maintaining their own pressure area care and on steps they
can take to prevent the formation of pressure damage.
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Introduction
Pressure ulcers have been referred to as pressure sores, bed sores and
decubitus ulcers (Benbow, 2009). Currently, the term ‘pressure ulcer’ has
become the commonly used term for describing these unique ulcers and
describes more accurately their actual aetiology. The European Pressure Ulcer
Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel
(NPUAP) have developed an international consensus on pressure ulcer
definition, classification, prevention and management. They define pressure
ulceration as follows:
“A pressure ulcer is a localised injury to the skin and/or underlying tissue
usually over a bony prominence, as a result of pressure, or pressure in
combination with shear. A number of contributing or confounding factors are
also associated with pressure ulcers, the significance of those factors is yet to
be elucidated.” (EPUAP and NPUAP, 2009, p5)
The use of the word injury in this definition is important as it distinguishes
pressure ulcers from other types of ulcers like venous leg ulcers or diabetic foot
ulcers whose cause is pathological. The injury caused to the skin from directly
applied pressure is influenced by both the duration and intensity of pressure.
Low pressure applied to the skin for several hours will cause similar tissue
damage equivalent to very high pressure being applied for a shorter period of
time (Bryant, 2000). The intensity of pressure applied to the skin results in
capillary closing and prolonged capillary closure occludes the flow of
oxygenated blood to the cells of skin tissue. As a result of this occlusion,
hypoxia and cell death occurs. In a seminary piece of research, Landis (1930)
discovered that capillaries in the skin close when external pressure exceeds
33mmHg. This is important as interface pressures from beds and cushions
quantify the intensity of pressure applied between the skin and the contact
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surface. It has been found that interface pressures vary from 80mmHg on a
standard hospital mattress to 300mmHg on a wheelchair with no cushion
(Nottingham City NHS, 2009; Bryant, 2000). Shear is also mentioned in the
above definition and this occurs in conjunction with gravity and friction. Shear
is created by the interaction of gravity and friction (resistance) against the
surface of the skin. For example, when a patient is sat up in bed the force of
gravity pushes the body downward, but resistance generated by the bed or
chair holds and pushes the skin in the opposite direction. The definition above
also mentions how there are contributing factors which can predispose to the
development of pressure ulceration. These factors are immobility, age,
nutritional status, incontinence etc, but it is not clear as to the degree some of
these factors may contribute to pressure ulcer development. What is interesting
about some of these so called factors, such as immobility, nutritional status and
incontinence, are that they can also be associated with an increase in age. The
degree to which age as a factor contributes to pressure ulcer development may
therefore outweigh some of the effects of the other contributing factors.
1) Pressure ulcer risk assessment
Risk assessment must always be undertaken by a registered nurse who has
undergone training. Most wards and units in the Trust will use the Braden risk
assessment tool to identify patients at risk of pressure ulcer development
(diagram 1). The Childrens’ hospital use the Glamorgan risk assessment tool
(See appendix).
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Critical care areas use the Cubbin and Jackson risk assessment tool (See
appendix 4). Although different risk assessment tools are used, the process of
risk assessment will be the same. Certain areas in the Trust such as outpatients, ED, the neonatal unit, etc. will adapt the advice in this guideline to
ensure appropriate pressure ulcer risk assessments are carried out in their
areas.
The Braden scale has six subscales: sensory perception, skin exposure to
humidity, physical activity, mobility, nutrition, friction and shear turning into skin
damage, with a functional term definition to be checked for each of these
subscales (table 1). When a Braden Score is obtained, a full patient skin
assessment should be carried out. Full attention should be focussed on
examining bony prominences and the potential for possible device related
pressure ulcer damage. The course of action that is taken will be dependent on
the Braden score, if any skin damage is noted on assessment, and also on
clinical judgement. See flow-chart (diagram 2) for guidance on the course of
action to take following assessment.
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Diagram 1 - Braden risk assessment tool
Sensory
Perception
Ability to respond
meaningfully to
pressure related
discomfort
Moisture
Degree to which
skin is exposed to
moisture.
1 Completely
Limited
2 Very Limited
3 Slightly Limited
4 No Impairment
Unresponsive (does
not moan, flinch or
grasp) to painful
stimuli, due to
diminished level of
consciousness or
sedation OR limited
ability to feel pain
over most of body
surface
Responds only to
painful stimuli.
Cannot
communicate
discomfort except
by moaning or
restlessness OR
has a sensory
impairment which
limits the ability to
feel pain or
discomfort over ½ of
Responds to verbal
commands but
cannot always
communicate
discomfort or need
to be turned OR has
some sensory
impairment which
limits ability to feel
pain or discomfort in
1 or 2 extremities.
Responds to verbal
commands. Has no
sensory deficit
which would limit
ability to feel or
voice pain or
discomfort.
3 Occasionally
Moist
4 Rarely Moist
1 Constantly Moist
body.
2 Very Moist
Skin is often, but
not always moist.
Linen must be
changed at least
once a shift.
Skin is occasionally
moist, requiring an
extra linen change
approximately once
a day.
Skin is usually dry,
linen only requires
changing at routine
intervals.
Activity
Skin is kept moist
almost constantly
by perspiration,
urine, etc.
Dampness is
detected every time
patient is moved or
turned.
1 Bedbound
2 Chairbound
3 Walks
Occasionally
4 Walks
Frequently
Degree of physical
activity
Confined to bed.
Ability to walk
severely limited or
Walks occasionally
during day, but for
Walks outside the
room at least twice
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Mobility
Ability to change
and control body
position
Friction and
Shear
Nutrition
Usual food intake
pattern
non-existent.
Cannot bear weight
and/or must be
assisted into chair
or wheelchair.
2 Very Limited
very short distances
with or without
assistance. Spends
majority of each
shift in bed or chair.
3 Slightly Limited
a day and inside
room at least once
every 2 hours
during waking
hours.
4 No Limitations
Makes occasional
slight changes in
body or extremity
position but unable
to make frequent or
significant changes
independently.
2 Potential
Problem
Makes frequent
though slight
changes in body or
extremity position
independently.
Makes major and
frequent changes in
position without
assistance.
Requires moderate
to maximum
assistance in
moving. Complete
lifting without sliding
against the sheets
is impossible.
Frequently slides
down in bed or
chair, requiring
frequent
repositioning with
maximum
assistance.
Spasticity,
contractures or
agitation leads to
almost constant
friction.
1 Very Poor
Moves freely or
requires minimum
assistance. During
a move skin
probably slides to
some extent against
sheets, chair
restraints of other
devices. Maintains
relatively good
position in chair or
bed most of the
time but
occasionally slides
down.
Moves in bed and in
chair independently
and has sufficient
muscle strength to
lift up completely
during move.
Maintains good
position in bed or
chair at all times.
2 Probably
Inadequate
3 Adequate
4 Excellent
Never eats a
complete meal.
Rarely eats more
than 1/3 or any food
offered. Eats 2
servings or less of
protein (meat or
dairy products) per
day. Takes fluids
poorly. Does not
take a liquid dietary
supplement OR is
Nil by Mouth and /or
maintained on clear
liquids or IV’s for
more than five days.
Rarely eats a
complete meal and
generally eats only
about ½ of any food
offered. Protein
intake includes only
3 servings of meat
or diary products
per day.
Occassionally will
take a dietary
supplement OR
receive less than
optimum amount of
liquid diet or tube
feeding.
Eats over half of
most meals. Eats a
total of 4 servings of
protein (meat, dairy
products) each day.
Occassionally will
refuse a meal, but
will usually take a
supplement if
offered. OR is on a
tube feeding or TPN
regimen which
probably meets
most of nutritional
needs.
Eats most of every
meal. Never
refuses a meal.
Usually eats a total
of 4 or more
servings of meat
and dairy products.
Occasionally eats
between meals.
Does not require
supplementation.
1 Completely
Immobile
Does not make
even slight changes
in body or extremity
position without
assistance.
1 Problem
3 No Apparent
Problem
Table 1 – Braden risk assessment sub-scales.
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Diagram 2 – Flow chart for Braden risk assessment.
2) Skin inspection and identifying pressure damage
The skin tolerance test is a method of identifying the difference between
reactive hyperaemia and a grade 1 pressure ulcer.
Reactive hyperaemia can be defined as a temporary reaction to pressure being
applied locally to the skin. The hyperaemia, also known as excess erythema
and redness is caused by vasodilation of the intact capillaries surrounding the
point of pressure. Vasodilation is a natural biological response, which allows
additional oxygen and nutrients to reach the site of pressure to compensate for
the temporary capillary occlusion. Reactive hyperaemia is not a grade 1
pressure ulcer and the redness will resolve following relief of pressure (Bliss,
1999; Collier, 1999)
A grade 1 pressure ulcer is also denoted by hyperaemia or a patch of erythema
where the pressure has been applied. However, reactive hyperaemia will
blanch on the application of light finger pressure, a grade 1 pressure ulcer will
not blanch (EPUAP, 2009).
The skin tolerance test is demonstrated in the following three pictures.
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Hyperaemic response to
pressure.
Press finger over reddened area
for 15 seconds, then lift finger up.
If the area blanches (as in the
picture on the left), it is not a
grade 1 pressure ulcer. If it stays
red and is non-blanchable, it is a
grade 1 pressure ulcer.
For patients with pigmented skin, the skin tolerance test is not as
reliable.
In patients with pigmented skin, observation of erythema is prevented resulting
in the observation of early signs of tissue damage being less visible than lightly
pigmented skin (Scanlon, 2004). Close examination of the skin is required to
ensure that effective preventative strategies can be implemented. Additional
supporting signs to look for are:
 Purplish/bluish discolouration to the localised area of tissue
 Localised heat which, if the tissue becomes damaged, is replaced by
coolness
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 Localised oedema
 Localised induration
 Localised pain
It is also important to note that non-blanching persistent erythema is difficult to
identify when the patient’s circulation is poor, and purplish discolouration may
be detected when ischaemia is present (Scanlon, 2004). In assessing skin, any
colour change is significant and there may be other reasons for the presence of
erythema, such as infection, incontinence dermatitis, and allergic reactions.
Examining the individual’s risk factors and associated conditions is therefore a
pre-requisite to holistic assessment and diagnosis (Scanlon, 2004).
Common sites for the development of pressure ulceration
Diagram - 3 Anatomical sites at risk of developing pressure ulcers. The bony prominences most frequently
affected include the sacrum, ischial tuberosities and the heels.
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The National Institute for Health and Clinical Excellence (NICE, 2014)
recommends the EPUAP and NPUAP (2009) system for grading pressure
ulcers.
Chart 1 – Pressure Ulcer Grading
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Reverse, or retrograde grading is not recommended by the EPUAP (2009)
because it does not accurately define the physiological changes taking place as
the ulcer heals. Wounds that have healed are composed of granulation or scar
tissue that does not replace lost muscle, subcutaneous fat or dermis (Bryant,
2000). Pressure ulcers cannot therefore progress from grade 4 to grade 3 or
subsequently become a grade 2 or grade 1. When a grade 4 ulcer has healed it
should be described as a healed grade 4 pressure ulcer and healing pressure
ulcers should be described using a wound assessment tool (Baranoski and
Ayello, 2004).
There are occasions where it is difficult to determine the stage of an ulcer and
even if the cause of the skin damage is pressure related. Two examples of
pressure damage where classification is difficult are –
Unclassified pressure ulcers
Where the pressure ulcer is unclassified, this may go on to develop into a
stage-4 pressure ulcer once the eschar has been debrided. It may also go on
to develop into a superficial and clean stage-2 pressure ulcer once the eschar
has been debrided.
Suspected deep tissue injury
Suspected deep tissue injury is also difficult to determine. In most cases this
damage will develop in to a full thickness pressure ulcer over time, but there are
occasions when this may resolve causing only superficial skin damage.
Moisture lesions
Skin inflammation resulting from exposure to urine and/or faeces. It manifests
as skin redness, with or without blistering or erosion, and often presents with
irregular shaped edges.
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The affected skin is red with areas of partial thickness skin loss (no necrotic
tissue present) with or without blistering and oozing serous exudates, or
possible bleeding.
It may be over a bony prominence, in skin folds, anal cleft or as peri-anal
irritation. Where there is necrotic tissue within the moisture lesion, this will be a
combination of both pressure and moisture damage (See flow chart 1 and table
2).
Flow chart 1 – Moisture lesion prevention and management
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Table – 2 Moisture lesions
3) Equipment and devices used for the redistribution of pressure
Pressure relieving mattresses and cushions should be sought as soon as
possible when a patient’s level of risk indicates these devices are needed. The
nurse or Occupational Therapist (OT) making this decision should refer to the
equipment flow chart for guidance. The flow chart is only for guidance so there
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will be instances were on clinical judgement the registered nurse or OT feels
that a patient requires a mattress or cushion that provides a greater degree of
pressure redistribution than what is indicated on the flow chart (see flow chart
2).
Flow chart – 2 Pressure Mattresses
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Patients will have the suitability of equipment regularly reassessed taking into
consideration progress or deterioration in:
 Physical condition, in particularly movement and mobility
 Nutritional status
 Skin state
 Level of risk
 General skin assessment
 General health status
 Patient comfort/concordance
 Lifestyle of the patient
 Ability of the patient to reposition, or be repositioned.
 Bariatric requirements
Regular reassessment creates the ability to step a patient down from high risk
equipment once it is no longer needed and vise versa. Stepping patients up
and down from beds and mattresses allows appropriate distribution of these
resources to those patients that need them.
 Pressure reducing aids may be used for specific parts of the body to
prevent pressure ulceration. These aids can also be used to prevent
medical device related skin damage. The types that can be used are Heel
pads
 Pressure redistribution cushions, wedges and heel boots.
 Non-adhesive tapes that prevent friction damage.
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It is crucial that any equipment ordered is used safely. Staff should have an
understanding of how the equipment works and how to spot faults and damage
to equipment (NUH, 2013).
If a patient is to be discharged and needs equipment ordering for home, you will
need to contact the Tissue Viability Team. If the patient is being seen by
Occupational Therapy they may well already be organising equipment for
discharge.
4) Mobilisation and repositioning
All patients should be assessed within two hours of admission or transfer to
another ward or unit. All patients identified at risk will be prescribed a
repositioning regime on a SSKIN bundle (diagram 4 – SSKIN bundle for high
risk patients). The prescribed repositioning regime will be recorded in the
pressure ulcer prevention care plan. There should also be a daily documented
in the nursing evaluation summarising the care given in regards what pressure
area care was provided.
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Diagram 4 – SSKIN bundle for high risk patients.
For patients who are acutely ill, at high risk of pressure ulcer development, or
have existing tissue damage to the sacral area or ischial tuberosities, it is
advisable that they remain on ‘bed-rest’. Although on ‘bed-rest’, it is still
possible for rehabilitation to take place if a physiotherapist wants to help
mobilise the patient. In this situation is acceptable to help a patient to stand,
walk and sit on the edge of the bed.
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The 30-degree tilt provides an alternative position to aid comfort and is
considered effective in reducing interface pressures over bony prominences
(Colin et al., 1996; Preston, 1998; Defloor, 2000). However, this method of
repositioning is only appropriate for pressure ulcer prevention. Evidence
suggests that where patients have existing pressure damage to the sacrum
and coccyx, pressure may in fact be increased using this tilting method
(Okuwa et al., 2005).
30-Degree Tilt Procedure
It is recommended that a minimum of two people carry out this procedure
(Hampton and Collins, 2004). The following pictures illustrate the procedure
whilst the patient is lying in the recumbent position. The bed should be raised
to waist level. Two extra pillows are necessary for this procedure and a third
pillow can be used lengthways to support the other leg if required (Hampton
and Collins, 2004).
Step 1
The patient should be lying in the middle of the bed, with their head
comfortably supported by two pillows. The lower pillow should be positioned to
ensure support for the neck.
Pressure ulcer prevention guideline – Final version Final. Stuart Thompson-Mchale 23/09/2014. Amended October 2015
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Step 2
The patient should be rolled towards one side of the bed. A pillow is positioned
to support the lumbar region and shoulder. This tilts the patient on to one
buttock and lifts the sacrum clear of the mattress.
Step 3
The full length of the leg should be supported by “moulding” a pillow around it.
The heel should be overhanging the end of the pillow to relieve pressure and
care should be taken to avoid pressure being applied to the back of the leg or
calf.
Step 4
An additional pillow may be used to support the other leg, if required. Tuck the
pillow behind the Achilles tendon and ensure that the space behind the knee is
supported by the edge of the pillow. Do not use the full bulk of the pillow to
Pressure ulcer prevention guideline – Final version Final. Stuart Thompson-Mchale 23/09/2014. Amended October 2015
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support this leg as this will distort the bodies’ alignment and cause the patient
discomfort. Again, the heel should be clear of the mattress.
Step 5
The following picture demonstrates the final position of the patient
NB. In the event of foot drop occurring, please refer to physiotherapy for
further advice
Principles of Seating and Positioning
The position within a chair will directly affect the seated person’s posture
(Collins, 1998) and if positioning in the chair is poor, it will disrupt optimum
pressure redistribution (Hampton and Collins, 2004), and comfort will also be
reduced.
Correct seating and positioning will help to:
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 Reduce the patients vulnerability to pressure ulcers
 Reduce discomfort and pain
 Reduce spasm
 Reduce contractures
 Enhance mobility and ability
Aiming for pressure distribution in a neutral sitting position will greatly reduce
pressure ulcer risk (Beldon, 2007). The underlying principle of pressure
redistribution is to relieve pressure as widely as possible by spreading the load
and eliminating localised areas of high pressure. Providing a pressure-reducing
cushion should provide the individual with support and maximise contact
between the patient’s skin and support surface.
Points to remember:
 Inspect cushions regularly to ensure that they are fit for use
 Consider how long a patient will be sitting in one chair or in one position.
This will help you to decide on the most appropriate cushion
 Consider the patient’s risk assessment score and associated risk factors.
This will help you determine an appropriate repositioning regime
 Ensure that there are regular positional changes based on the individual’s
needs
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Best practice guidance
Patients with pressure ulcers will receive an ongoing wound
assessment. This should include:
 Cause of ulcer
 Site/location
 Dimensions of ulcer
Note that the maximum length, width and deepest part of the wound
should be recorded
 Grade
Note that pressure ulcers cannot be reverse graded i.e. a grade 4
pressure ulcer
does not become a grade 3 but is described as a healing grade 4
pressure ulcer
 Exudate amount and type
 Local signs of infection
 Pain
 Wound appearance
 Surrounding skin
 Undermining/tracking
 Odour
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REFERENCES
Baranoski, S. and Ayello, E.A. (2004) Wound Care Essentials. Practice
Principles. London: Lippincott Williams and Wilkins
Beldon, P. (2007) Sitting safely to prevent pressure damage. Wound
Essentials 2: pp. 102-104.
Benbow, M. (2009) Quality of life and pressure ulcers. Journal of Community
Nursing 23(12): pp.14-18.
Bliss, M. R. (1999) Hyperaemia. Journal of Tissue Viability 8(4): pp. 4-13.
Bryant, R.A. (2000) Acute and chronic wounds. Nursing management. 2nd
ed. Missouri: Mosby.
Bliss, M. R. (1999) Hyperaemia. Journal of Tissue Viability 8 (4): pp. 4-13.
Colin, D., Abraham, P. and Preault, L. (1996) Comparison of 90 degrees and 30
degrees laterally inclined positions in the prevention of pressure ulcers using
transcutaneous oxygen and CO2 pressures. Advanced Wound Care 9 (30): 35
– 38
Collins, F. (2000) Selecting the most appropriate armchair for patients. Journal
of Wound Care 9 (2): pp. 73 – 76.
Collins, F. (1998) Sitting pretty. Nursing Times 94 (38): pp. 66-73
Collins, F. and Shipperley T. (1999) Assessing the seated patient for the risk of
pressure damage. Journal of Wound Care 18 (3): pp.123-126
Collier, M. (1999). Blanching and non-blanching hyperaemia. Journal of
Wound Care 8 (2): pp 63 – 64
Pressure ulcer prevention guideline – Final version Final. Stuart Thompson-Mchale 23/09/2014. Amended October 2015
30
Defloor, T. (2000) The effect of position and mattress on interface pressure.
Applied Nursing Research 13(1): pp. 2-11.
European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer
Advisory Panel (NPUAP) (2009) Pressure ulcer treatment: quick reference
guide. Washington D.C.: NPUAP.
Hampton, S. and Collins, F. (2004) Tissue Viability. London. Whurr
Landis, E.M. (1930) Micro-injection studies of capillary blood pressure in human
skin. Heart 15: pp.209-228. Cited in: Bryant, R.A. (2000) Acute and chronic
wounds: nursing management. 2nd ed. St Louis: Mosby Inc.
Okuwa, M., Sugama, J., Sanada, H., Konya, C. and Kitagawa, A. (2005)
Measuring the pressure applied to the skin surrounding pressure ulcers while
patients are nursed in the 30°
position. Journal of Tissue Viability 15(1): pp. 3-8.
Preston, K.W. (1998) Positioning for comfort and pressure relief: the 30 degree
alternative. CARE-Science and Practice 6 (4): pp. 116-119.
NICE (National Institute for Clinical Excellence) (2014) NICE (2014) Pressure
ulcers: prevention and management of pressure ulcers. London: NICE.
Nottingham City NHS (2009) Nursing practice guidelines: pressure ulcer
prevention and treatment policy. Nottingham: Nottingham City NHS.
NUH (2011a) photography and video recordings of living patients confidentiality,
consent, copyright & storage policy [online]. Available at:
http://nuhnet/nuh_documents/Documents/Photography%20And%20Video%20R
ecordings%20Of%20Living%20Patients%20%20Confidentiality,%20Consent,%20Copyright%20and%20Storage%20Policy.
doc [Accessed 29 April].
NUH (2012) Manual Handling Policy. Nottingham: Nottingham University
Hospitals Trust.
Pressure ulcer prevention guideline – Final version Final. Stuart Thompson-Mchale 23/09/2014. Amended October 2015
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NUH (2013) Management of Medical Equipment Devices Policy.
Nottingham: Nottingham University Hospitals Trust.
Scanlon, E. (2004) Pressure ulcer risk assessment in patients with darkly
pigmented skin. Professional Nurse 19(6) 339-341
Authors:
Stuart Thompson-Mchale – Matron for Tissue Viability
Dawn Woolley – Tissue Viability Nurse Specialist
NPGG Link:
For Review:
Ellie Dring – Practice Development Matron
2019
Pressure ulcer prevention guideline – Final version Final. Stuart Thompson-Mchale 23/09/2014. Amended October 2015
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Glamorgan Scale, Paediatric Pressure Ulcer Risk Assessment Scale (2008)
Date of Admission: ____________
Patient Label
Consultant: __________________
Assess baby within 2 hours of admission and then re-assess daily and
every time there are significant changes in baby’s condition
RISK FACTOR
SCOR
E
DATE & TIME OF ASSESSMENTS
(reassess at least daily and every time condition changes)
(If data such as serum albumin or
haemoglobin is not available, write NK
– not known and score 0)
Child cannot be moved without great
difficulty or deterioration in condition /
general anaesthetic
20
Unable to change his/her position
without assistance /cannot control body
movement
15
Some mobility, but reduced for age
10
Normal mobility for age
0
Equipment / objects / hard surface
pressing or rubbing on skin
15
Significant anaemia (Hb <9g/dl)
1
Persistent pyrexia (temperature >
38.0ºC for more than 4 hours)
1
Poor peripheral perfusion (cold
extremities/ capillary refill > 2 seconds
/ cool mottled skin)
1
Inadequate nutrition (discuss with
dietician if in doubt)
1
Low serum albumin (< 35g/l)
1
Weight less than 10th centile
1
Incontinence (inappropriate for
age)
1
TOTAL SCORE
ACTION TAKEN
(Yes or no – Ensure plan of care is
implemented / reviewed for all areas of
concern)
Signature, Print, & Designation
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RISK
SCORE
0
CATORGORY
10 - 14
At risk
15 - 19
High risk
20+
Very high risk
Not at Risk
GOAL: TO PREVENT PRESSURE ULCER DEVELOPMENT
ACTION PLAN
Re-assess at least daily in intensive care and weekly in special & transitional care plus reassess
each time the baby’s condition changes
Inspect skin with nappy changes at least 6 hourly and relieve pressure, by repositioning the
infant.
Record action taken and position of baby on observation chart.
Nurse Infant on a Repose Air Mattress and record in nursing notes.
Use 30 degree tilt if unable to turn baby.
Inspect skin with nappy changes at least 6 hourly and relieve pressure, by moving infant and
repositioning any equipment pressing on skin.
Aim to move or turn before redness develops.
If non blanching hyperaemia is present on skin assessment, reposition baby/equipment more
frequently.
Ensure Infant is on a Repose Air Mattress. (Babies nursed on a cooling mattress or billiblanket
cannot be nursed on a Repose Air Mattress. Skin inspection and repositioning should be a
minimum of 4 hourly – more frequent if skin becomes red)
Use 30 degree tilt if unable to turn baby.
Record action taken and position of baby on observation chart.
Record in ‘Plan of Care for Today’ if repositioning more frequently than 6 hourly is necessary.
Consider using Duoderm extra thin to protect skin from friction
Consider using Dermal Tape under objects pressing on skin
Care as for High Risk babies.
Pay particular attention to objects pressing on skin, remove if possible or reposition object 2-4
hourly, if this can be achieved with minimal disturbance to the baby
Babies requiring minimal handling for cardio-respiratory instability will require careful
assessment to balance skin integrity with minimal handling.
Please record in nursing notes any special circumstances re baby’s cardio-respiratory status and
record in ‘Plan of Care for Today’ the regime for repositioning both equipment and baby
Refer to CPAP guideline for specific care of the nose and NUH Pressure Ulcer Prevention and Treatment Policy for
background information and assessment of non-blanching hyperaemia
Refer to NICU guidelines regarding treatment of anaemia & inadequate nutrition
If unable to reposition baby, please document in nursing notes and state the reason
PRESSURE ULCER ASSESSMENT
Using numbers, indicate on the diagram below any pressure ulcers, then using the box describe the ulcer, the date it was
first observed, and the outcome (resolved or not resolved)
LESION
NUMBE
R
GRADE
DATE
ULCER
FIRST
OBSERVED
BRIEF
DESCRIPTION OF
PRESSURE ULCER
(also document in
child’s nursing record)
OUTCOME
(resolved /
not resolved)
DATE OF
REASSESS
MENT
PLEASE NOW CARRY OUT A WOUND ASSESSMENT
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PRESSURE ULCER CLASSIFICATION GUIDE
Stage 1 – Non-blanching redness of intact skin
Intact skin with non-blanchable erythema of a localized area usually over a bony
prominence. Discoloration of the skin, warmth, oedema, hardness or pain may
also be present. Darkly pigmented skin may not have visible blanching.
Further description: The area may be painful, firm, soft, warmer or cooler
compared to adjacent tissue.
Category/Stage I may be difficult to detect in individuals with dark skin tones.
May indicate “at risk” persons.
Stage 2 – Partial thickness skin loss or blister
Partial thickness loss of dermis, presenting as a shallow open ulcer with a
red/pink wound bed, without slough. May also present as an intact or
open/ruptured serous-filled blister
Further description: Presents as a shiny or dry shallow ulcer without slough or
bruising
This stage should not be used to describe skin tears, maceration or
excoriation caused by incontinence
Stage 3 – Full thickness skin loss (fat visible)
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or
muscle are not exposed. Some slough may be present. Ulcer may undermine
Further description: The depth of a Stage 3 pressure ulcer varies by anatomical
location. The bridge of the nose, ear, occiput and malleolus do not have
subcutaneous tissue so Stage 3 ulcers can be shallow
In contrast, areas of significant subcutaneous tissue (buttocks/hips) can develop
deep Stage 3 ulcers. Bone and/or tendon is not visible or palpable
Stage 4 – full thickness skin or tissue loss (Muscle/bone visible)
Full thickness tissue loss with exposed bone, muscle or tendon. Slough or eschar
may be present. Often undermining visible.
Further description: The depth of a Stage 4 pressure ulcer varies by anatomical
location. The bridge of the nose, ear, occiput and malleolus do not have
subcutaneous tissue and these ulcers can be shallow
Exposed muscle and bone is visible and palpable
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Nottingham University Hospitals NHS Trust
MOISTURE LESION GUIDE
Skin inflammation resulting from exposure to urine and/or faeces. It manifests as skin
redness, with or without blistering or erosion and often presents with irregular shaped edges.
The affected skin is red with areas of partial thickness skin loss (no necrotic tissue present)
with or without blistering and oozing serous exudate or possible bleeding.
It may be over a bony prominence, in skin folds, anal cleft or as peri anal irritation. Where
there is necrotic tissue within the moisture lesion, this will be a combination of both pressure
and moisture damage.
Pressure ulcer
Moisture lesion
Cause
Pressure and/or shear
Moisture; shining wet skin
Location
A wound not over a bony
prominence is unlikely to be a
pressure ulcer
Shape
Circular or regular shape, limited to
one spot. Exclude possible friction.
Depth
Partial - full thickness, from grade 2
– grade 4
Necrosis
Present in full thickness pressure
damage
No necrosis or eschar present
Edges
Distinct edges, clear demarcation.
Raised edges usually chronic
Diffuse, irregular edges
Colour
Red, yellow, green, black
May be over bony prominence, in
skin folds, anal cleft, peri-anal
redness/skin irritation
Diffuse superficial spots or irregular
shape.
Linear shape in cleft and skin folds
Superficial – partial thickness skin
loss
Redness that is not uniformly
distributed.
Pink or white maceration
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Pressure Ulcer Prevention Adult Critical Care
AICU, CCD, D56 and E12
Nursing Documentation Required:
Cubbin & Jackson Assessment Guide
Protocols of care for pressure damage prevention A and / or B
Critical Care Cubbin & Jackson Assessment Record
The enclosed document provides you with the assessment tools and protocol of
care for the assessment of patients who are at risk of developing pressure ulcers
in critical care areas.
The following policy statements are in line with European Pressure Ulcer
Advisory Panel Guidelines (2010), NICE (2014), NUH Pressure Ulcer Prevention
Guideline (2014)
The Cubbin & Jackson risk assessment will be completed within 6 hours of the
patient’s admission to the department then reassessed every 24 hours or
sooner if the patient’s condition changes and documented.
The appropriate protocol of care will be followed depending on the outcome of
the Cubin and Jackson score.
 If a score of 29 or less or any pressure damage is present Protocol B must
be followed.
 Each patient position change will be documented on the critical care 24 hour
chart, if patient is too unstable to change position this must be documented by
the doctor in the medical notes.
 If the patient is showing signs of sleep deprivation or delirium and has no
current pressure damage, 4 hourly turns can be commenced overnight to aid
sleep in the best interests of the patient and documented in the nursing notes
the rationale for this decision.
 The patient’s skin must be checked at sites identified as “at risk” by invasive
equipment as per guidance
 This document must be completed in addition to the Wound Treatment Plan
 Refer to the Trust Pressure Ulcer Prevention Policy and Treatment Guidelines
for further supporting evidence and guidance.
 All Stage 3, 4 and unstageable pressure ulcers must be referred to the Tissue
Viability Team.
 A Clinical Incident Form must be completed for any newly developed hospital
acquired pressure ulcers.
 Any pressure damage classed as stage 2, 3 or 4 must be photographed and
uploaded to Web Hiss.
 A RCA must be completed for all newly developed stage 3 and above pressure
ulcers.
 Moisture lesions are t to be reported on Datix as a moisture lesion and not
classed as pressure damage.
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Tissue Viability Protocols of care for pressure damage prevention,
for use in conjunction with Cubbin & Jackson pressure ulcer risk assessment tool
ALL PATIENTS WITHIN CRITICAL CARE WILL BE NURSED ON A CLINACTIV MATTRESS UNLESS
CLINICAL CONDITION INDICATES ALTERNATIVE BEDFRAME AND MATTRESS e.g. a respistar (for
respiratory therapy), duo mattress (for stage 4 pressure ulceration), burns patients consider Clinactive Zephr
All patients
Protocol A – At Risk
Patients scoring
between 40 and 30
Action
A Complete head to toe assessment of skin integrity is undertaken
twice every 6 hours.
Graduated compression stockings removed twice in a 12 hour
period to permit inspection of heels and legs, SSKIN code to be
documented on 24 hour chart and then re-applied.
Intermittent pneumatic compression devices (Flowtrons) removed
every 4 hours, skin inspected and SSKIN code documented on 24
hour chart, then re-applied.
Patient is repositioned every 4 hours & a recorded position change
is documented on the 24 hour chart using SSKIN bundle codes
Patient is actively encouraged to move & be involved in
repositioning where appropriate
Saturation probe is re-positioned every 4 hours & SSKIN code
documented on 24 hour chart
Catheter G strap to be changed to alternate legs every 4 hours and
labia or penis checked and SSKIN code documented on 24 hour
chart.
Pillows are appropriately placed to prevent bony prominences from
having direct contact with each other
Oedematous limbs are raised to reduce swelling unless medically
contra-indicated, using appropriate aid e.g. pillow
Heels, if red, free from pressure by offloading with pillows or repose
boots.
Sheets are as crease free as possible and no objects, catheters or
lines are located underneath the patient
A pressure relieving cushion must be used if the patient is sat out &
recorded in nursing documentation
Skin is cleansed immediately after any episodes of incontinence
and appropriate continence aids are used
Appropriate manual handling devices are used to minimise friction
and shearing on repositioning
Liaise with other specialist teams as indicated; continence,
dietetics, pain and physiotherapy
Protocol B – High
Risk
Patients scoring 29 or
less
All of actions above
Patient / carer is given Trust information booklet on pressure ulcer
prevention
A Complete head to toe assessment of skin integrity is undertaken
twice every 4 hours.
Graduated compression stockings are removed every 4 hours to
permit inspection of heels and legs, SSKIN code to be documented
on the 24 hour chart and then re-applied.
In the presence of heel ulceration, consider alternative methods of
DVT prophylaxis, e.g. intermittent pneumatic compression devices
Pressure ulcer prevention guideline – Final version Final. Stuart Thompson-Mchale 23/09/2014. Amended October 2015
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with the addition of
these
(Flowtron)
Patient is repositioned every 2 hours & a recorded position change
is documented on the 24 hour chart using SSKIN bundle codes
Patient limited to one hour (with pressure relieving cushion) sat out
in a chair.
Catheter G strap to be changed to alternate legs every 2 hours and
labia or penis checked and SSKIN code documented on 24 hour
chart.
Tissue Viability Protocols of care for pressure damage prevention,
for use in conjunction with Cubbin & Jackson pressure ulcer risk assessment tool
Specific care for invasive equipment at risk of causing pressure damage
All patients
Patients with Endotracheal tube (ETT)
with tapes in situ
Patients with Endotracheal tube (ETT)
with an anchor fast in situ
Patients with tracheostomy tube
(Discuss with doctors first if surgical
Tracheostomy)
Patients with Naso Gastric Tubes
Ears due to oxygen delivery device and
nasal bridge due to NIV mask
Patients with spinal precautions
Action
Change the tapes and reposition the tube
documenting on the 24 hour chart every
– 12 hourly for protocol A
- 8 hourly for protocol B
Skin inspections to take place and a SSKIN code
documented on the 24 hour chart every 4 hours
for each protocol of care.
The anchorfast can remain in situ 5-7 days (see
additional guideline of care for more information)
The tube should have the position changed and
documented and skin inspections to take place
and a SKKIN code documented on 24 hour chart
every
- 4 hourly for protocol A
- 2 hourly for protocol B
Remove site sutures after 5 days unless
otherwise indicated.
Skin inspection 4 hourly and SSKIN code
documented on 24 hour chart, change tapes 12
hourly and documented on 24 hour chart.
Wound care plan assessment daily.
Skin inspection 4 hourly for protocol A, 2 hourly
for protocol B and SSKIN code documented on
24 hour chart
Retention Dressing changed every 24 hours or as
required
Ensure ears and nasal bridge are checked and
SKKIN code documented on the 24 hour chart
every
- 4 hourly for protocol A
- 2 hourly for protocol B
Examine under the front of the collar 4 hourly,
SSKIN code documented on 24 hour chart.
Discuss with orthotics of the collar is a poor fit or
in situ for a prolonged period for an alternative
collar to be provided.
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Other equipment causing potential
pressure ulcer risk problems:Splints /halo traction/x fix/POP
Patients nursed in prone position
Elevate limbs to prevent oedema
Check traction pin sites and skin under halo
jacket 4 hourly. If concerned or unable to assess
skin beneath halo jacket contact orthotics
department and document concerns.
Check areas that are visible around POP and for
perfusion to limbs, document any changes and
discuss with plaster nurses if a change in the
POP is required.
Nursed on respistar bed
Arm and head position changed as per proning
protocol & documented on 24 hour chart
Pillows are appropriately placed to manage
generalised oedema
DO NOT prone with anchorfast in situ
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