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Pressure ulcer management
Short Text
Introduction
Pressure ulcers (previously known as pressure sores, bed sores, pressure damage, pressure injuries and decubitus ulcers) are areas of localised skin damage, which can extend to underlying muscle and bone.
They can develop in any area of the body. In adults damage is usually over bony prominences, such as the sacrum. In infants and children it is more often on, for example, the occipital area or ears.
Damage is believed to be caused by a combination of factors including pressure, shear forces, friction and moisture.
Pressure ulcers are more likely to occur in people who are seriously ill, people with spinal cord injuries, or people who cannot move or have difficulty moving. They are also a problem in people who eat poorly, are obese, have poor posture, or who use equipment such as seating or beds that do not provide appropriate pressure relief. Older people and pregnant women are also at risk.
Pressure ulcers create psychological and physical problems for patients, carers and their families. They are associated with an increased incidence of infection and increased risk of death in older people in intensive care units.
Based on data that are available, new pressure ulcers are estimated to occur in 4–10% of people admitted to acute hospitals in the UK, the precise rates depending on case mix. In the community, new pressure ulcers affect an unknown proportion of people as reliable data is not available.
The financial costs to the NHS are considered to be substantial. Total costs in the UK have been estimated to be £1.4–2.1 billion annually, equivalent to 4% of the total NHS expenditure.
Source guidance
The NICE guidance that was used to create the pathway.
Pressure ulcers: the management of pressure ulcers in primary and secondary care. NICE clinical guideline 29 (2005)
The MIST Therapy system for the promotion of wound healing. NICE medical technologies guidance 5 (2011)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
Implementation
Audit support
Audit support provides ready-to-use criteria, including exceptions, definitions, suggested data sources and a data collection tool.
Slide sets
Slide sets provide a framework for discussion and assist in local dissemination of the guidance. The slides contain the key messages from NICE guidance and can be tailored for local presentations.
Pathway information
Updates to this pathway
19 October 2012 Minor maintenance updates
Information for patients and the public
NICE produces booklets for patients and the public, called 'Understanding NICE guidance'. They summarise, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written a booklet for patients and the public explaining its guidance on each of the following topics.
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Government. If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children.
Supporting information
Glossary
National Patient Safety Agency
Person at risk of, or with, a pressure ulcer
Person at risk of, or with, a pressure ulcer
Person at risk of, or with, a pressure ulcer
Perform initial risk assessment in first episode of care (within 6 hours).
Initial and ongoing ulcer assessment is the responsibility of a registered healthcare professional.
Examples of people vulnerable to pressure ulcers include people:
- undergoing surgery
- in critical care
- with orthopaedic conditions
- with spinal injury
- with diabetes
- with peripheral vascular disease
- with a history of pressure ulcers
- at extremes of age.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAssessing risk
Assessing risk
Assessing risk
Risk factors include:
- pressure
- shearing
- level of mobility, including walking, ability to reposition (for example in bed or a chair) or transfer (for example from bed to chair)
- sensory impairment
- continence
- level of consciousness
- acute, chronic and terminal illness
- comorbidity (for example, assess systemic signs of infection, blood supply, medication)
- pain – whether the person is in pain, what is causing it, the level of pain (use an appropriate tool to measure it), location and management interventions
- posture
- cognition
- psychological status, including ability to self-care
- social factors, including the suitability of the home environment, level of supportive provision and the involvement of local support services
- previous pressure damage
- extremes of age
- nutrition and dehydration
- moisture to the skin
- friction.
Document the assessment of risk, noting all relevant factors.
Reassess on an ongoing basis and in particular if the person's circumstances change.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeSkin assessment
Skin assessment
Skin assessment
Assess skin regularly.
- Frequency should be based on vulnerability and condition of person being assessed.
- Inspect all vulnerable areas.
- Encourage people (or their carers) to inspect the skin (using a mirror if necessary).
Look for:
- persistent erythema
- non-blanching hyperaemia
- blisters
- localised heat
- localised oedema
- localised induration purplish/bluish localised areas
- localised coolness if tissue death occurs.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAssessing pressure ulcers
Assessing pressure ulcers
Assessing pressure ulcers
Assess:
- cause
- location
- dimensions, including the longest length as an estimate of surface area, and depth (measured using a sterile probe)
- stage or grade
- exudate amount and type
- local signs of infection
- pain, including cause, level, location and management interventions
- wound appearance
- surrounding skin
- undermining/tracking, sinus or fistula
- odour.
Ensure initial and ongoing pressure ulcer assessment. Reassess frequently (at least weekly).
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeRecording the pressure ulcer assessment
Recording the pressure ulcer assessment
Recording the pressure ulcer assessment
Document depth and estimated surface area.
Grade using the European Pressure Ulcer Advisory Panel classification system of pressure ulcer grades.
Support document with photography and/or tracings (calibrated with a ruler).
Pressure ulcers should not be reverse graded. A grade 4 pressure ulcer does not become a grade 3 as it heals. As the ulcer heals it should be described as a healing grade 4 pressure ulcer.
All pressure ulcers graded 2 and above should be documented as a local clinical incident.
The above recommendation was correct at the time of publication of the NICE clinical guideline on the prevention and treatment of pressure ulcers in 2005.
The NPSA has updated its guidance to say that pressure ulcers of grade 3 and above should be reported as a serious incident requiring investigation. Further information can be found at the NPSA website.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeTreatment and management
Treatment and management
Treatment and management
A registered health professional should choose the dressing, topical agent, method of debridement or adjunct therapy based on:
- ulcer assessment
- general skin assessment
- treatment objective
- characteristic of dressing or technique
- previous positive effect of dressing or technique
- manufacturer's indications for use and contraindications
- risk of adverse events
- the preference of the person with the pressure ulcer.
Consider preventative measures.
Create an optimum wound healing environment using modern dressings (for example, hydrocolloids, hydrogels, hydrofibres, foams, films, alginates, soft silicones).
Appendix C of the full guideline on Surgical site infection: prevention and treatment of surgical site infection provides more information about wound dressings.
Consider antimicrobial therapy in the presence of systemic and/or local clinical signs of infection.
Consider referral to a surgeon.
NICE medical technologies guidance
NICE medical technologies guidance addresses specific technologies notified to NICE by manufacturers. The 'case for adoption' is based on the claimed advantages of introducing the specific technology compared with current management of the condition. This case is reviewed against the evidence submitted and expert advice. The medical technology guidance on the MIST Therapy system for the promotion of wound healing recommends further research. This recommendation is not intended to preclude the use of the technology in the NHS but to identify further evidence which, after evaluation, could support a recommendation for wider adoption.
The MIST Therapy system for the promotion of wound healing
The MIST Therapy system shows potential to enhance the healing of chronic, 'hard-to-heal', complex wounds, compared with standard methods of wound management. If this potential is substantiated then MIST could offer advantages to both patients and the NHS.
The amount and quality of published evidence on the relative effectiveness of the MIST Therapy system is not sufficient, at the time of writing, to support the case for routine adoption of the MIST Therapy system in the NHS.
Comparative research is recommended in the UK to reduce uncertainty about the outcomes of patients with chronic, 'hard-to-heal', complex wounds treated by the MIST Therapy system compared with those treated by standard methods of wound care. This research should define the types and chronicity of wounds being treated and the details of other treatments being used. It should report healing rates, durations of treatment (including debridement) needed to achieve healing, and quality of life measures (including quality of life if wounds heal only partially). It is recommended that centres using the MIST Therapy system take part in research that delivers these outcomes. Current users of the MIST Therapy system who are unable to join research studies should use NICE's audit criteria to collect further information on healing rates, duration of treatment and quality of life and publish their results.
NICE will review this guidance when new and substantive evidence becomes available.
These recommendations are from the MIST Therapy system for the promotion of wound healing (NICE medical technologies guidance MTG5).
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleWhen to refer to a surgeon
When to refer to a surgeon
When to refer to a surgeon
Refer to surgeon on the basis of:
- failure of previous conservative management interventions
- level of risk (anaesthetic and surgical intervention, recurrence)
- the preference of the person with the pressure ulcer (lifestyle, abilities and comfort)
- ulcer assessment
- general skin assessment
- general health status
- competing care needs
- assessment of psychosocial factors regarding the risk of recurrence
- practitioner's experience
- previous positive effect of surgical techniques.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
Pathway created: January 2012 Last updated: October 2012
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