SSKIN CARE BUNDLES

A care bundle is a collection of interventions that may be applied to the management of a particular condition or as a preventative measure to reduce the risk of complications.

The SSKIN bundle was developed by NHS Scotland Quality Improvement based on work developed in the USA. The components of the bundle are:

• Skin Inspection
• Surface
• Keep moving (repositioning)
• Incontinence and increased moisture
• Nutrition and hydration

NHS Improvements 2018 have amended the Pressure Ulcer core curriculum of the SSKIN bundles, changing it to aSSKINg recognising that the segments have different emphases, with SSKIN representing the fundamental elements of care delivery – i.e. those things that need to be implemented to prevent pressure ulcers occurring – while the others (A and G) underpin and support successful implementation of care.

Implementing aSSKINg bundles should not only identify patients at high risk of developing pressure ulcers but should improve the level of care delivered to patients. It also enables the level of prevention and care delivered to be measured, e.g. with audits.

Care bundles are used as part of the patient’s care plan and are completed each shift by the nurse responsible for the patient’s care. In a community setting, care bundles should be completed every time the patient is seen by a nurse.

Assessment risk

Carry out an assessment of risk to understand and identify factors that could lead to the development of a pressure ulcer/injury.

Use a validated risk assessment tool, such as Waterlow, Braden or PURPOSE T.

The inclusion of a malnutrition scoring tool such as MUST can be useful.

Consider other factors that can affect risk, such as moving and handling, and pain. Reassess the risk if there is a change in clinical status, e.g. after surgery, on worsening of an underlying condition or with a change in mobility. (NICE 2020)

Skin

Ensure that the skin is clean, dry and well hydrated. Regularly inspect the skin for early signs of damage, such as discolouration or breaks to the skin. This can be done when giving assistance to your patients when getting washed and dressed.

Surface

Support surfaces alone neither prevent nor heal pressure injuries. However, they play a significant role in a comprehensive management plan. Pressure injury risk factors vary from person to person. Choosing a support surface for an individual should consider their specific needs. Reassessment of support surfaces and equipment is required daily to ensure that the equipment is functioning and is the right choice for the individual.

Keep moving

Encourage patients to move around as often as possible or reposition the patient at regular intervals by using a repositioning chart. Consider the 30^o tilt to position the patient using pillows below the neck, shoulders, back and legs. Also, encourage early mobility and regular movement to relieve pressure over bony prominences and improve circulation.

Incontinence and increased moisture

Skin can be damaged by both urine and faeces. Regular toileting can prevent soiling or the use of both continence products and management systems. Thorough, gentle cleaning and patting skin dry can promote healthier skin. It can also be affected by excess moisture from other sources, e.g. exudate, sweating, oedema. Where able, remove or address the cause. Consider using a barrier preparation to prevent skin damage.

Nutrition and hydration

Perform a nutritional assessment using a nutritional screening tool (e.g. MUST) to determine the risk of malnutrition and other factors (EPUAP, 2019). Consider a nutritional assessment by a dietitian and further involvement from the multi-disciplinary team (MDT), e.g. a speech therapist. (NHS Improvements, 2018; NICE, 2020)

Once a pressure ulcer has developed, nutrition plays a vital role in the healing process. The body needs protein, energy, vitamins and minerals, e.g. vitamin C, iron and zinc, and plenty of fluids to support the wound healing process (BDA, 2020). Offer nutritional supplements and encourage and provide adequate water/fluid intake to adults with a pressure ulcer who have a nutritional deficiency. (EPUAP, 2019; NICE, 2020)

(Please see Module Three, Nutrition for more information)

Giving information

Good communication and appropriate patient information ensure that both patients and carers are prepared and fully aware of the next steps in their pathway. The involvement of patients and carers in their care improves their overall experience. (ACT, 2018)

It is essential when communicating with the MDT that the information given is factual and imparts the relevant level of importance/urgency and that it is conveyed in a clear, structured way meeting the appropriate professional standards and guidance. (Fletcher, 2020)

If aSSKINg bundles are being implemented, then a patient’s risk of developing a pressure ulcer will be identified and documented. Furthermore, care pathways will be put into place to prevent or reduce the risk of any further damage. aSSKINg bundles can also be used for the care of patients who have developed pressure ulcers as part of their treatment pathway. Please contact your Local Tissue Viability Nurse for further clarification on aSSKINg Bundles.

Skin and soft tissue assessment is the basis of pressure injury prevention and treatment. It is an essential component of any pressure injury risk assessment and should be conducted as soon as possible after admission as part of a full risk assessment.

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 injury risk factors. A comprehensive skin and soft tissue assessment should be conducted on discharge to ensure that an appropriate pressure injury prevention and treatment plan is in place. EUPAP, 2019; Norton et al., 2018