Clinical
Assessment, Prevention and Management of Pressure Ulcers
Policy
Document Control Summary
Status:
Version:
Author/Title:
Owner/Title:
Approved by:
Ratified:
Related Trust Strategy
and/or Strategic Aims
Implementation Date:
Review Date:
Key Words:
Replacement.
Replaces C/YEL/cm/17 (Pressure Ulcers Policy 2011)
v1.0
Date:
March 2016
Pat Wain – Associate Director of Physical Health
Kenny Laing – Deputy Director of Nursing
Policy and Procedures Committee
Date:
Trust Board
Date:
Awaiting
Ratification
Clinical Strategy
March 2016
March 2019
Bed sore, nursing care, pressure sores
Associated Policy or
Standard Operating
Procedures
Contents
1.
Introduction .............................................................................................................. 2
2.
Purpose ..................................................................................................................... 2
3.
Scope ........................................................................................................................ 2
4.
Pressure Ulcers ........................................................................................................ 3
5.
Assessment / Management Guidelines................................................................... 3
6.
Key Priorities for Assessment ................................................................................. 4
7.
Pressure Ulcer Prevention ....................................................................................... 6
8.
Skin Care................................................................................................................... 6
9.
Treatment of Existing Pressure Ulcers ................................................................... 7
10.
Removing Damaged Skin......................................................................................... 8
11.
Education .................................................................................................................. 8
12.
Process For Monitoring Compliance And Effectiveness ....................................... 8
13.
References ................................................................................................................ 8
Assessment, Prevention and Management of Pressure Ulcers Policy/March 2016
Change Control – Amendment History
Version
Dates
Amendments
1. Introduction
This policy supports the national drive to improve the quality of care in relation to reducing
harm to patients by pressure area damage, in collaboration with the national nursing
strategy, ‘Compassion in Practice’ and previous ‘High Impact Actions for Nursing’, which
both set standards of no avoidable pressure ulcers within the care environment by providing
guidance on the early identification of patients at risk of developing pressure ulcers.
Recommendations apply equally across the primary and secondary care interface, including
specialist units, for example older people and eating disorders services.
“Avoidable” means that the person receiving care developed a pressure ulcer and the
provider of care did not do one of the following:
• Evaluate the person’s clinical condition and pressure ulcer risk factors.
• Plan and implement interventions that are consistent with the person’s needs and goals
and recognised standards of practice.
• Monitor and evaluate the impact of the interventions or revise the interventions as
appropriate.
2. Purpose
The Trust has a duty to ensure the protection and safety of service users in receipt of care,
from avoidable pressure ulcers by the development and deployment of an evidence based
policy and training.
3. Scope
It is the responsibility of all divisional directors, service managers and ward managers to
ensure that all staff are aware of the Trust policy for pressure ulcer prevention and
management. Managers should also ensure that clinical staff follow the Authorised
Documents Policy relating to receipt of policies.
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Assessment, Prevention and Management of Pressure Ulcers Policy/March 2016
Senior managers have a responsibility to identify any issues which mitigate against the
implementation of this policy within clinical practice and identify any staff training deficits.
All staff working in clinical areas are responsible for ensuring that patients physical
healthcare is subject to assessment and necessary intervention. This policy provides the
framework for ensuring that those most at risk of developing pressure area damage are
identified and clinical interventions are undertaken in a timely way to prevent or improve
them.
4. Pressure Ulcers
Pressure ulcers, commonly referred to as pressure sores, bed sores, pressure damage,
pressure injuries and decubitus ulcers, are areas of localised damage to the skin, which can
extend to underlying structures such as a muscle and bone. Damage is believed to be
caused by a combination of factors including pressure, shear forces, friction and moisture.
They can develop in any area of the body and in adults damage usually occurs over bony
prominences such as the sacrum.
Pressure ulcers are more likely to occur in those who are seriously ill, neurologically
compromised, have impaired mobility, suffer from impaired nutrition or do not avail of
appropriate pressure relief. In addition a combination of poor mobility, particularly in the
elderly and medication with sedative action, can contribute to the development of pressure
ulceration.
5. Assessment / Management Guidelines
The patient’s risk of developing a pressure ulcer and the extent of any existing damage will
be assessed at first contact, and reassessed throughout an individual’s episode of care. A
plan of care will be drawn up, carried out, and reviewed regularly. NICE recommends that
healthcare professionals work together with patients so that patients can play where
possible, an active part in making decision about their care. The treatment offered should
therefore take into account patient’s individual needs and preferences.
Screening / Assessment should always be undertaken at initial contact and the need for
reassessment of patients / clients should be continuously considered using a Waterlow
pressure ulcer risk assessment tool. (see separate Associated documents). Adapted for
service users with an eating disorder (see separate Associated documents).
Risk assessment tools should only be used as an adjunct to clinical judgement and should
not replace it.
Examine all patients fully taking into account the presence of any of the risks described
under the headings below:
 Mobility – Patients with impaired consciousness, undergoing prolonged surgery /
procedure (i.e. on table >2 hours) or who have paralysis, neuropathy or orthopaedic
trauma (below waist / spinal)
 Patients who have impaired ability to reposition themselves or where activity is
limited to bed or chair. Epidural anaesthesia may increase patient risk of developing
pressure damage.
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Assessment, Prevention and Management of Pressure Ulcers Policy/March 2016

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Skin Health & Nutrition – Poor nutritional status.
Previous history of pressure ulcers, inflammation, disease, oedema or thinning
(tissue paper) of skin. Body parts affected by anti-embolic stockings.
Tissue perfusion and oxygenation – Very poor tissue oxygenation occurs in patients
with severe illness. In the presence of shock, hypoxia, low blood pressure or when
medicated with high dose of steroids, vasoconstrictors or inotropes; and in those with
cardiac failure, vascular disease, anaemia, multiple chronic disorders.
Neurological deficits e.g. diabetes, multiple sclerosis, cerebro-vascular accident,
paraplegia; and in smokers.
Incontinence – Urine and faeces and other body fluids can rapidly cause maceration
or excoriation damage to the skin.
For all patients / clients identified at risk screening must progress to further assessment.
6. Key Priorities for Assessment
An initial and on-going risk assessment in the first episode of care (within 6 hours)
The pressure ulcer grade should be recorded using the European Pressure Ulcer Advisory
Panel Classification system. (see separate Associated documents).
An initial and on-going pressure ulcer assessment process should be in place supported by
photography and/or tracings with measurements
All those identified as vulnerable to pressure ulcers should as a minimum be placed on a
high specification foam mattress.
Patients with grade 1-2 as a minimum should be placed on a high specification foam
mattress/cushion with pressure-reducing properties and be closely observed for skin
changes
Patients with grade 3 -4 pressure ulcer should at a minimum be placed on high specification
foam mattress with an alternating pressure overlay, or a sophisticated continuous low
pressure system, air flotation. See mattress assessment (see separate Associated
documents).
The optimum wound healing environment should be created by using modern dressings e.g.
hydrocolloids, hydrogels, hydrofibres, foams, films, alginates, soft silicones.
Following further / comprehensive assessment of those ‘at risk’ record the risk and record
your assessment of the patients risk, e.g. LOW, MEDIUM or HIGH RISK
Patients with acute illness who have many of the above factors present are likely to be at
HIGH RISK of developing pressure ulcers, patients with fewer factors MEDIUM RISK, many
self-caring patients with few of the above factors may be considered to be at LOW RISK.
Examine your patient fully, especially vulnerable areas – any bony prominence. Describe
any existing pressure ulcers / tissue damage.
Record comprehensively in the plan of care the location and history of the pressure ulcer –
when it appeared, what treatment has been given, the grade of the pressure ulcer (see
below).
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Assessment, Prevention and Management of Pressure Ulcers Policy/March 2016

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GRADE 1 – Discolouration of intact skin, including non-blanching hyperaemia (i.e.
redness that persists when fingertip pressure released).
GRADE 2 – Partial-thickness skin loss or damage involving epidermis and / or
dermis.
GRADE 3 – Full thickness skin loss involving damage or necrosis of some
subcutaneous tissues.
GRADE 4 – Full thickness skin loss with extensive destruction and tissue necrosis
extending to the underlying bone tendon or joint capsule.
BLACK NECROTIC – Grade cannot be determined document, black necrotic tissue.
Record the dimensions of the ulcer; length, width, and estimate of depth cm;
presence of sinus tracts, tunnelling, and odour.
Record the appearance of the ulcer on formal wound assessment chart (see separate
Associated documents). and Wound Treatment Care Plan.
 Necrotic (black)
 Sloughy (Yellow/Green)
 Granulating(Red)
 Epithelialising(pink)
 Haematoma
 Bone/tendon visible
 Amount and description of any fluid exudates e.g. serous, pus or bloody) Record
condition of surrounding skin e.g. dry, scaly, oedema, eczema, cellulitic, inflamed,
discoloured or moist.
Improve nutritional status – malnutrition delays, inhibits and complicates the process of
wound healing.
Food nutrition facilitates the process. Neglecting nutrition can compromise all other wound
management plans and have resource implications.
The key nutrients involved in good wound healing are carbohydrate, fat, vitamins especially
A and C, iron and zinc. The optimum way to meet the requirements for these nutrients is
from normal food. Supplementation and excessive consumption may have a detrimental
impact.
Assessing nutritional status is essential to help recognise and limit malnutrition and
dehydration and its effect on wound healing. Assessment will ensure the identification and
correction of the underlying cause (s) AND address any shortfall.
The Nutrition / Hydration guidelines should be used to assess and manage the diet and fluid
needs of service users. Ready reckoners for weight loss management and acceptable fluid
intake comparable to age and weight are available for use.
(see separate Associated documents).
All completed Waterlow assessments and subsequent required information must be
recorded for each service user on the Trust Electronic Patient Record RiO.
All pressure ulcers graded as 3 and above must also be reported through the incident
reporting process and additionally reported to the Associate Director of Physical Healthcare
through matrons.
Any pressure ulcer graded as a 4 should be reported as a SERIOUS INCIDENT and the
policy for serious incident reporting must be followed.
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Assessment, Prevention and Management of Pressure Ulcers Policy/March 2016
7. Pressure Ulcer Prevention
The following steps should be considered in the prevention of pressure ulcers/ damage:

 Relieve pressure – use correct handling techniques.
 Manual handling devices should be used correctly in order to minimise shear and
friction damage.
 After manoeuvring, slings, sleeves or other parts of handling equipment should not
be left underneath individuals.
 Avoid positioning on a pressure ulcer or on a vulnerable area.
 Patients who are ‘at risk’ should be repositioned and the frequency of repositioning
determined by the results of skin inspection and individual needs not by ritualistic
schedule.
 Positioning of patients should ensure that; prolonged pressure on bony prominences
is minimised and that bony prominences are kept from direct contact from one
another to minimise friction and shear damage.
 A repositioning schedule, agreed with the individual, should be recorded and
established for each person ‘at risk’.
 Individuals should when able, be encouraged to do circulation and stretching
exercises. Physiotherapy advice should be sought for these movements.
 High risk individuals should restrict chair sitting to less than 2 hours until their general
condition improves.
 Individuals / carers, who are willing and able, should be taught how to redistribute
weight.
 Individuals identified as High Risk may require a pressure reducing foam mattress
Med – high risk or an upgrade to a dynamic pressure-relieving mattress.
Use of aids: The following should not be used as pressure reducing / relieving aids:

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Water filled gloves
Synthetic sheepskins
Genuine sheepskins
Doughnut type devices
8. Skin Care
Skin inspection should be based on an assessment of the most vulnerable areas of risk for
each patient. Older age adults and people with an eating disorder who have lost body mass
are particularly at risk. These patients will have lost body mass, are not very mobile and are
at risk from pressure, shearing and friction forces. These areas are typically:
 Heels
 Sacrum
 Ischial tuberosities
 Parts of the body affected by anti-embolic stockings
 Femoral trochanters
 Parts of the body where pressure, friction and sheer are exerted in the course of
individuals daily living activities.
 Scapular and shoulder region
 Vertebrae
Individuals who are wheel chair users should be encouraged to use a mirror to inspect areas
that they cannot see easily or get others to inspect them.
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Assessment, Prevention and Management of Pressure Ulcers Policy/March 2016
Health care professionals should be aware of the following signs which may indicate
incipient pressure ulcer development:
 Persistent Erythema
 Non-blanching hyperaemia
 Blisters
 Discolouration
 Localised heat
 Localised oedema
 Localised induration
In those with darkly pigmented skin:
 Purplish / bluish localised areas of skin
 Localised heat, which, if tissue becomes damaged, is replaced by coolness.
Signs of Infection; one or more of the following indicate a possible infection and prescribing
guidelines if applicable should be followed:
 Heat
 New Slough
 Increasing Pain
 Increasing Exudate
 Increasing Odour
 Friable Granulation Tissue
Skin changes should be documented / recorded immediately on the formal wound
assessment chart and a care plan developed and appropriate action taken.
A plan of care should be documented within the integrated health records, and wound
treatment care plan and reviewed at least weekly or more often if there is a change in an
individual’s condition.
Patient / carers should be included within the assessing and planning and information /
education provided on the following:
9. Treatment of Existing Pressure Ulcers
To help to heal as quickly as possible NICE recommends the use of modern dressings.
Some examples are listed below but in addition consult the local
Wound Care Formulary available from the Chief Operating Officer’s Directorate.

 Hydrocolloids – an adhesive dressing that gels over the wound but sticks to the
surrounding skin
 Hydrogels – a simple gel that keeps wounds moist and can help clean wounds
 Foams – available in different shapes and sizes. Foams are designed to absorb and
retain fluid.
 These specialist dressings should be used in preference to basic dressings such as
gauze, paraffin gauze and simple dressing pads.
 Sometimes in complex wounds, other treatments may be needed including electrical
stimulation, which uses electrical currents to promote healing, and negative pressure
therapy where suction is applied to the wound. For advice consult with the Thief
Operating Officer’s Directorate.
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Assessment, Prevention and Management of Pressure Ulcers Policy/March 2016
10. Removing Damaged Skin
In some cases it may be necessary to remove dead tissue from an ulcer to encourage
healing. This is called ‘debridement’ and can be done with dressings or cutting away areas
of dead tissue. Advice on this should be sought from the Chief Operating Officer’s
Directorate
11. Education
All relevant healthcare professionals will be updated in the prevention and treatment of
pressure damage and will attend up-dates every 2 years or as directed.
The training will ensure that staff are well informed in order to advise patent/client and their
carers of the elements of risk of pressure damage and their role in maintaining tissue
integrity.
12. Process for Monitoring Compliance and Effectiveness
Information to follow
13. References
Information to follow
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