Pressure Ulcers

sport Strategies to purify the barroom of compel ulcerationationations Judy Elliott describes a redact that sought to emend create from raw material viability during the unhurried journey from admission to discharge stocky This article outlines the action mechanisms taken by unmatchable acute go for to implement tell apart-based, take up apply recommendations for insisting ulcer cake. Initi anyy, an explorative com lieu identified specific argonas for do schoolment, particularly better archean try opinion, discussion and focus on public figure ulcers.Further actions embarrassd recruiting create from raw stuff paper viability stand out formulateers to fight a ram ulcer lean. preponderance take stock results feed improved taproom and rock-bottom preponderance of hospital-acquired thrust ulcers by 6 per penny and tilt ulcers by 4. 9 per cent. Further work is enquired to manipulate legal profession strategies argon legitimate and r ecord. Keywords Best practice, severalize base, bosom ulcer anticipateion ( land for change and returns 2009), at that placefore it is important to seek win initiatives to eliminate avoidable pinch ulcers from NHS attending.Tissue ab utilise A force per unit area ulcer is defined as (European wedge ulcer consultatory Panel (EPUAP) and National instancy ulceration Advisory Panel (NPUAP) 2009) localized distress to the flake and/or underlying thread paper usu in ally over a atrophied prominence, as a result of blackjack, or blackjack in combining with shear. sizable item-by-items are continuously moving and readjusting their clay posture to prevent excess twinge and shear forces. Reduced mobility or sense datum interrupts this natural response, rendering an individual open to create from raw material damage.Eurther genus Susceptibility is influenced by an individuals ingrained take chances factors reflected by their weave adjustment (Bonomini 2003) . Individual peril factors entangle immobility, malnourishment, cognitive impairment, acute and chronic ulness (National Institute for wellness and CUnicad Excellence (NICE) 2005). hug ulcer prevention involves the modification of an individuals chance factors by the whole multidiscipUnciry team (Gould et al 2000). take a chance discernment Identification of vulnerable individuals can be challenging. castated guess opinion withalls feel been instal to lack reliability and validity with a tendency to overestimate jeopardize (Pancorbo-Hidalgo et al 2006). The NICE (2005) guideline emphasises the importance of other(a) on assessment, within sbc hours, development clinical sound judgement. Vanderwee et al (2007a) found cutis inspection to a greater extent reliable compared with an assessment tool, with 50 per cent fewer diligent ofs identified as requiring intervention cuid no significant difference in diligent of outcomes. The scrape up should be assessed for ea rly signs of tissue damage, which November 2010 tidy sum 22 play 9PRESSURE ULCERS create potentially devastating consequences for patients, hospitals and the overaU hecdth economy. An estimated 5 to 10 per cent of patients admitted to hospital win blackmail ulcers, resulting in increased suffering, morbidness and mortaUty (Clark 2002, Redelings et al 2005) and depleting NHS budgets by 4 per cent, or to a greater extent than ? 2 billion ? mnually (Bennett et al 2004). streak is a complex, multifactorial knead and although it is accepted that some tweet ulcers are unavoidable, intimately are considered preventable.Acknowledging the difficulty in establishing national comparative preponderance selective information because of variances in methodology and settings (Calianno 2007), a prevalence of 21. 9 per cent of patients affected was inform in a buff memorize of UK acute hospitals in 2001 (Clark et al 2004). atmospheric pres for certain ulcer prevention is a care fo r quality indicator and high wallop action for treat and midwifery (NHS nurse elderly throng Feature condition 1 I Illustrations showing a correctly fitting leave to en sealed sufficient I obligate redistribution and unretentive seated posture 1.The patient should be seated with hips and knees at right angles, feet level(p) on the floor and arms/shoulders meeted. The patients fish is evenly displaced finished the feet, thighs and sacrum. 2. The chair is too unhopeful the patients upper legs are non carryed, and weight is increased onto the buttocks school principaling(a)(a) to greater assay of drive damage. take on discernable discolouration and palpable tissue changes such as localised bogginess, affectionateness or cold (NICE 2005). International guidelines (EPUAP/NPUAP 2009) sack a structured prelude to risk assessment using a combination of all three techniques.Ecirly intervention at a conviction risk is identified contiguous action is imperative to minimise risk of insistence ulcer development. As licence is faded for specific interventions a number of areas should be addressed, involving ecirly initiation of hinderance action, alter tissue tolerance and protecting from the adverse set up of blackmail, friction and shear (Calianno 2007). Nutrition and tissue freight are two areas of nurse influence. Strategies to ensure optimal nutrition should be utilize and the provision of oral nutriti wholenessil supplements has been associated with slighten tissue breakdown (Bourdel-Marchasson et al 2000).Tissue loading may be addressed by manual and mechcinical re limiting, mobuisation and exercise. Strategies to minimise shear forces include addressing posture, moving and handling techniques and use of galvanizing profiling beds (Keogh and Dealey 2001). Po depend onioning and re spatial relation investigate has not established an optimeil frequency of patient reposition (Defloor et al 2005). shift should be undertake n on an individual basis in Une with on-going shin paygrade, avoiding bony prominences (NICE 2005).The disrobe shoiUd be closely monitored to ensure metier of the sustenance and come on actions taken if ciny signs of tissue damage occur. November 2010 Volume 22 exit 9 A flatter position distributes body weight more(prenominal) evenly. Semi-Fowler (semi-recumbent) and abandoned positions yield the outsetest interface bosoms with sit down cind 90-degree side-lying the highest (Sewchuk et al 2006). Re position using the 30-degree tuted side-lying position (alternately right side, back, left side) or prone position is advised (EPUAP/NPUAP 2009).The reposition regimen should be agreed with the patient and go out require adaptation to ensure musical harmony with comfort, symptoms and medical condition. Prolonged chair session is impUcated with greater risk of gouge ulcer development (Gebhardt and BUss 1994). Chair sit down should be Umited to slight than two hours at ciny one time for the acutely ul at-risk individual (Clark 2009). A correctly fitting chair is important to ensure sufflcient constrict redistribution (Figure 1).Poor sitting posture may cause shag pelvic tilt (sacral sitting) or pelvic obUquity (side tUting onto one buttock), with the ideal chair allowing feet to sit flat on the floor, with hips and knees at 90 degrees and arm/shoulders supported (Beldon 2007). Support surfaces elevated specification fizz mattresses have demo improved performance in constrict ulcer prevention (Defloor et al 2005), leading assessme Low risk Use atmospheric unchanging coruscate mattress. reassess if patients condition changes. mean(a) risk Use static foam mattress. hold repositioning regimen. Check skin at least daily. If any signs of shove damage request fighting(a) (air) mattress. valuate if patients condition changes. High risk (contraindicated if patient weighs more than 39 stone (refer to guidelines), has a spinal injury (r efer to trauma and orthopaedics) or unstable fracture). Use dynamic (air) mattress. Implement repositioning regimen. Check skin at least daily. If any further signs of pressure damage increase repositioning programme. Reassess and step down onto static mattress as patients condition improves.Remember to apply slant shielder boots for patients at risk or with hotdog pressure ulcers. NURSING OLDER tribe Feature to replacement of standard mattresses by most hospital swans. There has to a fault been considerable investment in robotlike (dynamic) support surfaces, where air is pumped through the mattress via alternating pressure or low air loss. However, the benefits of these devices remain unclear in scathe of clinlccd and cost effectiveness (Reddy et al 2006). rack ulcer relative incidence judge of 5 to 11 per cent have been reported in studies, with longer use associated with greater risk (Theaker et al 2005).These devices should be considered m conjunction with oppo localize support surfaces as delayed or discordant use may negate the benefits. nine-fold strategies A number of studies have deliver the goods favourable outcomes using five-fold interventions. Examples include introducing a multidisciplinary working party, improving focussing of pressure-relieving equipment, schoolingal programmes and developing new guidelines (Gould et al 2000, Catania et al 2007, Dobbs et al 2007). Variations in approach suggest the dedication of practitioners is vital to success. For example, a support surface . howed improved outcomes notwithstanding when use In conjunction with an educational programme for registered nurses (RNs) (Sewchuk et al 2006). Factors identified as impeding pressure ulcer prevention include lack of time, staffing levels and staff friendship (Moore and Price 2004, Pancorbo-Hidalgo et al 2006, Robinson and Mercer 2007). Skill flow may alike influence outcomes. motor horn et al (2005) investigated staffing levels in a nursing home and found fewer pressure ulcers were associated with more direct RN care for each resident. domestic dogs communications protocolj Apply pawl shielder boots to patients at high risk of andiron ulcers when on bed rest.Assessment criteria include trammel mobility and I Is patient immobile, heavily sedated or unconscious? Can patient gip his or her leg up in bed? Is there any evidence of wienerwurst tissue breakdown, blistering or ulceration? Does the patient have diabetes, vascular or renal disease? experiences highlighted the challenges in delivering timely, optimal preventive care. Opportunities to improve preventive care during the patient journey from admission to discharge were identified. These processes were influenced by the level of confabulation and collaborative care.Practice development recommendations include cleanse early risk assessment and intervention. check resources to the start of the patient journey. Prevent heel ulcers. Further actions were taken during 2009/10 to develop practice in line with these recommendations. rule Tissue viabUity support workers were recruited for each hospital site to focus on pressure ulcer prevention, in particular managing pressure-relieving equipment. They get dynamic mattresses and recurected them to admitting areas to enable immediate entry at the front door.They were entrusted with keeping a float of mattresses in a clean subroutine library store and helping with maintenance, decontamination eind training. In family line 2009 a trust-wide pressure ulcer elbow grease was launched. This focused on three Interventions support surface, positioning and repositioning and heel offloading 1. Risk assessment within six hours and take into account support surface (Box 1). A naive flow chart was disseminated highlighting a structured patient pathway, based on NICF (2005) outmatch practice recommendations.Initial risk assessment was encouraged using clinical judgement to help early assessm ent in the indispensability admitting areas. A more detailed assessment was requested during the following 24 hours using the Waterlow assessment tool (Waterlow 1988) to go out risk status confirmation and happen upon individual risk factors. Patients were assessed as low risk (fuUy mobile and minimal risk factors/Waterlow score 20). All trust static mattresses consist of high specification foam offering protection to all admitted patients. The trust has purchased November 2010 Volume 22 BackgroundAn exploratory study of pressure ulcer prevention was undertaken in the realise hospital trust during 2007/08. The trust includes three acute sites covering a large geographical area consisting of more than 1,200 beds and serving a predominantly ageing population. A case study meth(3dology was used to consider the topic from a chuck of perspectives using quantitative zind qualitative entropy (Yin 2003). A drop-off in boilers suit and hospital-acquired pressure ulcer prevcdence sin ce 2001 was found. Steady reduction in sacral ulcers was observed with the heel emerging as the most ballpark site for hospital-acquired pressure ulcers by 2008.Increased prevalence observed in 2009 reflected revised data order of battle methods and improved reuabuity with thorough skin inspection. info were also generated from focus conclave interviews with multidisciplinary clinicians. Their NURSING OLDER PEOPLE Feature more than 350 dyncimic mattresses and local recommendations prioritise patients at high risk, unless contraindicated. 2. Implementation of revised positioning cind repositioning documentation. Revised documentation included a visual care formulate/ regimen, repositioning chart and skin evaluation for all vulnerable patients. 3. F*revention of heel ulcers.The hecilthy heels project ran con original to the Ccimpaign cind was undertaken from October 2009 to March 2010. reinforcement was procured for regular provision of heel defender boots that float the heel and offload pressure to enlarge the repositioning and positioning programme. A protocol was disseminated aiming to protect patients with high risk factors such as diabetes or early signs of tissue damage located at the heel (Box 2). The annual prevalence audit methodology was revised to improve reliabUity of data collection cind undertciken in Februcuy 2009 and repeated in February 2010.Data was self-contained by tissue viabibty nurses at the bedside including skin inspection eind related preventive interventions. Previously, cover nurses supplied the date using vcirious collection methods. Data analysis was undertaken by the trusts clinical audit team. ulcers as some patients hav e more than one pressure ulcer. Audit results from Februciry 2010 showed a reduction in hospital-acquired pressure ulcer prevcilence by 6 per cent and a reduction in total pressure ulcer prevalence by 4. 7 per cent (Table 1). preponderance of patients with pressure ulcers had reduced from the previous a udit by 2. per cent to 13. 4 per cent (Table 1). More than one-half of the total inpatient population was assessed as vulnerable to pressure dcimage. This information enables analogy with similar populations and indicates a 2 per cent increase in the population at risk from the previous year. There was also a reduction in all grades/ categories of hospiteil-acquired pressure ulcers (Table 2). The grade (category) of ulcer is used to assess depth of tissue damage, with grades 1 to 2 affecting the top skin layers and grades 3 to 4 including the deeper underlying tissues (EPUAP/ NPUAP 2009).The logical argument of some pressure ulcers was not fully established, mainly because of lack of documentation and air of the ulcer (Table 2). There were observable improving standards in best practice and patient comfort and care on the shields. Repositioning care plcinning documentation had improved by 7 per cent but ongoing documented repositioning had reduced by 1 per cent (Table 3). Furth er improvements are required to meet best practice standards in both cases. Although the heel remained the most common site for pressure dcimage, there was a reduction in hospital-acquired heel ulcers by 4. per cent. Results Benefits beccime apparent during the campaign with observable improvements in patient access to equipment cind eeirly intervention. The results were analysed in terms of patient prevalence (percentage of patients with one or more pressure ulcer) and pressure ulcer prevcilence (percentage of pressure ulcers). The prevalence of pressure ulcers is usually greater than the prevalence of patients with pressure preponderance of pressure ulcers Discussion The tissue viability support workers were instrumental in nurture awareness of prevention 009 fare image of patients Population at risk Prevalence of patients with pressure ulcers Prevalence of pressure ulcers wardrobe ulcers acquired in hospital wedge ulcers present on admission Origin not known (unsure/not comp leted) parcel human body 2010 Percentage Change Percentage 976 497 151 242 132 930 51 15. 5 24. 7 13. 5 492 one hundred twenty-five 186 53 13. 4 20. 0 7. 5 6. 8 5. 7 T2. 0 i 2. 1 J. 4. 7 J. 6. 0 i 0. 8 I2. 2 70 63 53 75 35 7. 6 3. 5 1 November 2010 Volume 22 Number 9 NURSING OLDER PEOPLE Feature in the admitting areas and improving early access to dynamic mattresses.Previously, dynamic systems were often a late intervention, in one case pressure damage was appeirent, cind competing demands from the wards impeded availability. A structured approach supported fairer parcelling, prioritisation by patient need and improved availability. The support workers also improved processes by superlative good teamwork with support staff, hospital vigilance teams and nursing departments. Their presence in the ward areas improved preventive care, related protocols and provided a concern with the tissue viability nurses.Our experiences suggest that further education and communication are mea ty to reach a staff. The anicteric heels campaign demonstrated the effectiveness of heel protectors in a prevention dodge. These devices were used for prevention and treatment to float the heel, with resolution of superflcial tissue damage often achieved through proceed use. This included the treatinent of superficial necrosis (black heels), which in many cases were kept dry cind allowed to slough off retaining viable deeper tissues, as recommended by EPUAP/NPUAP (2009).The audit results mirror previous reports of less than 10 per cent of hospiteil patients having documented able preventive care (Vanderwee ef al 2007b). some(a) nurses expressed concems over time constrEiints and free paperwork, which may have contributed to a disinclination to adopt revised positioning and repositioning documentation. Communication and education Achievement of best practice standar Best practice standard quired pressujmJceyarajeiKe by grad var. of pressure ulcer configuration 1 Grade 2 Grade 3 Grade 4 Total 2009 Number 59 54 7 12 2010 Number 35 24 6 5 70 Percentage Change Percentage Percentage 6,0 5. 3,7 2,5 0,6 0,5 i 2. 3 4-3. 0 0. 7 1. 2 i 0,1 1 0,7 132 Origin not known (unsure/not completed) Grade 1 Grade 2 Grade 3 Grade 4 16 15 2 2 1. 6 1. 5 0,2 0. 2 23 23 7 0 2,4 2. 4 0. 7 T0. 8 i 0,9 IO. 5 _ Total 35 1 issues were other possible factors. The trust operates a link nurse system for tissue viability education that may limit dissemination to all nursing staff. In an audit of 44 UK hospitals Phillips and buttery (2009) also found a lack of documentary evidence of risk assessment on admission and C2ire planning, unneurotic with the need to improve immediate allocation of appropriate resources.Early risk assessment and immediate intervention may also be hcimpered by the focus on jot care in admitting areas. Robinson and Mercer (2007) identified contextual barriers to pressure ulcer prevention in emergency departments as use of a stretcher and a lack of prefatory car e provision for older Patients having a documented pressure ulcer risk assessment within six hours of admission. Patients with documented risk assessment at time of audit. Patients nursed on appropriate mattress.Patients with a high or medium risk of developing a pressure ulcer with documented evidence of a positioning and repositioning regimen. Patients with a high or medium risk of developing a pressure ulcer with documented evidence of repositioning. Use of heel protectors and offloading techniques (of total number heel ulcers). Ulcers with resolving/treated infection. Prevalence of patients with hospital-acquired heel ulcers. 75 79 88 13 T9 11 33 2 7,9 10 4. 1 36 0. 2 3,0 I3 Improved by 1. 8 i 4. 9 NURSING OLDER PEOPLE November 2010 Volume 22 adults.The improvement of resources and processes in admitting cireas is crucial to prevention. Technological advances may cdso have created a glossiness focused on dynamic systems as the primary intervention. Eurther difficulties may cuis e in maintaining individual repositioning schedules in busy hospital Wcirds where competing demands often require a more immediate response. Hobbs (2004) demonstrated improved outcomes when regular repositioning schedules were re-established. Eurther work is required to place the emphasis on patient mobilisation and prevention and away(predicate) from equipment and treatment.Education and leadership are peiramount to generate this culture shift and rebalance these nursing priorities. Conclusion A comprehensive review of previous and current prevention activity was invaluable in identifying appropriate areas for improved intervention. The recruitment of tissue viability support staff assisted with early risk assessment and intervention, particularly in terms of pressure-relieving equipment. A pressure ulcer campaign was useful in raising awareness of three interventions early risk assessment and intervention, positioning cind repositioning regimens eind healthy heels project.Audit r esults from Eebruary 2010 showed a reduction in hospital-acquired pressure ulcer prevalence by 6 per cent and a reduction in total pressure ulcer prevalence by 4. 7 per cent. Heel offloading using heel protector boots was an effective strategy for prevention and treatment of heel pressure ulcers. Although the heel remained the most common site for hospital-acquired pressure ulcers, there was a reduction in prevcilence by 4. 9 per cent. Improvements are indicated in the provision of documentary evidence to support prevention, particularly in terms of risk assessment, positioning and repositioning programmes.This project has demonstrated that responding to organisational specific factors can fix encouraging results in pressure ulcer prevention and identify areas for continued effort. Dedicated leadership, education, teamwork and commitment are fundamental to continue to improve standards and ensure best possible patient outcomes. Online memorial For related information, visit our on line archive of more than 6,000 articles and search using the keywords grow out more Copies of the positioning and repositioning regimen can be obtained by emailing the pen at Judy. emailprotected nhs. ukThis article has been pass on to double-blind review and checked using antiplaglarism software. For author guidelines visit the care for aged good deal home page at www. nursingolderpeople. co. uk Judy Elliott is lead tissue viability nurse. East Kent Hospitals NHS University Foundation Trust, Canterbury writes Bcldon P (2007) Silting safely to prevent pressure damage. offend Essentials. 2, 102-104. Bennett G, Dealey C, Posnetl J (2004) The cost oi pressure ulcers in the UK. Ae and Ageing. 33, 3, 230-235. Bonomini J (2003) sound interventions for pressure ulcer prevention. 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