Note: The information provided by this tool is to be used as a general guide and not to be solely relied upon. It is highly recommended that you discuss your personal risk factors and results of this risk assessment with your doctor. This website is the result of a collaboration between these organisations. The information available on this website should not be used as a substitute for advice from a properly qualified medical professional who can advise you about your own individual medical needs.
It is not intended to constitute medical advice and is provided for general information purposes only. About Us Contact Us. Hit enter to search or ESC to close. Close Search. What additional resources are available to identify best practices for pressure ulcer prevention? Some of the factors that make pressure ulcer prevention so difficult include: It is multidisciplinary: Nurses, physicians, dieticians, physical therapists, and patients and families are among those who need to be invested.
It is multidimensional: Many different discrete areas must be mastered. It needs to be customized: Each patient is different, so care must address their unique needs. It is also highly routinized: The same tasks need to be performed over and over, often many times in a single day without failure. It is not perceived to be glamorous: The skin as an organ, and patient need for assessment and care, does not enjoy the high status and importance of other clinical areas.
The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment. Standardized pressure ulcer risk assessment. Care planning and implementation to address areas of risk. The challenge to improving care is how to get these key practices completed on a regular basis. Some of the advantages of these clinical pathways are to: Reduce variation and standardize care. Provide efficient, evidence-based care. Improve outcomes.
Educate staff as to best practices. Improve care planning. Facilitate discussion among staff. This color-coded tool can be used by the hospital unit team in designing the new system, as a training tool for frontline staff, and as an ongoing clinical reference tool on the units.
This tool can be modified, or a new one created, to meet the needs of your particular setting. If you prepared a process map describing your current practices described in section 2 , you can compare that to desired practices outlined on the clinical pathway. Practice Insights Given the complexity of pressure ulcer preventive care, develop a clinical pathway that describes your bundle of best practices and how they are to be performed.
Return to Contents 3. These include: Identify any pressure ulcers that may be present. Assist in risk stratification; any patient with an existing pressure ulcer is at risk for additional ulcers. Determine whether there are other lesions and skin-related factors predisposing to pressure ulcer development, such as excessively dry skin or moisture-associated skin damage MASD. Identify other important skin conditions. Provide the data necessary for calculating pressure ulcer incidence and prevalence.
J Wound Ostomy Continence Nurs ; Incontinence associated dermatitis a consensus. J Wound Ostomy Continence Nurs ;34 1 Usual practice includes assessing the following five parameters: Temperature. Moisture level. Skin integrity skin intact or presence of open areas, rashes, etc. Practice Insights Take advantage of every patient encounter to evaluate part of the skin. Always remind staff performing comprehensive skin assessments of the following helpful hints: Don't forget to wash your hands before doing the skin assessment and after and to use gloves.
Make sure the patient is comfortable. Minimize exposure of body parts while you are doing the skin assessment. Ask for assistance if needed to turn the patient in order to examine the patient's backside, with a particular focus on the sacrum. Look at the skin underneath any devices such as oxygen tubing, indwelling urinary catheter, etc.
Make sure to remove compression stockings to check the skin underneath them. Action Steps Assess whether your staff know the frequency with which comprehensive skin assessment should be performed. Action Steps Assess the following: Are results of the comprehensive skin assessment easily located for all patients? Are staff comfortable reporting any observed skin abnormalities to physicians and nurse managers?
Practice Insights Have a standardized place to record in the medical record the results of the skin assessment. A checklist or standardized computer screens with drop-down prompts with key descriptors of the five components of a minimal skin assessment can help capture the essential information obtained through the patient examination.
Communication among licensed and unlicensed members of the health care team is important in identifying and caring for any skin abnormalities. Some places have found it effective to use a diagram of a body outline that an unlicensed heath care worker can mark with any skin changes they might see while bathing or performing care activities. Be especially concerned about the following issues: Finding the time for an adequate skin assessment: As much as possible, integrate the comprehensive skin examination into the normal workflow.
But remember that this is a separate process that requires a specific focus by staff if it is to be done correctly. Determining the correct etiology of wounds: Many different types of lesions may occur on the skin and over bony prominences.
In particular, do not confuse moisture-associated skin changes with pressure ulceration. If unsure about the etiology of a lesion, ask someone else who may be more knowledgeable.
Using documentation forms that are not consistent with components of skin assessments: Develop forms that will facilitate the recording of skin assessments. Having staff who do not feel empowered to report abnormal skin findings: Communication among nursing assistants, nurses, and managers is critical to success.
If communication problems exist, staff development activities targeting cross-level communication skills may be in order. Nurses and managers may need to solicit and positively reinforce such reporting if nursing assistants do not have confidence in this area. Develop methods to facilitate communication.
One example would be a sticky note pad that includes a body outline, patient name, and date. Aides would mark down any suspicious lesions and give the note to nurses. Tools An example of a notepad to be used for communication among nursing assistants, nurses, and managers can be found in Tools and Resources Tool 3C, Pressure Ulcer Identification Notepad.
Encourage staff to: Ask a colleague to confirm their skin assessments. Having a colleague evaluate the skin assessment will provide feedback as to how they are doing and will help correct documentation errors.
Perform skin assessments with an expert. Consider having an expert or nurse from another unit round with unit staff quarterly to confirm findings from the comprehensive skin assessment. Ask for clarification when they are unsure of a lesion. Take advantage of the local wound care team or other staff who may be more knowledgeable. Use available resources to practice their ability to differentiate the etiology of skin and wound problems.
Resources This slide show illustrates how to perform a skin assessment: www. Practice Insights A full-body skin inspection does not have to mean visualizing all aspects of the patient in the same time period. When applying oxygen, check the ears for pressure areas from the tubing.
If the patient is on bed rest, look at the back of the head during repositioning. When checking bowel sounds, look into skin folds. When positioning pillows under calves, check the heels and feet using a hand-held mirror makes this easier. When checking IV sites, check the arms and elbows. Examine the skin under equipment with routine removal e. Each time you lift a patient or provide care, look at the exposed skin, especially on bony prominences.
Action Steps Ask yourself and your team: Do you have a policy about who is responsible for the risk assessment on admission and thereafter? Does everyone know the process for performing risk assessment? Pressure ulcer risk assessment is essential for a number of reasons: It aids in clinical decisionmaking.
Occurrence of pressure ulcer development according to the National Pressure Ulcer Advisory Panel classification. Length of follow up not reported. Development of skin breakdown in the buttock region within 10 days of admission was reported by the nursing staff and photographed. Redness alone, however marked or persistent, was not categorized as a pressure sore.
Follow up not reported. Occurrence of pressure ulcers development grade according to the European Pressure Ulcer Advisory Panel classification system in the course of ICU treatment. Table 16 Clinical evidence profile: skin assessment tools for prediction of pressure ulcers. Table 17 Non-blanchable erythema by finger test or transparent disc. Table 18 Thermography. Economic evidence adults No relevant economic evaluations were identified. Economic evidence neonates, infants, children and young people No relevant economic evaluations were identified.
Clinical adults One study in people in hospital with 8 pressure ulcers, gave an unadjusted odds ratio of 9. One study in 97 surgical inpatients with 15 pressure ulcers, showed, in multivariable analysis, that the subjective nursing assessment of non-blanchable erythema was a significant predictor of pressure ulcers grade according to the European Pressure Ulcer Advisory Panel classification system OR 7.
A second large study in people in hospital with 56 pressure ulcers, gave an unadjusted odds ratio of 5. One study in 91 people in hospital with 6 pressure ulcers, who were not given preventative treatment, gave an unadjusted odds ratio of Recommendations and link to evidence 8.
Adults View in own window Recommendations 8. 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. View in own window Recommendations 9. Relative values of different outcomes The GDG placed the most importance on the randomised evidence for skin assessment in conjunction with targeted preventative treatment and its impact on patient outcomes. They also considered the predictive ability of skin assessment in discriminating patients at risk, particularly taking into account absolute risk differences from multivariable analyses.
People at high risk according to each of these 2 methods were given preventative treatment. There was no clinically important difference between interventions in terms of the incidence of pressure ulcers. However, there was a large difference in the number of preventative treatments given, with more treatments being given to the combined assessment approach than to NBE alone. The absolute risk of pressure ulcer development in people defined by each strategy to be at low risk was larger for NBE alone, but the GDG did not consider this to be an important difference.
The evidence from Part 1 of the review suggested that NBE was an independent predictor of pressure ulcers; there was also some limited evidence on the use of thermography to predict pressure ulcer development, although the evidence included few events. Although no evidence was identified comparing risk assessment versus skin assessment and therefore, it was not possible to ascertain the value of skin assessment in addition to risk assessment, the GDG felt that the assessment of skin was important for reasons of patient care.
The GDG felt that, where erythema or discoloration of the skin was identified, evidence supported the use of diascopy to determine whether the erythema was blanchable or non-blanchable, in addition to a formal risk assessment see recommendation 1.
However, the GDG noted that there were some situations in which transparent plastic discs were not available or where the use of these tools posed a specific infection risk. As such, the GDG highlighted that the use of finger palpation to identify whether erythema was blanching or non-blanching would be appropriate and preferable to any delay in obtaining specific tools. The GDG used informal consensus to agree that this reassessment should take place at least every 2 hours, until this has been resolved.
Economic considerations No economic evidence was identified. Once erythema or discoloration has developed, it is vital to determine whether it is blanchable or non- blanchable, as non- blanchable erythema is indicative of pressure damage. The primary concern here is to prevent any pressure damage from worsening, and therefore the use of finger palpation or diascopy is considered essential. The GDG did not anticipate that using finger palpation or diascopy would substantially increase resource use over that required for the clinical skin assessment.
The GDG agreed that where non-blanchable erythema is identified, regular skin assessments are required in order to prevent pressure ulcers developing through application of appropriate preventative strategies. The prevention of pressure ulcers at this stage would lead to improvements in quality of life and substantial cost savings.
Quality of evidence The evidence in the RCT was rated as low quality. The evidence in the prognostic studies was of very low quality: there were very few pressure ulcers, multivariable analysis was not always conducted and the results were confounded, in some studies, by the use of preventative treatments, which were not taken into account in the analysis. Other considerations The GDG felt that it was important to highlight that people who had non-blanchable erythema would also be more likely to develop a pressure ulcer on that site, as well as other sites.
Therefore, the GDG felt that people who have been identified as having non-blanchable erythema should be offered preventative treatment and reassessed on a regular basis to identify any changes in skin condition. The GDG noted that following reassessment, the individualised care plan including the use of preventative measures should be adapted to account for any change in risk status. Neonates, infants, children and young people View in own window Recommendations Take into account: skin changes in the occipital area.
View in own window Recommendations Relative values of different outcomes The GDG was interested in any predictors for pressure ulcer development and their identification through clinical assessment by a healthcare professional. Evidence from multivariable analysis of risk was considered to be the most important. Trade-off between clinical benefits and harms The GDG used 1 statement from the Delphi consensus survey to inform the recommendation.
The statement was accepted by the Delphi consensus panel. Further detail on the Delphi consensus survey can be found in Appendix N. The GDG discussed the statement and agreed that a recommendation should be developed to ensure that healthcare professionals are aware of specific sites that may be at risk of developing a pressure ulcers in neonates, infants, children and young people, as they differed from other populations for example, adults. What is the patient's age? View state listings by area.
What is the patient's gender? Is the patient's complexion light, medium, or dark? Does the patient have a history of blistering sunburn one or more? Ask the patient: After repeated and prolonged exposure to sunlight, at the age you are now, would your skin become very brown and deeply tanned, moderately tanned, lightly tanned, or no tan at all?
No tan at all.
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