Celebrating life

A Strategy for the

Prevention &
Management
of Pressure Ulcers

Issue Date :

September 2013

Review Date :

September 2016

Barchester Healthcare, Confidential

CONTENTS

Celebrating life
Executive Summary

Page 3

Introduction

Page 3

Aim/ Objective

Page 4

National Policy Context including NICE Guidelines

Page 4

Implementation
Identifying Risk

Page 5

Repositioning and Equipment Selection

Page 7

Education and Training

Page 9

The Role of Nutrition in Tissue Viability

Page 11

Management of Residents with Established Pressure Ulcers

Page 12

Wound Management

Page 15

References

Page 21

Useful Contacts

Page 22

Appendix
A Summary of Nutrients Involved in Wound Healing

Page 23

EPUAP Pressure Ulcer Category Scales

Page 24

Remobilising onto a healed ulcer

Page 25

MY MOP Wellbeing assessment questionnaires

Page 27

Pressure Ulcer Risk Assessment and prevention Flow Chart

Page 29

Pressure Ulcer Grading, Reporting & Management Flow Chart

Page 30

Barchester MI SKIN campaign Background & Resources

Page 31

EXECUTIVE SUMMARY

Celebrating life

The Strategy for the Prevention and Management of Pressure Ulcers has been
designed to assist Barchester Healthcare staff take a proactive approach to
dealing with pressure ulcer prevention and management issues within their
homes.
Barchester Healthcare is committed to on-going evaluation of current
recommended processes and practice, with a view to continuing
improvements in the service we provide. Improvements will be measured
using statistics from clinical governance systems as well as individual
feedback, and will be within the current framework of national policy and
Best Practice.
Guidance and recommendations within this strategy should be used to support
and assist in clinical decisions and not replace clinical assessments and
judgement.
It should be utilised and modified with the consensus of all of the qualified
practitioners according to the environment and the identified needs of each
individual.
INTRODUCTION
This company strategy provides information obtained through national
strategies and current knowledge of the social care sector regarding the
implementation of pressure prevention. This strategy will pay particular
attention to the aim of a pro active approach to managing risk of pressure
damage and provision of optimum care.
The strategy will highlight challenges the company may face and the key
areas for focus while offering some explanation for changes needed to
improve service provision.
This strategy will also link to the relevant Barchester policies, tools and
information, both local and national that are available on or via the
company intranet.
The purpose of this Pressure Prevention Strategy and recommendations is to
guide evidence-based care to prevent the development of pressure ulcers.
This strategy will apply to all individuals residing in our homes and is
intended for the use of Barchester Healthcare staff who are involved in the
care of individuals that are at risk of developing pressure ulcers.
Pressure ulcers continue to be a concern nationally, that affect all age groups
and are costly in terms of resources and individual health outcomes which
could result in individual suffering, physical complication and possible death.
Barchester recognise that It is envisaged due to an aging population that the
number of individuals with Pressure Ulcers will increase (European Pressure
Ulcer Advisory Panel) (EPUAP 2009)
The first three chapters, Identifying Risk, Repositioning and Equipment
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Celebrating life
Selection and Education and Training, are based almost entirely on the
guidelines produced by the National Institute for Clinical Excellence, EPUAP
on Pressure Ulcer Risk Assessment, Prevention and treatment and are
incorporated here with their permission.
AIMS
To provide appropriate policies and best practice that focuses on the
needs service users, their families and our staff and reflects the quality
standards that are outlined in the National Service Framework for
Older People, the National Minimum Care Standards / Essential
Standards / National Care Standards and the National Institute Clinical
Excellence guidance for managing pressure care.
To assist in the standardisation of Prevention of pressure damage
policies and practices across the Barchester Healthcare group
To develop a strategic approach across the organisation in the
provision of appropriately structured programmes of education and
learning in the area of promotion of good skin care and prevention of
pressure damage.
To ensure that service users who are at risk of pressure damage are
identified by individualised risk assessment and that the care then
provided is appropriate, safe and suitably recorded and monitored.
To ensure that appropriate action is taken following the event of
serious pressure ulcer formation and that any learning is implemented.
To ensure that appropriate clinical governance reporting mechanisms
are in place and any relevant audits are undertaken to provide
assurance of compliance with policies and practice.
To ensure that arrangements are in place for effective treatment of
pressure ulcers should they develop.
To safeguard individuals within Barchester Healthcare
To adopt a proactive attitude to pressure ulcer prevention
To prevent initial tissue damage, prevent the deterioration of an ulcer
to a more severe wound and to prevent complications.
These aims will be achieved by providing healthcare professionals with
guidance on the early identification of patients at risk of developing pressure
ulcers, and the provision of preventative and management interventions.
NATIONAL POLICY
This strategy is led by NICE Best practice Guidelines.
Barchester also identify with the Department Of Health Protecting
Patients from Avoidable Harm measures(2013)
European Pressure Ulcer Advisory Panel Guidelines on Pressure
Ulcer Prevention and Management (www.epuap.org)
Tissue Viability Society (2009) Seating and Pressure Ulcers:
Clinical Practice Guidelines www.tvs.org.uk

Celebrating life

IDENTIFYING RISK

Outcome All individuals will be assessed for the risk of developing

pressure ulcers within six hours of admission to the home, reassessed on a
monthly basis or if there is a change in the residents condition that
increases risk. If an individual is identified as at risk an individual plan
of care will be developed.
Staff will be aware through the pre admission assessment of the potential risk
of pressure damage on every individual admitted to the home.
Assessing an individuals risk of developing pressure ulcers should involve
both formal and informal assessment procedures. Formal: being through
documented risk assessment, informal through visual assessment and clinical
judgement.
All individuals will be assessed for the risk of developing pressure ulcers
using the Waterlow Risk Assessment Tool and Barchester Healthcares MI
SKIN principles combined. MI SKIN principles and associated resources can
be found in the appendix.
Risk assessment should be carried out by staff who have undergone
appropriate training and judge themselves to be self competent to recognise
the risk factors that contribute to the development of pressure ulcers and know
how to initiate and maintain correct and suitable preventative measures.
The timing of risk assessment should be based on each individual case.
However, it should take place within six hours of admission to the home.
If an individual is considered not at risk on initial assessment, reassessment is
undertaken as part of a monthly review, or if there is a change in the
individuals condition which increases the risk.
All formal assessments of risk should be documented in the individuals care
profile.
The Waterlow Risk Assessment Tool is only part of the assessment and
should be used in conjunction with clinical judgement.
An individuals potential to develop pressure ulcers may be influenced by the
following intrinsic risk factors which therefore should be considered when
performing a risk assessment:

Reduced mobility or immobility

Sensory impairment
Acute illness
Level of consciousness
Extremes of age
Vascular disease
Severe chronic or terminal illness
Previous history of pressure damage
Malnutrition or dehydration
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Celebrating life
The following extrinsic risk factors are involved in tissue damage and should
be removed or diminished to prevent injury:
Pressure
Shearing
Friction
The potential of an individual to develop pressure ulcers may be exacerbated
by multiple factors which should be considered when performing a risk
assessment, these include, but are not limited to :
Medication
Moisture to the skin
All individuals will have a nutritional assessment completed as part of their
admission assessment within 24 hours. Individuals will be weighed on
admission where possible and their body mass index recorded. This will be
reviewed monthly or as determined by clinical need and level of risk.
All individuals will have a moving and handling risk assessment completed on
admission. They will be reassessed at least monthly or more frequently if their
condition changes.
If an individual is identified as having a continence problem, a continence
assessment will be completed and an individualised care plan commenced.
Skin inspection should occur on admission and reviewed regularly. The
frequency determined in response to changes in the individuals condition in
relation to either deterioration or recovery.
Skin inspection should be based on an assessment of the most vulnerable areas
of risk for each resident. These are typically:
Heels
Ankles
Sacrum
Ischial tuberosities
Greater trocanters
Elbows
Temporal region of the skull
Shoulders
Back of head
Toes
Parts of the body where pressure, friction or shear is exerted in the
course of a residents daily living activities
Parts of the body where there are external forces exerted by equipment
or clothing.
Other areas should be inspected as necessitated by the residents
condition.
Blisters identified on main vulnerable areas as detailed above need to be
assumed as pressure damage and recorded and treated as such.

Celebrating life
Individuals who are willing and able should be encouraged, following
education, to inspect their own skin. For example, Individuals who are
wheelchair users should be encouraged to use a mirror to inspect the areas that
they cannot see easily, or get others to inspect them.
Direct individual and carer education by staff and from available patient
literature has an important role to play in pressure ulcer prevention and
management.
Information can be downloaded from www.nice.org.uk/CG029.
Healthcare professionals should be aware of the following signs which may
indicate incipient pressure ulcer development:
Persistent erythema
Non-blanching hyperaemia previously identified as non-blanching
erythema
Blisters
Discolouration
Localised heat
Localised oedema
Localised induration
In individuals with darkly pigmented skin:
Purple/bluish localised areas of skin
Localised heat which, if tissue becomes damaged, is replaced by
coolness
Localised oedema
Localised induration
Skin changes should be reported to the trained nurse or senior carer and
documented immediately. A MI SKIN handover communication sheet is
available on the BHC intranet to support identification of skin changes and
key clinical changes on a daily basis which may affect skin integrity.
On discharge or transfer, all individuals will have the condition of their skin
recorded on a body map and the current Waterlow Risk Assessment score
recorded. If the individual has an existing pressure ulcer, the Wound
Assessment Chart will be completed. The original documents will be filed in
the individuals care profile. Photocopies of these documents will be sent with
the individual as part of the transfer documentation.

REPOSITIONING AND EQUIPMENT SELECTION

Outcome Any individual identified to be at risk, will be provided with
appropriate pressure relieving devices. In addition, a plan of
repositioning will be available within six hours of admission.
Individuals should be informed of their risk status in order for health
promotion and education to be offered.
7

Celebrating life
Individuals who are at risk of pressure ulcer development should be offered
repositioning and the frequency of the repositioning should be determined and
reviewed by the results of the skin inspection and individual needs, not by a
ritualistic schedule.
Repositioning should take into consideration other relevant matters, including
the individuals medical condition, their comfort, the overall plan of care and
the support surface.
Individuals who are considered to be acutely at risk of developing pressure
ulcers should restrict chair sitting to less than 2 hours until their general
condition improves.
Positioning of individuals should ensure that:
Prolonged pressure on bony prominences is minimised
Bony prominences are kept from direct contact with one another
Friction and shear damage is minimised
When individuals are in bed, the head of the bed should be at the lowest
degree of elevation consistent with medical conditions (i.e. the individual
should lie as flat as they can tolerate) to reduce shearing forces and distribute
weight more evenly.
A repositioning schedule, agreed with the individual, should be established
and documented for each resident at risk.
Individuals who are willing and able should be taught how to redistribute
weight.
Moving and Handling devices should be used correctly in order to minimise
shear and friction damage. After manoeuvring, slings, slide sheets or other
parts of handling equipment should not be left underneath individuals, unless
advised by the manufacturer or appropriate healthcare professional involved in
the individuals care.
The selection of pressure-relieving devices should be based on:
The Waterlow Risk Assessment score
Clinical judgement
The views of the resident
Barchester Healthcare Mattress selection Algorithm
National Institute Clinical Excellence (NICE) and other Nationally
recognised recommendations for Best practice.
Staff should refer to the manufacturers instructions for advice and guidance on
how to correctly use and maintain pressure-relieving devices. Any purchasing
of pressure relieving devices should be Barchester Healthcare approved. For
any specialist seating or equipment required for residents, training should be
sourced from the manufacturer or relevant healthcare professional and
guidelines kept in the care profile.
Currently, NICE Guidelines do not state the types of mattress that would be
suitable for individuals based on Waterlow score alone, therefore, staff will
8

document clearly in the individuals care plan the rationale for the mattress
selected for each individual.

Celebrating life

Fitted sheets should not be used on dynamic alternating pressure mattresses

and flat sheets should not be tucked in as they reduce the effectiveness of the
mattress. BHC recommend the use of Sleep knit fitted sheets (these are large
with a distinctive blue piped edge) that are specifically designed for use with
alternating pressure systems.
Any individual nursed in bed will have a repositioning chart used to evidence
reposition changes and mattress pressure settings. Staff need to ensure that the
pressure setting is in line with the individual weight of each user and
manufacturers settings.
All individuals in the home will be closely monitored for any deterioration in
their skin condition and the mattress or cushion upgraded or the frequency of
the repositioning schedule increased.
Seating assessments for aids and equipment should be carried out by trained
assessors who have acquired specific knowledge and expertise (for example,
physiotherapists and occupational therapists).
Advice from trained assessors with acquired specific knowledge and expertise
should be sought about correct seating positions.
Positioning of individuals who spend substantial periods of time in a chair or
wheelchair should take into account:
Distribution of weight
Postural alignment
Support of feet
Additional guidance for remobilising individuals following a healed pressure
ulcer is available in the appendix.
The 30 degree tilt should be considered for repositioning residents in bed
(Preston, 1988).
The following should not be used as pressure relieving aids:
Water filled gloves
Synthetic sheepskins
Genuine sheepskins
Doughnut-type devices

EDUCATION AND TRAINING

Outcome Individuals are cared for by staff skilled and knowledgeable in
the prevention and management of pressure ulcers and individuals are
involved in decisions concerning their care wherever practicable.
All healthcare professionals should receive relevant training or education in
pressure ulcer risk assessment and prevention.
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Celebrating life
As per NMC requirement, nurses have a duty to maintain knowledge and work
within evidence based best practice.
In order to maintain and refresh knowledge BHC promote the use of the MI
SKIN campaign within all its homes. Staff can access resources, additional
learning and evidenced based practice through this campaign and these can
located at :
http://barchester/departments/carequalityteam/Care_Specialist_Strategy/Forms
/AllItems.aspx?RootFolder=%2fdepartments%2fcarequalityteam%2fCare%5f
Specialist%5fStrategy%2fMI%20SKIN%20Matters%20Campaign&FolderCT
ID=&View=%7b5CA4B67B%2d8E9B%2d4C1D%2dB628%2dE8FBA46C4
FAF%7d.
Homes should ensure that new staff working in the home, understand MI
SKIN and the associated resources available, this should be covered in
induction.
In addition, A Tissue Viability Link Nurse will be identified in each home.
The Tissue Viability link nurse will have specific skills and expertise in the
prevention and management of pressure ulcers, or be willing to develop these
skills. They should ideally have achieved or be working towards a recognised
post graduate module or qualification in tissue viability.
The Tissue Viability link nurse should receive priority for study days around
tissue Viability and have completed the BHC MI SKIN and tissue viability
workbook.
The Tissue Viability link nurse will act as a local resource and cascade their
knowledge and skills to the other members of the healthcare team.
Training and education programmes should include:
Risk factors for pressure ulcer development
Pathophysiology of pressure ulcer development
The limitations and potential applications of risk assessment tools
Skin assessment
Skin care
Selection of pressure redistributing equipment
Use of pressure redistributing equipment
Maintenance of pressure redistributing equipment
Methods of documenting risk assessments and prevention activities
Positioning to minimise pressure
Shear and friction damage including the correct use of moving and
handling devices
Roles and responsibilities of inter-disciplinary team members in
pressure ulcer management
Policies and procedure regarding transferring residents between care
settings
Patient education and information giving
Grading of pressure damage.
The Tissue Viability link nurse will network with Tissue Viability link nurses
in other homes and with Tissue Viability Nurse Specialists in their area.
10

The Tissue Viability link nurse may coordinate tissue viability audits in the
home.

Celebrating life

Education can be achieved in a variety of ways including the use of company

representatives, E-learning, cascade of study days by the Tissue Viability link
nurse, videos and self-directed study.
Barchester Healthcare have produced two workbooks to assist with promoting
best practice with skin care. These are available on the intranet and can be
located at:
http://barchester/departments/carequalityteam/Care_Specialist_Strategy/Forms
/AllItems.aspx?RootFolder=%2fdepartments%2fcarequalityteam%2fCare%5f
Specialist%5fStrategy%2fTissue%20Viability&FolderCTID=&View=%7b5C
A4B67B%2d8E9B%2d4C1D%2dB628%2dE8FBA46C4FAF%7d
http://barchester/departments/carequalityteam/Care_Specialist_Strategy/Forms
/AllItems.aspx?RootFolder=%2fdepartments%2fcarequalityteam%2fCare%5f
Specialist%5fStrategy%2fMI%20SKIN%20Matters%20Campaign&FolderCT
ID=&View=%7b5CA4B67B%2d8E9B%2d4C1D%2dB628%2dE8FBA46C4
FAF%7d
Individuals who are able and willing should be informed and educated about
risk assessment and resulting prevention strategies.
Individual education should include providing information on the following:
The risk factors associated with them developing pressure ulcers
The sites that are of the greatest risk to them of pressure damage
How to inspect skin and recognise skin changes
How to care for skin and methods of pressure relief/reduction
Where they can seek further advice and assistance should they need it
Use of an electric profiling bed to relieve pressure themselves if
possible.
THE ROLE OF NUTRITION IN TISSUE VIABILITY
Outcome All individuals will be encouraged to eat a healthy balanced
diet in order to reduce the risk of pressure ulcer formation and promote
an optimum healing environment for those residents with existing
wounds.
All individuals will have a nutritional assessment completed on admission and
action taken as indicated by the risk identified.
Whereas good nutrition facilitates healing, malnutrition delays, inhibits and
complicates the process (Williams and Leaper 2000). Nutritional support is
fundamental to resident care and needs vary on an individual basis.
All individuals should aim to eat a healthy, balanced diet, with sufficient
quantities of energy and protein foods (Collier 2001). Refer to the table
Summary of Nutrients involved in Wound Healing in the appendix for
guidelines.
11

Individuals with diabetes are at a greater risk of poor wound healing

particularly if blood glucose levels are not well controlled (Bailey 2001).
These individuals may need referral to the Diabetes Nurse Specialist and the
Dietician for advice on management.

Celebrating life

Individuals suffering with any disease that may lead to malnutrition may need
particular attention e.g. Crohns disease, rheumatoid arthritis, alcohol abuse,
gastrointestinal surgery, liver disease, malignancy, major trauma,
inflammatory disease, fever, anaemia.
Effects of malnutrition include loss of muscle mass, loss of weight, impaired
immunity, delayed wound healing and increased risk of complications (Kings
Fund Report 1992).
Following assessment, if an individual is identified at risk of malnutrition an
individualised plan of care for nutrition will be instigated. The Chef will be
made aware of all at risk individuals so that the home can introduce
supplementation. Consideration will be given to a referral to the dietician via
the GP and the provision of dietary supplements.
Consideration of dietary intake for individuals with specific cultural
preferences should be made by referring to the BHC catering Manual, Section
4 for further advice and guidelines.
Consideration should also be made to referring the individual to an appropriate
healthcare professional such as dietician to assist with advice for meeting
nutritional need.
Staff should refer to BHC Nutrition Strategy for further guidance.
MANAGEMENT OF INDIVIDUALS WITH ESTABLISHED PRESSURE
ULCERS
Outcome All extrinsic and intrinsic factors which contribute to the
development of pressure ulcers will be assessed and their effects
minimised in order to prevent deterioration of the individuals existing
condition and provide the individual with the optimal wound-healing
environment.
All individuals will be assessed using the Waterlow Risk Assessment Tool and
those individuals with an existing pressure ulcer will be provided with an
individualised plan of care to optimise the wound-healing environment and
prevent deterioration.
Individuals with an established pressure ulcer will have it graded using the
European Pressure Ulcer Advisory Panel (EPUAP).
The BHC Wound Assessment Chart will be used to document dressing plans,
dressing changes and the ongoing assessment and progress of the wound
recorded. For individuals in residential homes, staff should access the local
community nursing teams to support the individual in a timely manner.
12

Photographs or tracings of the ulcer should be used to supplement this

information, and taken at regular intervals, appropriate to evidence
improvement or deterioration of the pressure ulcer.

Celebrating life

All photographs or tracings should be taken with the individuals agreement.

It is recommended that photographs should be taken as a minimum monthly or
more frequently if rapid deterioration or improvement.
Advice should be sought from the Tissue Viability Specialist Nurse or an
alternative suitably qualified health care professional in the management of
pressure ulcers, after a minimum of two weeks good care where no
improvement is observed.
Pressure should be eliminated or minimised through the use of pressurerelieving equipment or the implementation of a repositioning schedule.
All individuals will have a MUST nutritional assessment completed on
admission and action taken as indicated by the risk identified and this is
subject to on-going review.
Any individual with a chronic pressure ulcer should have their wellbeing
assessed by accessing the appropriate assessment tools, please see appendix
for examples of assessing wellbeing. Wellbeing is a dynamic matrix of
factors, including physical, social, psychological and spiritual. The concept of
wellbeing is inherently individual, will vary over time, is influenced by culture
and context and is independent of wound type, duration or care setting.
Within wound healing, optimising an individual wellbeing will be the result of
collaboration and interactions between clinicians, individuals their families
and carers, the healthcare system and industry. The ultimate goals are to
optimise wellbeing, improve or heal the wound, alleviate/manage symptoms
and ensure all parties are fully engaged in this process (Wounds international
2012).
Trigger Questions should be asked to any individual with a chronic wound
such as
1. Has your wound improved or got worse?
2. Has your wound stopped you from doing things in the last week?
3. What causes you the most disturbances/distress and when does this
occur?
4. Do you have a set routine to help you cope with your wound?
5. What would help to ease/improve your daily experience of living with a
wound?
Barchester Healthcare recognise that not all individuals will be able to answer
the above questions due to cognitive decline. However, staff should ensure
that wellbeing is still considered and discussed with those closest to the
individual and by monitoring behaviours that could indicate wellbeing
concern.
Reviewing of daily routine should be monitored to identify support that may
be required through the day eg pain may be worse first thing in the morning.
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Once wellbeing has been assessed, reference to any findings should be
addressed in the relevant care plan. For example if an individual is socially
isolated due to concerns around the odour of a chronic wound this should be
addressed in the care plan. Again, if a individuals life is limited due to pain
from the chronic wound, clear plans need to be produced in the pain care plan
with the individual for managing this.

An appropriate pain assessment tool must be implemented where a pressure

ulcer is present. Pain control whether topical or systemic should be given high
priority. Evidence must always be made of any pain on the wound assessment
chart Barchester Healthcare have a range of pain assessment tools that staff
can use and these are available on the intranet.
http://barchester/departments/carequalityteam/Assessments/Forms/AllItems.as
px
For All individuals a request should be made for a medication review. Many
drugs can contribute to the increase in the risk of pressure ulcer formation e.g.
sedation and analgesia can reduce sensation and level of mobility, steroids can
impair the healing process and some hypotensive drugs affect blood flow.
All individuals with an identified continence problem should have a
continence assessment completed, as moisture and acid from urine and faeces
can cause skin maceration and skin is more likely to be damaged (Clay 2000).
Barrier creams may help to give some protection but oil based products may
increase the potential for damage if not used sparingly where individuals are
supported with continence pads.
Staff should follow best practice guidance for management of continence and
this is accessible through the Barchester Healthcare strategy for Continence
Management.
Skin should be kept well hydrated and talcum powder used sparingly, as flaky
or cracked skin is more susceptible to damage. Dehydration should be
corrected by increased fluid intake and a topical moisturiser should be applied
(Clay 2000).
Individuals suffering with long term medical conditions should receive
appropriate treatment to help to maximise their healing capacity and reduce
their risk of further pressure ulcer development.
Any medical condition that reduces the blood supply increases the risk of
pressure ulcer development e.g. cardiac disorders, peripheral vascular disease
and anaemia.
Any respiratory disease that leads to reduced blood oxygen content may also
increase the risk due to tissue hypoxia (Clay 2000).
Individuals with neurological disease have an increased risk of pressure ulcer
development as they may have an altered appreciation of pain and reduced
mobility (Clay 2000).
Infection raises the metabolic rate and the demand for oxygen, which can
make an individual more susceptible to tissue damage (Clay 2000).
14

Smokers are more at risk of developing pressure sores, especially on their

heels due to the vasoconstriction effect of nicotine (Clay 2000).

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For Pressure ulcers on heels, a doppler investigation should be considered to

assess realistic healing potential. Individuals with necrotic (black heels) should
be referred for a vascular assessment.
In Palliative care healing may be unrealistic but it is important to reduce the
risk of further deterioration / damage, comfort must be the most important
consideration and good record keeping to evidence this.
WOUND MANAGEMENT
Outcome Any individual with a pressure ulcer will be provided with
wound management products that will provide the optimum environment
to assist the wound to heal.
The key to effective wound management is knowledge of the wound healing
process, the capabilities of particular dressings and how they should be used in
individual circumstances with potential contraindications. (Benbow 2001).
BHC have produced additional learning guidance in the form of a pressure
prevention workbook which addresses the wound healing process in one of the
units. This is available on the BHC intranet.
Wounds should be evaluated each time a dressing is applied or if there is any
cause for concern. The Wound Assessment Chart will be completed at each
dressing change and the progress of the wound recorded. Photographs or
tracings of the ulcer should be used to supplement this information and should
be taken with the residents agreement at intervals to clearly show progress or
deterioration of the wound. Photographs taken on a digital camera must be
saved on a read only file (to prevent digital enhancement / change to the
photograph). Wounds should be measured accurately through the use of
single use measuring strips that are supplied within the dressing packs or
available to order separately.
An aseptic dressing technique should be used where appropriate, BHC have
the Royal Marsden available for staff to access.
It is recommended that wound irrigation is the preferred method if cleaning
the wound bed. Cotton wool and gauze swabs should not be used to clean as
they leave fibres in the wound. The use of other solutions such as Normal
saline, sterile water, diluted 1% povidone iodine to cleanse the wound
should be either prescribed by the GP or advised by the Tissue Viability
Specialist Nurse.
Forceps should not be used as they can cause pain and damage and are clumsy
to use. Sterile gloves are a more suitable alternative and also help to reduce the
risk of cross-infection.
If the wound is clean and little exudate is present, repeated cleansing is
15

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contraindicated since it may damage new tissue, decrease the temperature of
the wound and remove exudate.
A wound dressing may be described as a material which, when applied to the
surface of a wound, provides and maintains an environment in which healing
can take place at the optimum rate.
This strategy discusses best practice around dressing selection. Each home
should have access to their own local dressing formulary as provided by their
CCG. Staff need to ensure they have the current version in the home at all
times and should seek advice from their local tissue viability nurse (or relevant
specialist other) if they are unfamiliar with any of the products.
According to Mallet and Dougherty (2000) a dressing must be capable of
fulfilling the following functions:
To remove excess exudate and toxic components.
To maintain a high humidity at the wound-dressing interface.
To allow gaseous interchange.
To provide thermal insulation.
To be impermeable to bacteria.
To be free from particle or toxic components.
To allow dressing change without trauma.
In addition the dressing should minimise pain, odour and bleeding and be
comfortable and acceptable to the resident (Mallet & Dougherty 2000).
Dry dressings do not fulfil most of the above criteria and should not be used
as a primary dressing (Dealey 1991).
Some dressing contents eg silver & iodine dressings absorb into the body and
require caution around the length of time an individual receives the treatment
for. Homes should be aware of the dressings that have specific instruction
around duration of treatment and discuss this with the prescriber.
Infected wounds are those where bacteria has invaded the host tissue. Signs
and symptoms of infection may include:
Redness, swelling and heat in the surrounding tissue.
An increase in wound exudates as immune cells in the area become
more active.
An increase in wound pain.
Fever and a general feeling of malaise.
Odour
If any of the above signs and symptoms are present it may be necessary to
seek advice to swab the wound in order to confirm symptomatic and treatable
infection.
Colonised wounds are those where bacteria is found in the exudate but not in
the host tissue. Colonised wounds should not be routinely swabbed. Refer to
the Royal Marsden for best practice around Swab procedures.
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Celebrating life
If there is any doubt as to the diagnosis of an infected or colonised wound,
advice on the management should be sought from the GP and/or the Tissue
Viability Specialist Nurse.
Topical antibiotics should only be used if prescribed by a GP or requested by
the Tissue Viability Specialist Nurse.
Refer to the Royal Marsden Manual of Clinical Nursing Procedures 7th
Edition for information on the physiology of wound healing.

All pressure ulcers Grade 2 and above, will be recorded on the clinical
governance data base within 24hrs of development / admission and the
pressure ulcer progress updated on the clinical governance data base at least
monthly.
Pressure ulcer grading is only appropriate for defining the maximum depth of
tissue involvement.
Using pressure ulcer grading systems to describe healing must assume that full
thickness pressure ulcers heal by replacing the same structural layers of body
tissue that were lost.
Clinical studies indicate that as grade 4 pressure ulcers heal to progressively
more shallow depth, they do not replace lost muscle, subcutaneous fat, and
dermis before they re-epithelise.
GRADING AND GOVERNANCE CONSIDERATIONS
A grade 4 pressure ulcer cannot become grade 3, grade 2, and/or subsequently
grade 1 ulcer.
Reverse grading should never be used to describe the healing of a pressure
ulcer. However, due to BHC current clinical governance and monitoring
systems, reverse grading will be used for accurate statistical analysis and
corporate awareness of active and open pressure ulcers. This holds no
financial implication. This addendum will be updated as IT systems are
reviewed and upgraded and in accordance with the strategy review date.
Pressure ulcer grading systems should only be used to document the maximum
anatomic depth of tissue involved in the ulcer after necrotic tissue has been
removed.
Healing of pressure ulcers should be documented by objective parameters such
as: size,depth, amount of necrotic tissue, amount of exudate , and presence of
granulation tissue.
All wounds grade 3 and above, regardless of their origin eg home acquired or
hospital/community acquired will be immediately reported to safeguarding
and the Care Quality Commission (CQC). For any identified EPUAP grade 3
and above home acquired pressure ulcers, a root cause analysis will be
17

Celebrating life
completed and submitted in a timely manner and sent to the above parties and
the Regional Care Specialist.
See appendix for a flow chart detailing the process the homes will take around
the management of identified pressure ulcers
WOUND CARE PROTOCOL
PRE-ADMISSION ASSESSMENT
Identify risk factors associated with skin integrity and ensure that any
specialist equipment is made available PRIOR to admission.
Ensure current skin integrity is recorded and waterlow (if possible) is
evidenced on pre admission documentation.
No service user should be admitted without the appropriate equipment in
place.

ASSESSMENT AND DOCUMENTION

All wounds will be assessed on admission and a wound assessment chart
commenced.
For different wound types (other than pressure damage) staff can access the
protocol for managing skin tears which advises on best practice around
dressing types and management. For all other wounds such as venous ulcers
and surgical wounds, Homes should expect to have access to clear
management plans from the discharge teams in hospital or the local
community. If staff do not have access to this information guidance needs to
be sought from the relevant healthcare professional in a timely manner.
This will take into account the following:
Size of wound
Location of wound
Grade of Wound (if pressure damage)
Any malodour
Any exudate
Prescribed wound dressings
Waterlow score
Consent for clinical photography
Body map must be completed
For any medical equipment in use eg high specification mattresses, a
serial number should be added to the documentation.
All wounds and or dressings require evaluation, the exact timing of this will be
identifyed on the wound assessment chart and in line with recommendations
from the specialist healthcare professional or manufacturers instruction.
Each time the wound is redressed an evaluation must be made of the condition
of the wound and the status recorded on the wound assessment chart.
All areas of the assessment should be complete.
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Celebrating life
The suitability of any pressure relieving equipment should be evaluated and a
rationale documented in the tissue viability care plan. Upgrades should be
sourced as required.
SUPPLEMENTARY DOCUMENTION
Ensure that the following documentation is completed as required:
Repositioning chart
Moving and handling assessment
Moving and handling care plan
Body Weight
Nutritional assessment
Nutritional care plan
Fluid balance record
Continence assessment
Ensure that and follow ups or referrals are evidenced including visits and
advice from the dietician and record in the health care professional
records.
PRESCRIPTIONS
The GP will need to be notified of changes in skin integrity of the resident
when a request for prescriptive dressings and creams needs to be made. If any
concerns regarding potential infection in the site of the wound are identified,
timely referral to the GP for advice will take place and outcomes will be
documented in the healthcare profession section of the care profile.
All prescriptions will be evidenced on the medication administration record
sheet.
Any delegated duties to carers for application of creams will be evidenced on
the appropriate Topical Medication Administration (TMAR) charts, but this
will need to be overseen by the nurses on duty and signed as agreed.
All dressings and creams must only be prescribed for the individual service
users and used solely for their prescribed locations.
All dressings undertaken will be documented on the Wound assessment chart.
Referral to this on the Medication administration record is acceptable.
TISSUE VIABILITY NURSE
Contact must be made with the tissue viability nurse when skin integrity has
not improved despite 2 weeks of ongoing treatment. The Tissue viability
nurse should also be made aware of any grade 3 or above pressure ulcers.
A record of any referral to the tissue viability nurse must be made in the
service users care plan.
The home has a duty to ensure that any referrals are followed up in a timely
manner.
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Celebrating life
The Tissue Viability Specialist nurse will be requested to record the visit, her
assessment and advice given should be made in the health care professional
section of the care plan. Any changes in wound care reflected in the wound
assessment chart and/or the tissue viability care plan.
The home will remain in contact with the GP or TVN until they have
discharged the resident from their care.

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REFERENCES
Bailey S (2001) Diabetes and wound healing. Nurse 2 Nurse. 2 (1) 24.
Benbow M (2001) Wound Management Product Guide. Nurse 2 Nurse 2 (1) 46-49
Clay M (2000) Pressure sore prevention in nursing homes. Nursing Standard. 14, 44,
45-50.
Collier J (2001) Nutrition and Wound Healing. Nurse 2 Nurse 2 (1) 20.
Dealey C (1991) Criteria for wound healing. Nursing 4 (29), 20-21.
Department of Health (1991) Dietary reference values for food energy and nutrients
for the United Kingdom. HMSO. London.
Kings Fund Report (1992) A Positive Approach to Nutrition as Treatment. London
Lawrence JC (1997) Wound Irrigation. Journal of Wound Care. 6 (1), 23-26.
M Loyd Jones (2011). Is it time to review the way we categorise pressure?
Wounds UK, 2011. Vol 7. No3

Mallet J & Dougherty L (eds) (2000) The Royal Marsden Hospital Manual of Clinical
Nursing Procedures. Blackwell Science. Oxford.
NICE Clinical Guideline The prevention and treatment of pressure ulcers (2005)
Preston KW (1998) Positioning for comfort and pressure relief: the 30
Care Science and Practice. 6 (4) 116-119.

alternative.

Reid J & Morison M (1994) Towards a consensus: classification of pressure sores.

Journal of Wound Care. 3 (3) 157-160
Waterlow J (1998) Pressure Sore Prevention Manual (revised). Newtons. Taunton.
Williams L & Leaper D (2000) Nutrition and Wound Healing. Clinical Nutrition
Update. 5(1), 3-5.
Your turn org.uk
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory panel
Prevention and treatment of pressure ulcers. Quick reference guide Washington DC.
Wounds International (2012) An expert working group review, Optimising wellbeing
in people living with a wound.

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Celebrating life
USEFUL INFORMATION
Wound grids and pens can be obtained from Convatec. Contact the Wound
Care Help Line for the name of your local company representative who will
provide them free of charge.
Convatec Wound Care Help Line 0800 289738
www.convatec.com
www.smith-nephew.com
www.smtl.co.uk
Tissue Viability Society
Glanville Centre
Salisbury District Hospital
Salisbury
Wilts SP2 8BJ
Tel 01722 336262 ext 4057
Fax 01722 425263
Email tvs@dial.pipex.com
Website www.tvs.org.uk
National Institute for Clinical Excellence
11 Strand
London
WC2R 5HR
Website www.nice.org.uk
Tissue Viability Nurses Association
Glanville Centre
Salisbury District Hospital
Salisbury
Wilts SP2 8BJ
Tel 01722 336262 ext 4057
Fax 01722 425263
European Pressure Ulcer Advisory Panel
EPUAP Business Office
14, Ashton Street
Oxford, OX4 1EP
United Kingdom
Tel-01865 791725
Fax- 01865 791725
www.epuap.org/

22

A Summary of Nutrients involved in Wound Healing

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Nutrient
Energy

Role
As part of the healing
process the body enters a
hypermetabolic phase with
an increase in demand for
carbohydrate. If insufficient
carbohydrates are eaten, the
body breaks down protein to
provide glucose for cellular
activity.

Requirements
3 Meals per day
plus or minus
snacks

Sources
Most food and
drink provides
calories.

Protein

Protein is needed as part of

the inflammatory process, in
the immune response and in
the development of
granulation tissue. The main
protein synthesised during
wound healing is collagen
and its strength determines
the strength of the wound.

Include at every
meal

Meat, fish, eggs,

pulses, milk and
dairy products
and Tofu.

Vitamin
C

Vitamin C has an important

role in collagen synthesis, in
the formation of bonds
between strands of collagen
fibre, helping to provide
extra strength and stability.
Vitamin C is also involved in
the immune response.
Zinc is needed for protein
synthesis. There is an
increased demand during cell
proliferation and protein
secretion. Zinc has an
inhibitory effect on bacterial
growth and is involved in the
immune process.
Iron is a co-factor in collagen
synthesis, and iron deficiency
delays wound healing.

5 or more
portions of fruit
and vegetables
per day.

All fruit and

vegetables
including fruit
juice, frozen and
tinned varieties.

Maintains the elasticity of the

skin

Minimum of 6-8
glasses per day.

Zinc

Iron

Fluid

23

Red Meat, offal,

eggs, cheese.
Seafood and
marmite. Note
Protein enhances
absorption of
zinc.
Red Meat, offal,
eggs, pulses, sun
dried fruit and
fortified
breakfast cereal.
Note Vitamin C
enhances the
absorption of
iron
Nutritious drinks
are useful in
residents with
poor dietry
intake.

WOUND CLASSIFICATION

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EPUAP PRESSURE ULCER CLASSIFICATION SYSTEM

CATEGORY / STAGE 1
Non blanchable erythema of intact skin. Discoloration of the skin, warmth,
oedema,induration or hardness may also be used as indicators, particularly on
individuals with darker skin.
CATEGORY / STAGE 2
Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is
superficial and presents clinically as an abrasion or blister.
CATEGORY / STAGE 3
Full thickness skin loss involving damage / necrosis of subcutaneous tissue,
that may extend down to but not through underlying facia.
CATEGORY / STAGE 4
Extensive destruction, tissue necrosis or damage to muscle, bone or supporting
structures, with or without full thickness skin loss.
Glossary of signs that may indicate pressure development:

EPUAP Puclas system Self assessment training is available on the BHC

intranet for staff to access and can be accessed at
http://barchester/departments/carequalityteam/Care_Specialist_Strategy/Tissue
%20Viability/PUCLAS%20tool%20(EPUAP).mht

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Celebrating life
REMOBILISING ONTO A HEALED PRESSURE ULCER
It is important that enough time is allowed for skin to build up pressure
tolerance over the area that has been treated surgically or conservatively.
Therefore to prevent further skin damage it is recommended that time spent up
in a wheelchair is at first limited.
NB it is recommended that the resident waits for 3-4 days after the pressure
ulcer is healed completely before getting up. The specialist team will assess
when it is safe for residents to recommence mobilising.
The following table is meant as a guide to start re-mobilising. It is
recommended that these stages are followed in order.
Staff should not skip a stage to increase mobilising times the resident will be
at risk of repeated skin damage if the regime is not adhered to. In some
instances individual regimes may be required and this should always be
discussed with the appropriate health care professional.
PRESSURE RELIEF
If the resident is able to pressure relieve, this should be carried out every 20
minutes for 20 seconds. (20/20)
Pressure relief helps to prevent disruption of the blood flow for long periods of
time to the seating area.
It allows fresh blood to be pumped to the weight bearing areas and allows
waste products to be drained away essential needs for healthy skin.
Pressure relief can be achieved by lifting the bottom off the seating area or by
leaning side to side or forward, to move the body weight off the bony
prominences.
An adequate pressure lift involves fully lifting off the ischial tuberosities (the
boniest part) off the cushion.
SKIN
It is essential that skin is checked for signs of discoloration or marking (ie
Pressure marks) before getting the resident up into the wheelchair and
immediately on return to bed.
When in bed, all pressure should be relieved from any pink or red marks until
the mark has faded completely.
For skin marking that has completely faded before 30 minutes, relieve all
pressure from the area until the mark has completely disappeared and when
getting up again, go back to the previous stage e.g if the resident marked after
4 hours, go back to the previous stage, 3 hours 30 minutes.
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If skin marking is persistent, take into account factors that may be possible
causes of the problem i.e infection, weight loss, condition of equipment etc
and seek advice.
If a pressure mark causes at least 3 days of bed- rest before it disappears,
restart at the beginning of the guidelines (eg day 1) when remobilising.
MOBILISING GUIDELINES
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Mobilising Time
Up for 15 minutes once a day
Up for 30 minutes once a day
Up for 45 minutes once a day
Up for 1 hour once a day
Up 1 hour 15 minutes once a day
Up 1 hour 30 minutes once a day
Up 1 hour 45 minutes once a day
Up 2 hours once a day
Up 2 hours 15 minutes once a day
Up 2 hours 30 minutes once a day
Up 2 hours 45 minutes once a day
Up 3 hours once a day
Up 3 hours 30 minutes once a day
Up 4 hours once a day
Up 4 hours 30 minutes once a day
Up 5 hours once a day
Up 5 hours 30 minutes once a day
Up 6 hours once a day

It is important to follow the mobilising times daily as per regime to prevent

further skin breakdown.
Do not exceed more than 6 hours once a day when mobilising times have been
built up, until this has been reviewed and assessed as safe by the appropriate
specialist overseeing the residents care.
The mobilising times are intended as a guide only and may be tailored to suit
specific individual need.

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MYMOP2 WELLBEING ASSESSMENT TOOL (intial)

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Full name ..................................................................... Date of birth ............................

Location ........................................................................................................................
..........................................................................................................................................
Todays date ................................................... Nurse ......................................................
Choose one or two symptoms (physical or mental) which bother you the most. Write
them on the lines. Now consider how bad each symptom is, over the last week, and
score it by circling your chosen number.
SYMPTOM 1: ................. 0 1 2 3 4 5 6
.............................................. As good as it
As bad as it
.............................................. could be
could be
SYMPTOM 2: ................ 0 1 2 3 4 5 6
.............................................. As good as it
As bad as it
.............................................. could be
could be
Now choose one activity (physical, social or mental) that is important to you, and that
your problem makes difficult or prevents you doing. Score how bad it has been in the
last week.
ACTIVITY: ..................... 0 1 2 3 4 5 6
.............................................. As good as it
.............................................. could be

As bad as it
could be

Lastly how would you rate your general feeling of wellbeing during the last week?
0123456
As good as it
could be

As bad as it
could be

How long have you had Symptom 1, either all the time or on and off? Please circle:
0 - 4 weeks
years

4 - 12 weeks

3 months - 1 year

1- 5 years

over 5

Are you taking any medication FOR THIS PROBLEM ? Please circle: YES/NO
IF YES:
1. Please write in name of medication, and how much a day/week
..........................................................................................................................................
......................
2. Is cutting down this medication: Please circle:
Not important a bit important
very important
not applicable
IF NO:
Is avoiding medication for this problem:
Not important a bit important
very important
not applicable
Comments and actions as discussed with resident

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* MYMOP2 Follow up *
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Full name ......................................................... Todays date .........................................
Please circle the number to show how severe your problem has been IN THE LAST
WEEK.
This should be YOUR opinion, no-one elses!
SYMPTOM 1: ................ 0 1 2 3 4 5 6
....................................... As good as it As bad as it
....................................... could be could be
SYMPTOM 2: ................ 0 1 2 3 4 5 6
....................................... As good as it As bad as it
....................................... could be could be
ACTIVITY: ..................... 0 1 2 3 4 5 6
....................................... As good as it As bad as it
....................................... could be could be
WELLBEING: 0 1 2 3 4 5 6
How would you rate As good as it As bad as it
your general feeling could be
could be
of wellbeing?
If an important new symptom has appeared please describe it and mark how bad it is
below.
Otherwise do not use this line.
SYMPTOM 3: ................ 0 1 2 3 4 5 6
....................................... As good as it
As bad as it
....................................... could be
could be
The treatment you are receiving may not be the only thing affecting your problem. If
there is anything else that you think is important, such as changes you have made
yourself, or other things happening in your life, please write it here (write overleaf if
you need more space):
Are you taking medication FOR THIS PROBLEM ? Please circle: YES/NO
IF YES:
Please write in name of medication, and how much a day / week
..........................................................................................................................................
.....................
Comments and actions as discussed with resident

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Pressure Ulcer Risk assessment and
Prevention Flow Chart.
Using the Waterlow Risk Assessment
tool, Assess for Risk at Pre- Admission,
within 6 Hours of Admission and
Review as a minimum monthly, or if
condition changes.
Communication is vital in ensuring staff
Identify skin changes quickly. MI SKIN
principles should be used at every handover
to ensure staff are aware of the changing
needs of individuals in our care. The MI
SKIN handover sheet should be
implemented for staff to use to monitor
changes.

Risk assessment scores are used as an

aide memoir only, A Holistic approach to
assessment needs to be used, complete
High Risk proforma if assessment indicates
elevated risk of pressure damage.

Low Risk to Pressure Ulcers

Record assessments and skin changes

using the Waterlow and Tissue Viability
Care Plan.

Regular Skin inspection

Decide Frequency
Inspect areas
Encourage individuals to self inspect.
Look For
Persistent Erythema
Non Blanching Hyperaemia
Blisters, Heat, Oedema, induration.
(on dark pigmented skin look for
Purple/bluish areas, Localised Heat)

If deemed High risk and vulnerable

Consider the most vulnerable sites
for the individual.

Positioning

Equipment

Identify regime

Ensure M&H
equipment
minimises Shearing
and Friction

Ensure staff are
aware of how to
redistribute weight.

Ensure resident
has a repositioning
record

Document Plan of
Care on tissue
Viability Care Plan

Consider restriction
of less than 2 hours

Considerations: comfort, Skin assessment, health status,

lifestyle & ability, Critical Care need, acceptability, holistic
level of risk.

Consider ALL support systems mattresses, seating,
wheelchairs.

Take a 24 Hour approach

Use Mattress selection algorithm

Review equipment in line with altered condition and risk.

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Identified Pressure Ulcer

GOVERNANCE
DOCUMENTATION

ACCIDENT FORM
COMPLETED

IF GRADE 3 OR ABOVE (HOME

ACQUIRED OR COMMUNITY
ACQUIRED) INFORM CQC AND
LOCAL SAFEGUARDING
TEAM.

ROOT CAUSE ANALYSIS

COMPLETED (FOR HOME
ACQUIRED GRADE 3 OR
ABOVE PRESSURE
ULCERS)

PRESSURE ULCER TO BE
ADDED TO CLINICAL
GOVERNANCE DATABASE
WITHIN 24 HOURS..

MANAGEMENT & PREVENTION

COMMENCE A WOUND ASSESSMENT CHART,

PHOTOGRAPH (WITH CONSENT) AND
MEASURE WOUND. IDENTIFY DRESSING PLAN

UPDATE TISSUE VIABILITY CARE PLAN

IDENTIFYING NEW WOUND AND CROSS
REFERENCE TO WOUND ASSESSMENT CHART

INTRODUCE A PAIN ASSESSMENT TOOL TO

IDENTIFY AND ENSURE PAIN IS MANAGED
EFFECTIVELY.

REVIEW AND UPDATE THE WATERLOW SCORE

UPDATE TISSUE VIABILITY CARE PLAN TO

REFLECT REVISED PRESSURE PREVENTION
REGIME - USE MATTRESS SELECTION
ALGORITHM AND CLINICAL JUDGEMENT TO
IDENTIFY NEW REPOSITIONING REGIMES/
SURFACE EQUIPMENT

SAFETY CROSS UPDATED

ENSURE STAFF ARE

AWARE OF PRESSURE
DAMAGE THROUGH
HANDOVERS, DIARY,
MI SKIN HANDOVER
SHEET. DISCUSS AT
STAND UP MEETINGS.

DISCUSS WITH LINK ROLE

WITHIN HOME ANY
POTENTIAL TRAINING
NEEDS

REFER TO OTHER HEALTHCARE

PROFESSIONAL FOR ADVICE IF NO
IMPROVEMENT AFTER TWO WEEKS.

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31

MATTRESS SELECTION ALGORITHM

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[42]

Barchester recommend Triflex mattresses to use

for the majority of residents. Why are you
considering changing to a Dynamic air system?

Be aware that some resident complain that the

beds are noisy and may not sleep as well on the
dynamic system. Other residents have expressed
that it feels hard and can restrict self movement
around the bed.

YES
Comfort of resident?
Pressure damage
has developed?

Resident choice or
recommendation
from Tissue
Viability.

YES
Is the site of the
pressure damage on the
heel?

Does the person require

assistance in changing
their position?

NO

NO

Ensure this is implemented and strictly adhered to

before considering the dynamic system.

NO

Ensure that all staff are made aware through the

handover process and actions that need to be
taken to prevent damage.

NO

Discuss health promotion with your resident and

implement self help/programme to relieve
pressure.

Have you instigated 2 - 4 hourly repositioning and is this evidenced

on the repositioning chart?

NO

YES
Triflex is recommended for heel damage
as it is the only mattress that removes all
pressure.
YES

YES
Are all your staff aware of the risks of your resident developing a
pressure sore?

YES
Have you educated your resident on the importance of relieving
pressure?

YES

MATTRESS USE
A)HIGH SPEC FOAM MATTRESS
Any Waterlow Score - Skin intact or
individual with Grade 1 /2 pressure damage
that has the ability to reposition self or
comply with effective repositioning regime.
B) DYNAMIC SYSTEMS
Any Waterlow Score Grade 2 Not healing or deterioating (Caution
Heel site- Triflex recommended if other sites
intact).
In bed for more that 16 hours a day with skin
damage and compliance concerns.
Any individual with Grade 3 or 4 Skin damage.
Long term prevention where evidence is
available that High Spec Mattresses have not
been sufficient.

Have you ensured that the resident has a pressure relieving cushion in
their chair/ wheelchair?

NO

YES
Is the residents BMI <20 or/ med High Risk of malnutrition ?

YES
NO

Review the other surfaces your resident is on,

ensure all surfaces have pressure relieving
equipment and monitor time your resident is sat in
their chair during the day.
Implement guidelines from MUST assessment.
Consider referral to GP for mineral/vitamin review.
Discuss high protein diet with resident and chef to
aid nutrition.

Does your resident suffer from nausea or motion sickness?

YES
NO
Resident was previously on a dynamic system in another setting?

NO

Some residents experience ' a moving sensation'

from the air mattresses - caution needs to be taken
with these residents as it may increase the nausea
and loss of appetite.

YES
This does not mean the resident needs to be on an
air mattress now. Reassess the need for Dynamic
system.

Resident Waterlow score is deemed Very High Risk?

Mattress Recommendations in Line AS PER NICE Guidelines 2003.

Decisions about which pressure-relieving device to use should be based an
overall assessment of the individual and should not be based solely on scores
from risk assessment tools

32

The waterlow is only one part of the assessment of

risk and you need to look at the individual (for
example a resident could have a waterlow of 28
however be fully mobile and able to relieve their
YES own pressure). The decision to transfer to a
dynamic system cannot be based on Waterlow
alone.

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ROOT CAUSE ANALYSIS OF PRESSURE ULCER GRADE 3 AND ABOVE
Home
Name
Date of
admission

Unit
Date
Residents
Name
Name
Waterlow Score
BMI on
MUST Risk
on admission
admission
on admission
Current
Current BMI
Current
Waterlow Score
MUST Risk
Details when pressure ulcer was first noted.
Date first noted and recordedWho first
noted and recorded the ulcer..
Site of the ulcer .Grade and
size of the ulcer at this point

Also record the date when it was entered on to the Clinical Governance
Database
Details of what actions were taken when pressure ulcer first noted. Include use of
pressure relieving equipment such as mattresses and cushions both static and dynamic
and dates when commenced.

Details of documentation commenced when pressure ulcer first noted. Include

any body maps, wound assessments, care plans and repositioning charts etc with dates
of commencement.

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Current details of pressure ulcer. Please include the grade and size of the ulcer.

Concise history of any changes to any pressure relieving equipment outlined

above. Please include dates of any changes made.

Give details of any external advice that was sought. Include any referrals made to
TVNs, GPs, District Nurses etc including dates contact was made and dates of visits.

Give details of any thing which may have contributed to pressure relief not being
effective. Include if the person refused to consent to any specialist equipment being
used or support such as positional changes being given.

35

2
What sequence of events may have led to this damage. Include any changes to the
persons condition

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What conditions may have contributed to this occurring. Refer to MI SKIN

What other problems may have contributed. Consider communication, knowledge

and understanding

Referring to the above 3 boxes why has this occurred.

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3
ACTION PLAN
What will you do to prevent the problem happening again?

How will the solution be implemented, including dates?

Who will be responsible?

What, if any, are the risks of implementing the solution?

Date for review of RCA action plan:Person responsible for review:Person responsible to sign and date when action plan fully completed:-

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4
COPY OF FORM TO BE SENT TO CARE SPECIALIST ON COMPLETION
OF RCA AND WHEN ACTION PLAN FULLY COMPLETED

BARCHESTER HANDOVER RECORD

DATE:-

TIME:-

NAME OF PERSON COMPLETING HANDOVER RECORD:NAME

FOR
CPR

38

OTHER INFORMATION