PRESSURE ULCER/INJURY PREVENTION
Skin Care
Adequate skin care is crucial to preventing further skin breakdown and improved tolerance. The skin should be inspected and cleansed regularly. When cleansing the skin, a pH-neutral agent should be used. The optimal pH of human skin is 5.5, which is fairly acidic and helps to act as a bacterial barrier. Together, sweat and sebum combine to create the acid mantle, which is pH4 – 5.5. If an astringent soap is used, the ‘acid mantle’ is removed, leaving the skin vulnerable.
Excessive rubbing of the skin can cause damage when drying and may cause pain as well as damaging the tissue, especially over a bony prominence. After washing, the skin should be patted dry, and an emollient applied to rehydrate any dry skin. After the skin has been cleansed, moisturisers and, where applicable, a barrier cream should then be applied. Skin exposure to moisture, such as perspiration, wound exudate or urine, should be minimised because damp skin increases friction and skin maceration (See Moisture Associated Skin Damage section). Do not offer a skin massage or rubbing to adults to prevent a pressure ulcer/injury (NICE, 2015).
Each time the individual’s clinical condition changes, a comprehensive skin and tissue assessment should be conducted to identify any alterations to skin characteristics or integrity and to identify any new pressure ulcer/injury risk factors. This should also be conducted on discharge to ensure that an appropriate pressure ulcer/injury prevention and treatment plan is in place.
Pressure Relieving Equipment
A support surface is designed to take the weight of the patient when lying or sitting. It is intended to redistribute pressure exerted on the tissues in contact with that surface (Ovens, 2017). All patients who have been identified as being at risk should be provided with a pressure-redistributing surface that will meet their needs.
Factors to be considered when choosing equipment include:
- The person’s level of mobility
- The results of the skin assessment
- The person’s level of risk
- The site that is at risk
- The person’s weight
- The person’s general health
- The person’s care setting and the person’s, carer’s, and family’s knowledge
- The person’s neurological status and comorbidities
Pressure redistributing devices are widely accepted methods of prevention for those assessed as at risk.
Different types of devices include:
- Mattresses
- Cushions
- Boots
- Overlays
- Seating
Pressure relief, therefore, not only forms an important part of pressure ulcer/injury prevention but also the treatment.
Pressure ulcers/injuries will not be able to heal if they continue to be subjected to the forces that caused them. Pressure must be relieved to restore the circulation so that healing can take place. (Beldon, 2008)
Pressure redistributing devices are widely accepted methods of trying to prevent the development of pressure ulcers/injuries for people assessed as being at risk.
NICE (2014) recommend the use of a high-specification foam mattress for adults who are:
- Admitted to secondary care
- Assessed as being high risk of developing a pressure ulcer/injury in primary and community care settings
Using pressure redistribution devices as soon as possible can prevent pressure ulcers developing and help to treat them if they do arise, ensuring patient safety and improving the experience of people at high risk of pressure ulcers.
Manufacturer’s instructions for use must be followed, and equipment regularly maintained and properly cleaned. (Nice, 2015; Fletcher, 2020; Ovens, 2017)
Repositioning
NICE 2015 and EPUAP 2019 guidelines recommend that adults who have been assessed as being at risk of developing a pressure ulcer/injury should be encouraged 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. Furthermore, any time that the patient is repositioned, the skin and vulnerable areas such as heels, elbows and sacrum should be checked for areas of reddened skin. (Vuolo, 2009; Norton et al., 2018)
Repositioning and turning the patient will aid pressure reduction in vulnerable areas. This can range from small shifts in position undertaken by the patient to full lateral repositioning/turning by health care staff. Any repositioning should be tailored to the individual clinical need and should not be just routinely followed once or twice hourly. It is important to maintain repositioning despite being on a dynamic/pressure-reducing mattress. It is also a good idea to keep a repositioning chart to provide a record of when repositioning has occurred in the patient’s notes and show that interventions have been implemented.
The 30° tilt has recently become widely recommended as it dissipates any applied pressure by redistributing pressure from bony prominences to areas of larger tissue mass (Young, 2004; EUPAP, 2019). The 30° tilt is a repositioning technique that can be achieved by placing a pillow under the buttock or small of the back with the aim of tilting the pelvis forward by 30° while aiding the patient’s comfort. Another pillow may be situated lengthways under the legs. If correctly undertaken, the outcome of this position should be that there is no contact between the patient’s heel and sacrum and the support surface.
Note - no support surface provides complete pressure relief.
Pressure is always applied to some area of the skin. Repositioning for pressure redistribution must occur regularly. The frequency may vary with the pressure redistribution capacity of the support surface; however, the individual’s response to pressure should always guide the regularity. High-risk individuals with poor tissue tolerance may require more frequent repositioning.
Nutrition
Nutrition is an essential factor in preventing pressure ulcers/injuries and is included in the aSSKINg bundle. Helping the patient to have the right nutrition and hydration will improve skin integrity and their ability to heal.
(Please see Module Three, Nutrition for more information)