PRESSURE ULCER question
General stats and shit
Dryness of skin (xerosis) may = problems wtih skin barrier (Penzer & Ersser 2010)
Primary effect of pressure on skin occludes capillaries disrupts blood flow and reduces nutrient
transport. Pressure effects = immobility bed rest or too long in a chair. Key pathological mechanism
include injury from an abrupt reperfusion of capillary bed following occlusion of blood flow (Nixon
2001). Massive reperfusion = reactive hyperaemia which increases metabolite release from anoxic
cells and increase damage due to forces such as shear and cell death because fo prolonged direct
occlusion of blood vessels.
Factors affecting poor skin health: elderly very vulnerable, smoking, vascular disease or diabetes,
end stage renal failure, spinal cord injury (Walmsley and Wiles 1990).
Non blanching definition = returns to colour no less than 1-2 seconds Michael and Gillot 1991
Patients to receive pressure ulcre leaflet on admission
Bennett et al 2004: cost of treat grade 1 = £1,064, grade 4 = £10,551. Annual cost £1.4-£2.1 billion
Practices to prevent skin breakdown while washing – avoid excessive use of soap, where possible
use soap substitutecleanser, water not too hot, no harsh drying and emollients may be used (Penzer
& Ersser 2010).
Guidelines useful but set out different levels of evidence
Acknowledgement that risk assessment tool should be use but acknowledge that no tool is better
than another – most use Waterlow. All guidelines say use tool as aide memoire/adjunct to clinical
judgement not in replacement of.
Study that said using a tool is not proof of quality of care – reduction in PU is only proof.
Financial implications of shoving all at risk patients onto pressure relieving devices – should be
available to all patients 24hours/day but not – RCN 2005 recommendations about stage 1 – 2 on
high specification foam mattress only 3 – 4 on alternative pressure overlay too – case study RCN
PU are economic burden on NHS – 4% of NHS budget (Bennett et al 2004)
PUs are detrimental to patients physically, psychosocially and reduce quality of life maybe increase
mortality (Fox 2002).
Prevalence and incidence of PUs are key indicator of quality of care Clary 2000
Proof of what factors cause PUs is limited maybe should do structural equation modelling. Emphasis
on holistic approach, cost effectiveness, accountability and responsibility, MDT and IDT working –
referral to specialist services – TVN, dieticians, physios, OTs, etc.
Ethics of testing patients without risk assessment tool – Flanagen 1995 said would involve waiting
for breakdown of tissue and withholding assessment frompatients – ethically unacceptable. But
Vanderwee et al 2005 – no sig difference in PU dev for 2 groups – exp group Braden + NBE ctrl group
just NBE and random allocation to high specification foam mattress or alternating pressure overlay –
high sensitivity meant double amount of patients in exp group ended up on special mattresses.
Cultural stuff on assessing dark pigmented skin:
- Colour of dark pigmented skin may not blanch when pressure applied
- Localised skin colour changes can occus where pressure is applied
- Local areas of intact skin subject to pressure may be warm or cool when touched – do
without gloves – clean body fluids off first
- Healed areas may be lighter in clour
- Oedema +/- induration and skin may be taut and shiny
- Complaints of pain or discomfort
- RCN 2005
Management of PUs in primary and secondary care. By RCN, quality improvement programme and
guideline development group (GDG) funding from NICE.
Principles of practice
- Person centred care
- Information available for the public
- Patients and carers should be involved in decision making
- HCWs respect and incorporate knowledge from patients who have had or have a PU
- Patients and carers informed about risks of getting PU
Collaborative interdisciplinary working
- All members of MDT should be aware of guideline
- Integrated approach to management of PU clear strategy, policy, supported by
management. Commitment to education and training and all staff to update knowledge.
PUs more likely to occur:
- Seriously ill
- Neurologically compromised and spinal injuries
- Reduced mobility (Allman, 1997)
- Reduced nutrition (Casey 1998)
- Obesity (Gallagher, 1997)
- Poor posture
- Elderly e.g. Orlando 1998
- Pregnant mothers (Prior 2002)
Need to understand cost effective interventions
Previous systematic reviews little evidence massive call for more research.
Excluded studies if looked at interventions to reduce PU, study did not report costs.
Levels of evidence
1++ high quality meta-analyses systemative reviews of RCTs or RCTs and minimal bias
1+ well conducted meta-analyses
1- Metanalyses sytemative review with increased bias
2++ high quality systematic reviews of case control or cohort studies
4 expert opinion
Do not use ‘-‘ to give recommendations
But use expert opinion – are metaanalyses or systematic reviews with increased risk of bias not
better than expert opinion?
Grading of evidence:
A=at least 1 systematic review or metanalysis rated 1++ directly applied to target population or
systematic review of RCT rated 1+
B= body of evidence including studies 2++ directly attributable to target population
C = body of evidence 2+ directly attributable to target population
D = evidence basically case series or expert opinion or extrapolated evidence from 2+
D GPP = good practice point – recommended for best practice based on experience of GDG.
Authors argue that if there’s no scientific evidence still better to have expert opinion than to give no
recommendations (Woolf, 1992)
More useful to practitioners to have consensus based guidelines where no evidence base research
to use. Consensus at 80%+
RCN on Assessment tools:
- No consensus about which tool to use.
- Allman et al 1995 multivariate analyses identified significant risk factors for grade 1 – grade
2 PU progression:
o Stage 1 PU (obviously!)
o Dry skin
o Reduction in body weight
- Braden scale scored high for patients without PU than for those with (Williams et al 2000)
Only clear evidence is that if someone has a grade 1 PU it will progress to grade 2 PU 2+
Recommendations for what to include at assessment (level D):
- Health status: acute/chronic/comorbid e.g. diabetes, malnutrition
- Mobility status – all aspects to be recorded D
- Sensory impairment - GPP
- Loss of consciousness
- Systemic signs of infection GPP
- Nutritional status
- Previous pressure damage D
- Pain status D
- Psychological factors – motivation to care D
- Social factors – suitability of home environment support of local services D
- Continence status GPP
- Cognitive status
- Blood flow
Authors put this at D level which can include extrapolated evidence from 2+ study – Allman et al
1995 only gave evidence for importance of nutritional status and mobility status.
Also said gold standard design for investigating risk factors is prospective cohort design – no
Pressure relieving devices
Examined relative risk (PUs healed in exp group / PUs healed in control group) of 15 air mattresses.
Methodological flaws in each – namely small sample sizes
Paucity of good quality evidence to guide current clinical practice – poor quality of current trials lack
of replication in most comparisons. Many trials under powered – failure to detect clin sig differences
as statistically sig. Other problems = open randomisation, lack of baseline comparison. Further
research should address these deficiencies.
Some evidence air flotation reduce size of PUs compared to modified alternating pressure support.
No conclusive evidence to support the superiority of either alternating pressure support surfaces or
continuous low pressure supports in treatment of existing PUs.
Recommendations: pressurerelieving support surfaces
- Patients with PUs should have access to appropriate pressure relieving support surfaces
including mattresses cushions and repositioning 24 hours/day D
- Decisions about choice of pressure relieving support surfaces for patients with PUs should
be make by registered HCPs D
- Initial choice and subsequent decisions, following re-assessments related to provision of
pressure relieving support surfaces for patient swtih PUs should be based on D:
o Ulcer assessment (severity)
o Levels of risk from holistic assessment
o Location adn cause of ulcer
o General skin assessment
o General health status
o Acceptability and comfort for patient
o Lifestyle of patient
o Ability of patient to reposition themselves
o Availability of carer/HCP to reposition patient
o Cost consideration
- All individuals assessed as having grade 1-2 PU should be at least on a high specification
form mattress or cushion with pressure reducing properties combined wtih very close
observation of skin changes and documented positioning and repositioning regime D
- Perceived or actual deterioration of affected areas or further ulcer development an
alternative pressure (replacement or overlay) or sophisticated CLP system (low air loss, air
fluidised, air flotation, viscous fluid) should be used D. n.b individuals requiring bed rails AP
overlay should be placed on reduced depth foam mattress to maintain safety
Safe use of pressure relieving devices
1. Ensure mattress does not elevate individual to unsafe height
2. Ensure individual is within recommended weight range
3. Stuff about kids (not rel)
- EPUAP 2003 – nothing about incontinence just moisture
European Pressure Ulcer Advisory Panel (EPUAP) quick reference guide for prevention and
treatment of Pus used by HCWs across world.
Disclaimer – may not be appropriate for use in all settings, believe research supports
recommendations but can’t guarantee reliability and accuracy of individual studies (only what has
been reported). Educational and information purposes only.
Levels of evidence:
1 = large RCTs with clear cut results and low risk error
2 = small RCTs with uncertain results and mid to high error
3 = non random with moderate concurrent controls
4 = non RCTs with historical controls
5 = case series no controls
A = direct scientific evidence good study design stats results RCTs (level 1)
B = same as above but clinical series (levels 2, 3, 4, 5)
C = indirect evidence/expert opinion
Gives categories for grading – stages 1 – 4.
When considering prevention must know what stage 1 looks like: Non-blanching erythema = at risk
patients. So stage 2 + = full blown PU.
Risk assessment policy: the level next to statement is the level of evidence upon which teh
statement is based.
Need established risk assessment policy in all HC settings – timely documentation and
communication of risk level C (i.e. indirect evidence for this statement).
Educate HCWs to achieve reliable risk assessments level B
Document all risk assessments - care planning as benchmark to monitor progress level C
Structured appropriate to risk assessment – identify patients at risk level C risk assessment plus
comprehensive skin assessment and clinical judgement. This + skin care teams educational and care
protocols can reduce incidence of PUs.
Consider individuals who are bedfast and chairfast to be at risk – include mobility assessment – level
Include comprehensive skin assessment – consider individuals with alterations to skin e.g.
dry/erythema to be at risk. Level C
Structure approaches to risk assessment refined through clinical judgement e.g. knowledge of key
risk factors level C
Consider: Malnutrition – anaemia, HG, serum albumin weight – ME – NO STRICT GUIDELINES?!
Factors affecting perfursion – oxygenation – diabetes, vascular instability, hypotention, use of O2
Skin moisture, excessive + dry = risk
Consider impact of friction and shear (Braden), sensory perception, general health status, body
Structured risk assessment on admission and repeat reassess if patient’s condition changes level C
Develop prevention plan for those at risk Level C. What should be in prevention plan? ME – WE
NEED A FIRST LINE OF ACTION PLAN FOR TREAT/PREVENT STAGE 1 – 2 PUs.
Ensure skin assessment is part of risk assessment level C timing and documentation
Education professionals on how to do comprehensive skin assessment including how to assess NBE
heat oedema induration. Level B – underdetected in darker skin pigments.
Skin inspection should include assess for localised heat, oedema and hardness.
Ask patients to ID areas of pain/discomfort pain may = precursor to tissue breakdown level C
Observe skin for pressure damage by medical devices level C
Document all skin assessment details of pain C
Do not turn patient onto areas where still pressure C
Do not use massage for PU prevention B
Do not vigorously rub skin B
Use emollients to hydrate skin B
Protect skin from excessive moisture with barrier product C.
- NICE 2005
Relating to prevention – NICE clinical guidelines number 7
Take patient’s individual needs and preferences good communication is essential and evidence
based information needed to reach informed decisions about care
Key priorities for implementation:
Patients should receive initial and ongoing risk assessments in first episode of care
PU should be graded according to EPUAP specification
Patients should receive initial and ongoing assessment of PU supported by photos/tracings with ruler
All patients at risk should be on high specification foam mattress
Surgical patients minimal provision is high specification foam mattress or other pressure
All patients with grades 1 – 2 on high specification foam mattress plus cushion and close observation
for skin changes
Patients wtih grades 3-4 on high specification form and alternative pressure overlap (not small cell
pressure) optimum wound healing use modern dressings
Initial risk assess of risk factors:
- Sensory impairment
- Moisture to skin
- Acute/chronic/terminally ill
- Comorbidity, vascular, pain, diabetes etc.
- Cognitive and psychosocial (ability to independently care/check)
- Previous pressure damage
- Extremes of age
- Nutrition and hydration status
Record and document assessment identifying all risk factors
- Assessment regularly
- Frequently based on vulnerability and condition of patient
- Inspect all vulnerable areas
- Encourage patients to check own areas inspect with mirror if necessary
- LOOK FOR:
- Persistent erythema
- Non blanching hyperaemia
- Localised heat
- Localised oedema
- Localised induration
- Purple/bluish in darker pigmented skin
- Localised coolness (necrosis)
Patients vulnerable to PUs:
- Critical care
- Orthopaedic condition
- Spinal injury
- Peripheral vascular disease
- History of PU
- Extremes of age
- Consider mobilising, positioning and repositioning all patients (in beds, chairs, wheelchairs)
- Must consider acceptability to patients and carers
- Minimum pressure on bony prominences and reposition regularly
- Considering restricting sitting time to 2 hours per session
- Seek special advice on equipment and positions
- Record using reposition chart/schedule
Pressure Relieving devices: choose devices based on:
- Risk assessment
- PU assessment
- Location cause of PU if there
- Skin assessment
- General health
- Lifestyle and abilities
- Critical care needs
- Acceptibility and comfort
- Availability of carer, HCW to reposition patient
- Patient weight
- Cost considerations
Consider all of the surfaces used by patients
Patients should have 24 hours access to pressure relieveing devices
Change pressure reliving devices in response to alternating levels of risk, condition or needs
No rating of supporting evidence for these individual recommendations.
SHOULD ONLY BE ON HIGH SPECIFICATION FORM AND ALTERNATIVE PRESSURE OVERLAY IF GRADES
3 -4 OR MASSIVE IMMOBILE
- NICE 2001
Grading of evidence
1) Generally consistent finding multiple acceptable studies
2) Either based on single study or weak inconsistent finding from several studies
3) Limited scientific evidence includes expert opinion
Identifying patients at risk – all level 3
Risk Assessment should include and informal assessment
Risk assessment to be done by appropriately trained staff who know risk factors
Timing of assessment depends on individual but all within 6 hours
If patient not at risk reassess if condition changes
All formal assessments of risk to be documented and reported to MDT
Risk assessment scales to be aide memoire is only thing supported by evidence level 1
Risk factors all based on level 2 evidence:
Loss of consciousness
Extremes of age
Severe chronic and terminal illness
Previous history PU
Malnutrition & dehydration
Extrinsic factors include pressure, shearing, friction (2)
Consider medication and moisture of skin 2
Skin inspection all 3s:
Regularly check and recognise deterioration
Check all vulnerable areas: sacrum, ischial tuberosities, where TEDs worn, femoral
trochanters, anywhere where shear, friction, pressure
Encourage individual to check themselves using a mirror if necessary
Healthcare professionals to know signs of PU developing:
Persistent erythema, non-blanching erythema, blisters, discolouration, localised heat,
localised oedema, localised induration. In darker skin: purplish/bluish + above.
Report and document all skin changes.
Walsh and Dempsey 2011 reliability and validity of Waterlow risk assessment tool : literature
Waterlow is most frequently used – indeed is used in PortHosp acute NHS inpatient care plans
Identifies risk status on:
- Build/weight for height
- Skin type
- Tissue malnutrition
- Neurological deficit
- Major surgery/trauma
Score of >10 ‘at risk’, 15-20 ‘high risk’ >20 ‘very high risk’
Current staffing levels mean different people use tool different times (MacDonald 1995) and
waterlow has poor interrater reliability
Kelly 2005 – HCWs overrate 65% more than underrate 23%
Edwards 1995 point out that if female >80 years is already score of 7. Says tool is inappropriate for
use in elderly
Scale has increased sensitivity and reduced specificity – Pang and Wong 1998 – cost implications of
using expensive equipment.
Unequal weighting of male and female – no evidence given for why – Papanikolaou et al 2002
Boyle and Green 2001 – too many false positives and poor predictor of pts who went on to develop
May be better at predicting in certain patient groups
How to test properly? – Flanagen 1995 – determining true sensitivity and specificity would involved
withholding preventative interventions allowing tissue breakdown – ethically unacceptable. BUT
Vanderwee et al 2005 BELGIUM – experimental group Braden + NBE – random allocation to alt
pressure mattress or high specification foam and control: await presence of NBE then random
allocation of mattress. No sig difference in PU development exp: 53 (6.7%) control: 56 (6.8%).
Oversensitivity of Braden scale resulted in double amount of patients on special mattresses – very
Major problem is poor reliability in subscales of build/weight for height, mobility and skin type.
Cox 2011 – predictors of PU in adult critical care patients:
Direct logistic regression analyses: most variance explained by age, length of stay, mobility,
friction/shear, noepineprhine infusion and CVD. Need specific tool for risk assessment in critical
Nursing times case studies
Pressure ulcer one of 8 high impact actions Ward et al 2010
Most PUs are avoidable everyone should take responsibility for preventing – use risk assessment,
Ownership of problem is crucial
Need cros organisational approach
- Think about your high risk patients because risk is predictable
- Carry out timely risk assessment
- Make sure right equipment is available
- Increase nutrition adn hydration
- Initiate and maintain suitable measures of how you’re doing
- Use expertise available to you – TVN, dieticians, physio, OT etc
- Education should focus on prevention and treatment
NHS institute for innovation and improvement 2010 4 case studies:
Case study 1: ensure right equipment
NICE guideliens 2005 patietns should have access to right equipment. East Kent Hospital Uni Trust –
prioritise use of pressure relief mattresses – seconded HCAs did mattress amnesty encourage wards
to return to equipment library. Would infection prevalence down from 18% in 2008 – 9% in 2009
Case study 2: continence care
Kettering Genearl Hospital – new isolation ward requested 10 air mattresses costin £3000 each. TVN
identified that skin damage was moisture lesion not PU (Fletcher 2008 on identifying moisture lesion
instead of PU)– return to essentials of care clean continence when it happens. No moisture lesions
for a whole year
Culture of thinking that air mattresses prevent PUs above any other strategy – hard to be definite
but food for thought.
Case 3: nursing homes
Newham PCT very effective TVNs active education and training lots of referrals from nursing homes
grades 3-4 need hospitalisation.
Gave nursing home practice nurses to detect and intervene early with PUs – decreased severity and
number of PUs in nursing down by 50%. Admissions with PUs down 72.5%. massive saving £51
return for every £1 spent.
Case study 4: zero tolerance to PUs
Plastic surgery welsh hospital loads of patients referrals needing skin grafts and surgery for PUs.
Most had occurred in hospital
SKIN: Surface, Keep Moving; Incontinence; Nutrition
In place across trusts 4 sites and 92 wards. Anglesey ward 4.5% PUs to 0%.
RCN call for more RCTs on PU prevention an dtreatment.
Need development of reliable risk assessment took – no evidence to support efficacy and validity
reliability of waterlow but still widely used.
Case studies generally regarded as lowest forms of evidence but they’re doign something right –
Structural equation modelling?
Whitlock 2011- using SKIN to prevent PUs
Reddy et al 2006
- skin integrity can breakdown in hours
- frequent assessment prevents minor damage to major ulcers
- risk is predictable
- factors include increased age, immobility, sensory problems, incontinence, circulatory
- wet skin more vulnerable but dry skin also affected
- continual pressure over bony prominences increases risk
- pressure relieving mattresses and special cushions effective in preventing damage
SKIN developed in Florida 2004 introduced in Wales 2009.
Massive importance of organisational support – appoint executive lead to ensure released for
collaborative events, involves experts – TVNs, dieticians, etc., local clinical team to start programme
– physio, TVN, dietician, bring together acute, community and independent on health board.
Didn’t say what tool actually looked like/consisted of specifically.
Benbow 2009 assessing risk of PU development
Important that nurses need evidence base and strength and will to nurse (Henderson, 66)
NMC 2008 code – make care of people your first concern, respect dignitiy and treat as individuals.
NICE 2005 no consensus on how to prevent or treat PUs
Decision to intervene lies with the HCPro. Cost of air mattress for everyone is too high and increasing
bed occupancy numbers make repositioning of everyone unachievable. MUST ID VULNERABLE
PU risk assessment tools:
Norton et al 1962 use with elderly patients
Gosnell scale 1989
Knoll Assessment tool (Abruzzese 1982)
Braden scale (Bergstrom et al 1987)
Waterlow Risk Asessment scale UK (Waterlow, 1985; 2005)
Selected parameters from largely unscientific expert opinion (McGaegh 1999) Tenuous links
between patient risk factors and development of PU.
Balzer et al 2007 – Norton Braden & Waterlow – none correctly idenfitied patients who went on to
develop PUs. Waterlow and Braden most sensitive. Norton most specific followed by Braden.
Clark 2007: 2 critical clinical outcomes
1) Correct identification of vulnerable patients
2) Successful primary intervention
Voegli 2007 – good skin care recognised as key component of risk assessment and not always based
on clinical evidence and facors – idenfitied by clinical evidence overlooked.
Using a tool shows adherence to NICE 2005 nurses should clearly document intervention in line with
professional accountabilitiy and responsibility.
Griffiths 2010 risk assessment and auditing does not automatically = better care for patients
Standard of care = good clinical judgement and appropriate intervention not mere use of a tool.
Ultimately standard of care is measured by 0 PUs or at least a reduction.
Risk assessment for PU one of 8 high impact actions
Evidence says some strategies are good – turning, mattresses etc.
Evidence does not suppot use of risk assessment tools
Must use risk assessment tools and clinical judgement (RCN 2005)
Nurses must question the quality of the evidence and not shove everyone that teh tool says is high
risk on an air mattress.
Massive variability in accuracy of braden, Norton, water, and clinical judgement alone. As few as 5%
of patients identificed as being at risk actually developed a PU – Fancorbo-Hidalgo et al 2006.
Clinical judgement alone may miss more patients than tool alone.
There are no high quality systematic reviews comparising use of risk assessment tool and no risk
assessment tool. (Moore and Cannon 2008).
Vanderwee et al 2005 – N=1,617. Exp group = NBE + Braden, Ctrol group = NBE then random
allocation either to high specification foam mattress or alternating pressure mattress. No sig
difference in PU development (6.7% in exp, 6.8% in control) and double patients on special
mattresses in exp group.
Other types of risk assessment:
RCN 2005 says ‘at risk patients should be on high specification foam’ and ‘very high risk on
alternative pressure mattresses’
McInnes et al 2008 – systematic review estimates that moving patients from normal to high
specification foam mattress reduces PUs risk by 60% and moving from normal to alternating
pressure mattress reduce PU risk by 70%.
Say maybe we should just be using high specification foam mattress plus repositioning (consier RCN
2005 acceptability for patient – they might hate air mattresses but also hate being woken up to turn
every 2 hours). Clark et al 2002 say on 25 bed ward if 18 patients need repositioning every 2 hours
would equal 216 turns per day requiring 36-54 nursing hours per day. But would it be cheaper to
have more staff?!
Temptation is to use easily measurable care processes e.g. waterlow and mattresses without
evidence to support their use
Not enough evidence to clearly establish the role of any risk predictive tools in detecting effective
Presence of risk tool does not equal quality of care