Feature
USING A NATIONAL GUIDELINE TO PREVENT AND MANAGE PRESSURE ULCERS Julie Neilson and colleagues detail the updated National Institute for Health and Care Excellence guidance and its implications for senior nurses Correspondence [email protected] Julie Neilson is a senior research fellow Liz Avital is associate director Both at the National Clinical Guideline Centre, London Jane Willock is a clinical nurse specialist paediatric rheumatology at University Hospital of Wales, Cardiff Nigel Broad is a senior nurse at Powys Teaching Health Board Date of submission March 31 2014 Date of acceptance March 31 2014 Author guidelines nm.rcnpublishing.com
Abstract Developing pressure ulcers is a painful and distressing event for patients, and one that can be prevented. The National Institute for Health and Care Excellence pressure ulcer guideline has recently been updated to cover the prevention and management of this condition. This article focuses on the recommendations that are relevant to nurses, covering areas such as risk assessment, skin assessment, repositioning, pressure-redistributing devices, dressings, patient and carer information, and training and education. It also identifies what senior nurses and nurse managers must do to ensure their staff can prevent and manage pressure ulcers effectively. Keywords Pressure ulcers: management, national guideline A PRESSURE ulcer is caused when an area of skin and the tissues below are damaged as a result of being placed under enough pressure to impair blood supply. The damage is related to the amount and duration of the pressure, and can occur rapidly if, for example, it occurs over exposed bony areas such as the heels or sacrum. The latest National Institute for Health and Care Excellence (NICE) guidance (NICE 2014) replaces previous guidance on risk assessment and prevention (NICE 2003) and on management (NICE 2005), and is aimed at addressing the wide variation throughout
the UK in how pressure ulcers are prevented and treated. The guideline covers people of all ages and settings where NHS care is provided or commissioned, including primary, community and secondary care, and is aimed at all healthcare practitioners. Pressure ulcers are often preventable and their prevention is included in domain 5 of the NHS outcomes framework 2013/14, which states that every patient has the right to expect safe care (Department of Health 2012). The purpose of the latest guideline is to promote evidence-based care that prevents the development of pressure ulcers or, in cases where they have occurred, to ensure that patients are managed in a way that offers the best chance of healing. A multidisciplinary approach is vital to ensure optimal pressure ulcer prevention and care, and nurses play an important role in this process. Their involvement includes: hands-on care, risk assessment, prevention of harm, ensuring comfort and providing environments to help patients attain optimum health. The guideline is separated into two parts, prevention and management, and has separate recommendations for neonates, infants, children and young people. There are 95 recommendations in total, and Boxes 1-4, pages 20-21, show a selection of recommendations that are likely to affect nursing care. The terms ‘at risk’ and ‘at high risk’ are used in the guideline to identify people who may develop pressure ulcers, and the categories are defined as follows:
18 May 2014 | Volume 21 | Number 2
NURSING MANAGEMENT Nursing Management 2014.21:18-21. Downloaded from journals.rcni.com by 124.72.248.75 on 10/20/15. For personal use only.
Tim George
Nursing Management 2014.21:18-21. Downloaded from journals.rcni.com by 124.72.248.75 on 10/20/15. For personal use only.
Feature Box 1 Pressure ulcer guideline recommendations relevant to nurses: general
Box 2
No. Recommendation 1
Be aware that all patients are potentially at risk of developing a pressure ulcer.
2
Prevention: adults, neonates, infants, children and young people Risk assessment Carry out and document an assessment of pressure ulcer risk for people: ■■ Being admitted to secondary care or care homes in which NHS care is provided (adults). ■■ Being admitted to secondary or tertiary care (neonates, infants, children and young people). ■■ Receiving NHS care in other settings such as primary and community care, and emergency departments (adults, neonates, infants, children and young people), if they have a risk factor, for example: significantly limited mobility – for example, people with a spinal cord injury; significant loss of sensation; a previous or current pressure ulcer; nutritional deficiency; the inability to reposition themselves; significant cognitive impairment. ■■ Patients of any age considered to be at risk of developing pressure ulcers are those deemed to be so after assessment using clinical judgement, a validated risk-assessment tool or both. ■■ Patients of any age considered to be at high risk of developing pressure ulcers usually have multiple risk factors, such as significantly limited mobility, nutritional deficiency, inability to reposition themselves and significant cognitive impairment, which are identified during risk assessment. Those with histories of pressure ulcers or current pressure ulcers are also considered to be at high risk. Senior nurses need to be aware that the guideline’s recommendations should form part of every nurse’s armoury during their assessment, planning, implementation and review of care for patients and clients. Early identification of vulnerable patients is at the forefront of this guideline. Following risk assessment, if a patient is identified as being at high risk, it is vital that nurses provide an appropriate plan of care, at the centre of which should be a skin assessment of the patient. If there is a delay in assessing a patient who is at high risk, there is a greater chance that he or she will sustain a pressure ulcer. In addition to the prevention of trauma, disfigurement and pain for the patient, the benefits of preventing a pressure ulcer will also reduce the amount of staff time needed to treat patients. Senior nurses should ensure staff members know that alleviating pressure through repositioning is integral to preventing pressure ulcers. While there is a strong drive at national level to prevent pressure ulcers from occurring, this is not always possible, so the guideline provides
Pressure ulcer guideline recommendations relevant to nurses: adults
No.
Recommendation
3
Adults: skin assessment Offer adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional. The assessment should take into account any pain or discomfort reported by the patient and the skin should be checked for: ■■ Skin integrity in areas of pressure. ■■ Colour changes or discoloration.1 ■■ Variations in heat, firmness and moisture (for example, because of incontinence, oedema, dry or inflamed skin). 1
Non-blanchable erythema may present as colour changes or discoloration, particularly in darker skin tones or types.
4
Adults: repositioning Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every six hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.
5
Management of adults: pressureredistributing devices Use high-specification foam mattresses for adults with a pressure ulcer. If this is not sufficient to redistribute pressure, consider the use of a dynamic support surface. Do not use standard-specification foam mattresses for adults with a pressure ulcer.
6
Adults: dressings Consider using a dressing for adults that promotes a warm, moist wound-healing environment to treat grade 2, 3 and 4 pressure ulcers.
recommendations on managing the condition. These include advice on the measurement and categorisation of pressure ulcers, how to ensure patients receive adequate nutrition and hydration, the use of pressure-redistributing devices, dressings, and other treatments depending on individual needs of patients. Senior nurses must not forget the important part that education and training plays in implementing prevention and management
20 May 2014 | Volume 21 | Number 2
NURSING MANAGEMENT Nursing Management 2014.21:18-21. Downloaded from journals.rcni.com by 124.72.248.75 on 10/20/15. For personal use only.
Box 3 Pressure ulcer guideline recommendations relevant to nurses: neonates, infants, children and young people No.
Recommendation
7
Prevention: neonates, infants, children and young people Use a scale validated for this population (for example, the Braden Q scale for children), to support clinical judgement.
8
Neonates, infants, children and young people: skin assessment Offer neonates, infants, children and young people who are assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional. Take into account: ■■ Skin changes in the occipital area. ■■ Skin temperature. ■■ The presence of blanching erythema or discoloured areas of skin.
9
Neonates, infants, children and young people: repositioning Ensure that neonates and infants who are at risk of developing a pressure ulcer are repositioned at least every 4 hours.
10
Management: neonates, infants, children and young people Pressure-redistributing devices If pressure on the affected area cannot be adequately relieved by other means, such as repositioning, consider a dynamic support surface, appropriate to the size and weight of the child or young person with a pressure ulcer, if this can be tolerated. Tailor the support surface to the location and cause of the pressure ulcer for neonates, infants, children and young people.
11
Dressings Do not use iodine dressings to treat a pressure ulcer in neonates. Do not offer gauze dressings to treat a pressure ulcer in neonates, infants, children and young people.
strategies, and this should be integrated into every part of the service. Furthermore, to ensure optimal prevention and care, it is the responsibility of all nurse managers to ensure that sufficient resources are available, such as nursing staff with appropriate skills and experience, and equipment accompanied by training in how to use it. It is hoped that this NURSING MANAGEMENT
Box 4 Pressure ulcer guideline recommendations relevant to nurses: all ages No.
Recommendation
12
All ages: patient and carer information Offer timely, tailored information to people who have been assessed as being at high risk of developing a pressure ulcer, and their families or carers. The information should be delivered by a trained or experienced healthcare professional and include: ■■ The causes of a pressure ulcer. ■■ The early signs of a pressure ulcer. ■■ Ways to prevent a pressure ulcer. ■■ The implications of having a pressure ulcer (for example, for general health, treatment options and the risk of developing pressure ulcers in the future). Demonstrate techniques and equipment used to prevent pressure ulcers. Take into account individual needs when supplying information to people with: ■■ Degenerative conditions. ■■ Impaired mobility. ■■ Neurological impairment. ■■ Cognitive impairment. ■■ Impaired tissue perfusion (for example, caused by peripheral arterial disease).
13
All ages: healthcare professional training and education Provide training to healthcare professionals on preventing pressure ulcers, including: ■■ Who is likely to be at risk of developing a pressure ulcer. ■■ How to identify pressure damage. ■■ What steps to take to prevent new or further pressure damage. ■■ Who to contact for further information and for further action. Provide further training to healthcare professionals who have contact with anyone who has been assessed as being at high risk of developing a pressure ulcer. Training should include: ■■ How to carry out a risk and skin assessment. ■■ How to reposition. ■■ Information on pressure-redistributing devices. ■■ Discussion of pressure ulcer prevention with patients and their carers. ■■ Details of sources of advice and support.
guidance, at guidance.nice.org.uk/CG179, will inspire nurses to work within a multidisciplinary framework to provide the best available care to prevent and manage pressure ulcers. References Department of Health (2012) The NHS Outcomes Framework 2013/14. DH, London. National Institute for Health and Care Excellence (2003) Pressure Ulcer Prevention: Pressure Ulcer Risk Assessment and Prevention, Including the Use of Pressure-relieving Devices (Beds, Mattresses and Overlays) for the Prevention of Pressure Ulcers in Primary and Secondary Care. NICE Clinical Guideline 7. NICE, London. National Institute for Health and Care Excellence (2005) Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary Care. NICE Clinical Guideline 29. NICE, London. National Institute for Health and Care Excellence (2014) Pressure Ulcer Prevention and Management. NICE, London.
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
May 2014 | Volume 21 | Number 2 21
Nursing Management 2014.21:18-21. Downloaded from journals.rcni.com by 124.72.248.75 on 10/20/15. For personal use only.
USING A NATIONAL GUIDELINE TO PREVENT AND MANAGE PRESSURE ULCERS Julie Neilson and colleagues detail the updated National Institute for Health and Care Excellence guidance and its implications for senior nurses Correspondence [email protected] Julie Neilson is a senior research fellow Liz Avital is associate director Both at the National Clinical Guideline Centre, London Jane Willock is a clinical nurse specialist paediatric rheumatology at University Hospital of Wales, Cardiff Nigel Broad is a senior nurse at Powys Teaching Health Board Date of submission March 31 2014 Date of acceptance March 31 2014 Author guidelines nm.rcnpublishing.com
Abstract Developing pressure ulcers is a painful and distressing event for patients, and one that can be prevented. The National Institute for Health and Care Excellence pressure ulcer guideline has recently been updated to cover the prevention and management of this condition. This article focuses on the recommendations that are relevant to nurses, covering areas such as risk assessment, skin assessment, repositioning, pressure-redistributing devices, dressings, patient and carer information, and training and education. It also identifies what senior nurses and nurse managers must do to ensure their staff can prevent and manage pressure ulcers effectively. Keywords Pressure ulcers: management, national guideline A PRESSURE ulcer is caused when an area of skin and the tissues below are damaged as a result of being placed under enough pressure to impair blood supply. The damage is related to the amount and duration of the pressure, and can occur rapidly if, for example, it occurs over exposed bony areas such as the heels or sacrum. The latest National Institute for Health and Care Excellence (NICE) guidance (NICE 2014) replaces previous guidance on risk assessment and prevention (NICE 2003) and on management (NICE 2005), and is aimed at addressing the wide variation throughout
the UK in how pressure ulcers are prevented and treated. The guideline covers people of all ages and settings where NHS care is provided or commissioned, including primary, community and secondary care, and is aimed at all healthcare practitioners. Pressure ulcers are often preventable and their prevention is included in domain 5 of the NHS outcomes framework 2013/14, which states that every patient has the right to expect safe care (Department of Health 2012). The purpose of the latest guideline is to promote evidence-based care that prevents the development of pressure ulcers or, in cases where they have occurred, to ensure that patients are managed in a way that offers the best chance of healing. A multidisciplinary approach is vital to ensure optimal pressure ulcer prevention and care, and nurses play an important role in this process. Their involvement includes: hands-on care, risk assessment, prevention of harm, ensuring comfort and providing environments to help patients attain optimum health. The guideline is separated into two parts, prevention and management, and has separate recommendations for neonates, infants, children and young people. There are 95 recommendations in total, and Boxes 1-4, pages 20-21, show a selection of recommendations that are likely to affect nursing care. The terms ‘at risk’ and ‘at high risk’ are used in the guideline to identify people who may develop pressure ulcers, and the categories are defined as follows:
18 May 2014 | Volume 21 | Number 2
NURSING MANAGEMENT Nursing Management 2014.21:18-21. Downloaded from journals.rcni.com by 124.72.248.75 on 10/20/15. For personal use only.
Tim George
Nursing Management 2014.21:18-21. Downloaded from journals.rcni.com by 124.72.248.75 on 10/20/15. For personal use only.
Feature Box 1 Pressure ulcer guideline recommendations relevant to nurses: general
Box 2
No. Recommendation 1
Be aware that all patients are potentially at risk of developing a pressure ulcer.
2
Prevention: adults, neonates, infants, children and young people Risk assessment Carry out and document an assessment of pressure ulcer risk for people: ■■ Being admitted to secondary care or care homes in which NHS care is provided (adults). ■■ Being admitted to secondary or tertiary care (neonates, infants, children and young people). ■■ Receiving NHS care in other settings such as primary and community care, and emergency departments (adults, neonates, infants, children and young people), if they have a risk factor, for example: significantly limited mobility – for example, people with a spinal cord injury; significant loss of sensation; a previous or current pressure ulcer; nutritional deficiency; the inability to reposition themselves; significant cognitive impairment. ■■ Patients of any age considered to be at risk of developing pressure ulcers are those deemed to be so after assessment using clinical judgement, a validated risk-assessment tool or both. ■■ Patients of any age considered to be at high risk of developing pressure ulcers usually have multiple risk factors, such as significantly limited mobility, nutritional deficiency, inability to reposition themselves and significant cognitive impairment, which are identified during risk assessment. Those with histories of pressure ulcers or current pressure ulcers are also considered to be at high risk. Senior nurses need to be aware that the guideline’s recommendations should form part of every nurse’s armoury during their assessment, planning, implementation and review of care for patients and clients. Early identification of vulnerable patients is at the forefront of this guideline. Following risk assessment, if a patient is identified as being at high risk, it is vital that nurses provide an appropriate plan of care, at the centre of which should be a skin assessment of the patient. If there is a delay in assessing a patient who is at high risk, there is a greater chance that he or she will sustain a pressure ulcer. In addition to the prevention of trauma, disfigurement and pain for the patient, the benefits of preventing a pressure ulcer will also reduce the amount of staff time needed to treat patients. Senior nurses should ensure staff members know that alleviating pressure through repositioning is integral to preventing pressure ulcers. While there is a strong drive at national level to prevent pressure ulcers from occurring, this is not always possible, so the guideline provides
Pressure ulcer guideline recommendations relevant to nurses: adults
No.
Recommendation
3
Adults: skin assessment Offer adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional. The assessment should take into account any pain or discomfort reported by the patient and the skin should be checked for: ■■ Skin integrity in areas of pressure. ■■ Colour changes or discoloration.1 ■■ Variations in heat, firmness and moisture (for example, because of incontinence, oedema, dry or inflamed skin). 1
Non-blanchable erythema may present as colour changes or discoloration, particularly in darker skin tones or types.
4
Adults: repositioning Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every six hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.
5
Management of adults: pressureredistributing devices Use high-specification foam mattresses for adults with a pressure ulcer. If this is not sufficient to redistribute pressure, consider the use of a dynamic support surface. Do not use standard-specification foam mattresses for adults with a pressure ulcer.
6
Adults: dressings Consider using a dressing for adults that promotes a warm, moist wound-healing environment to treat grade 2, 3 and 4 pressure ulcers.
recommendations on managing the condition. These include advice on the measurement and categorisation of pressure ulcers, how to ensure patients receive adequate nutrition and hydration, the use of pressure-redistributing devices, dressings, and other treatments depending on individual needs of patients. Senior nurses must not forget the important part that education and training plays in implementing prevention and management
20 May 2014 | Volume 21 | Number 2
NURSING MANAGEMENT Nursing Management 2014.21:18-21. Downloaded from journals.rcni.com by 124.72.248.75 on 10/20/15. For personal use only.
Box 3 Pressure ulcer guideline recommendations relevant to nurses: neonates, infants, children and young people No.
Recommendation
7
Prevention: neonates, infants, children and young people Use a scale validated for this population (for example, the Braden Q scale for children), to support clinical judgement.
8
Neonates, infants, children and young people: skin assessment Offer neonates, infants, children and young people who are assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional. Take into account: ■■ Skin changes in the occipital area. ■■ Skin temperature. ■■ The presence of blanching erythema or discoloured areas of skin.
9
Neonates, infants, children and young people: repositioning Ensure that neonates and infants who are at risk of developing a pressure ulcer are repositioned at least every 4 hours.
10
Management: neonates, infants, children and young people Pressure-redistributing devices If pressure on the affected area cannot be adequately relieved by other means, such as repositioning, consider a dynamic support surface, appropriate to the size and weight of the child or young person with a pressure ulcer, if this can be tolerated. Tailor the support surface to the location and cause of the pressure ulcer for neonates, infants, children and young people.
11
Dressings Do not use iodine dressings to treat a pressure ulcer in neonates. Do not offer gauze dressings to treat a pressure ulcer in neonates, infants, children and young people.
strategies, and this should be integrated into every part of the service. Furthermore, to ensure optimal prevention and care, it is the responsibility of all nurse managers to ensure that sufficient resources are available, such as nursing staff with appropriate skills and experience, and equipment accompanied by training in how to use it. It is hoped that this NURSING MANAGEMENT
Box 4 Pressure ulcer guideline recommendations relevant to nurses: all ages No.
Recommendation
12
All ages: patient and carer information Offer timely, tailored information to people who have been assessed as being at high risk of developing a pressure ulcer, and their families or carers. The information should be delivered by a trained or experienced healthcare professional and include: ■■ The causes of a pressure ulcer. ■■ The early signs of a pressure ulcer. ■■ Ways to prevent a pressure ulcer. ■■ The implications of having a pressure ulcer (for example, for general health, treatment options and the risk of developing pressure ulcers in the future). Demonstrate techniques and equipment used to prevent pressure ulcers. Take into account individual needs when supplying information to people with: ■■ Degenerative conditions. ■■ Impaired mobility. ■■ Neurological impairment. ■■ Cognitive impairment. ■■ Impaired tissue perfusion (for example, caused by peripheral arterial disease).
13
All ages: healthcare professional training and education Provide training to healthcare professionals on preventing pressure ulcers, including: ■■ Who is likely to be at risk of developing a pressure ulcer. ■■ How to identify pressure damage. ■■ What steps to take to prevent new or further pressure damage. ■■ Who to contact for further information and for further action. Provide further training to healthcare professionals who have contact with anyone who has been assessed as being at high risk of developing a pressure ulcer. Training should include: ■■ How to carry out a risk and skin assessment. ■■ How to reposition. ■■ Information on pressure-redistributing devices. ■■ Discussion of pressure ulcer prevention with patients and their carers. ■■ Details of sources of advice and support.
guidance, at guidance.nice.org.uk/CG179, will inspire nurses to work within a multidisciplinary framework to provide the best available care to prevent and manage pressure ulcers. References Department of Health (2012) The NHS Outcomes Framework 2013/14. DH, London. National Institute for Health and Care Excellence (2003) Pressure Ulcer Prevention: Pressure Ulcer Risk Assessment and Prevention, Including the Use of Pressure-relieving Devices (Beds, Mattresses and Overlays) for the Prevention of Pressure Ulcers in Primary and Secondary Care. NICE Clinical Guideline 7. NICE, London. National Institute for Health and Care Excellence (2005) Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary Care. NICE Clinical Guideline 29. NICE, London. National Institute for Health and Care Excellence (2014) Pressure Ulcer Prevention and Management. NICE, London.
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
May 2014 | Volume 21 | Number 2 21
Nursing Management 2014.21:18-21. Downloaded from journals.rcni.com by 124.72.248.75 on 10/20/15. For personal use only.
