Chapter 18: Wound management
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Evidence‐based approaches
Pressure ulcers, although often preventable, remain a major healthcare issue and are debilitating for patients (NICE [78]). Pressure ulcers result in reduced quality of life, pain, infection, and prolonged hospital stay, and can be life threatening in the case of gangrene or sepsis (NICE [79]).
It is important to use a structured approach that involves skin assessment and identification of risks (Haesler [39]). As part of an American initiative in 2004, the ‘SKIN’ acronym was developed to provide a structured approach to pressure ulcer prevention (Whitlock et al. [115]). This was introduced into the NHS in 2009 and was subsequently developed into ‘SSKIN’ in 2011 (by NHS Scotland) and ‘ASSKING’ (or aSSKINg) in 2018 (by NHS England). While it is recognized that the fundamentals of care required to prevent pressure ulcers are found in SSKIN, it is agreed that ASSKING (Assess risk, Skin inspection, Surface, Keep moving, Incontinence, Nutrition, Giving information) supports clinician actions. This structured approach is the foundation of all pressure ulcer prevention treatment plans and bedside care bundles (Figure 18.10).
Figure 18.10 The Royal Marsden NHS Foundation Trust's ASSKING bundle.
Assessment of risk
The risk assessment (Figure 18.11) should be carried out within 6 hours (can vary locally) of admission and regularly thereafter (NICE
[79]) by a registered nurse or healthcare professional who has undergone appropriate training in recognizing and reducing the risk factors that contribute to the development of pressure ulcers; this person should also understand how to initiate appropriate actions and maintain correct and suitable prevention measures (Waterlow [112]) (Figures 18.12 and 18.13). The use of risk assessment tools (e.g. Figure 18.11) should be undertaken in conjunction with clinical judgement and skin inspection (Haesler [39]).
Figure 18.11 The Waterlow Pressure Ulcer Risk Assessment Tool.
Source: Reproduced with permission of The Royal Marsden NHS Foundation Trust.
Figure 18.12 Risk assessment flow diagram. PU, pressure ulcer.
Source: Reproduced with permission of The Royal Marsden NHS Foundation Trust.
Figure 18.13 Managing pressure ulcer risk factors.
Source: Reproduced with permission of The Royal Marsden NHS Foundation Trust.
An individual's potential for developing pressure ulcers may be influenced by the following intrinsic factors:
- reduced mobility or immobility
- acute illness
- level of consciousness
- extremes of age
- vascular disease
- severe, chronic or terminal illness
- previous history of pressure damage
- malnutrition and dehydration
- neurological compromise
- obesity
- poor posture.
The potential of an individual to develop pressure ulcers may be exacerbated by the following factors, which therefore should be considered when performing a risk assessment (Haesler [39]):
- Sedatives and hypnotics may make the patient excessively sleepy and thus reduce mobility.
- Analgesics may reduce normal stimulus to relieve pressure.
- Inotropes cause peripheral vasoconstriction and tissue hypoxia.
- Non‐steroidal anti‐inflammatory drugs impair inflammatory responses to pressure injury.
- Cytotoxics and high‐dose steroids may induce immunosuppression, which impairs inflammatory responses to pressure injury and may lead to an increased risk of wound infection.
- Moisture to the skin (e.g. from incontinence, perspiration or wound exudate) can contribute to pressure ulcer formation.
Skin inspection
Systematic skin inspection should occur regularly, with increased or decreased frequencies determined in response to changes in the individual's condition. Individuals at risk should have their skin inspected (including under medical devices) at least twice per day (Haesler [39]) if an inpatient or at every visit in the community setting.
Skin inspection should be based on an assessment of the most vulnerable areas of risk for each patient (Figure 18.14); this should include daily removal of antiembolic stockings and/or non‐slip socks. Areas for observation include heels, sacrum, ischial tuberosities, elbows, temporal region of skull, shoulders, backs of head and toes, and femoral trochanters, as well as parts of the body where pressure, friction and shear are exerted in the course of daily living activities, and parts of the body where external forces are exerted by equipment and clothing. Other areas should be inspected as necessitated by the patient's condition.
Figure 18.14 Common locations of pressure ulcers.
Source: Reproduced with permission of The Royal Marsden NHS Foundation Trust.
Individuals who are willing and able should be encouraged, following education, to inspect their own skin. Individuals who are wheelchair users should employ a mirror to inspect the areas that they cannot see easily or get others to inspect them.
Healthcare professionals should be aware of the following signs that may indicate incipient pressure ulcer development:
- persistent erythema
- non‐blanching erythema
- blisters
- discoloration
- localized heat
- localized oedema
- localized induration
- purplish/bluish localized areas of skin
- localized heat that, if tissue becomes damaged, is replaced by coolness.
Skin observation and changes should be documented immediately using the aforementioned grading system (Haesler [39]) to classify the ulcer stage and extent of tissue damage (see Figure 18.6). Appropriate emollients should be prescribed and administered for dry skin conditions. Avoid excessive rubbing over bony prominences, as this does not prevent pressure damage and may cause additional damage.
Surface (equipment)
Support surfaces (i.e. mattresses and cushions) designed to redistribute pressure loading on the skin should be selected on an individual basis. While in hospital, a high‐specification foam mattress and/or cushion should be provided to patients at risk as a minimum (NICE [78]).
An active support surface should be considered for patients:
- at high risk of pressure ulcer development
- who cannot be positioned off an existing pressure ulcer or who have pressure ulcers on opposing anatomical locations, limiting repositioning options
- who have existing pressure ulcers whose healing is stagnant or deteriorating (Haesler [39]).
Keep moving
The importance of ‘keeping moving’ should be discussed with each patient as appropriate. Mobility should be increased as quickly as tolerated (Haesler [39]) and a referral to physiotherapy should be considered.
Individuals who are willing and able should be taught how to redistribute their weight every 15 minutes via repositioning. Engage family and/or carers in how to assist patients to achieve this. Repositioning of patients who are unable do so independently aims to reduce prolonged pressure on bony prominences.
Individuals who are at risk of pressure ulcer development should be regularly repositioned and their heels elevated. The frequency of repositioning should be determined by the results of skin inspections and individual needs. A repositioning schedule, agreed with the individual, should be recorded and established for each person who is at risk, taking into consideration the following:
- Patients at high risk should be repositioned at least 4‐hourly (NICE [79]).
- Repositioning and factors affecting this should be documented after each intervention.
- Appropriate analgesia should be administered 20–30 minutes before repositioning patients who experience pain on movement (Haesler [39]).
- Individuals who are considered to be at risk of developing pressure ulcers should restrict chair sitting to less than 2 hours at a time until their general condition improves. Time sitting out can be increased incrementally.
- Avoid positioning individuals on an area of compromised skin integrity.
- Individuals with existing pressure ulcers anatomically located on or around the seating area should limit sitting out to 1 hour maximum for up to 3 times per day (Haesler [39]).
- Correct positioning of devices such as pillows and foam wedges should be used to keep bony prominences (e.g. knees, heels or ankles) out of direct contact with one another in accordance with a written plan. Care should be taken to ensure that these do not interfere with the action of any other pressure‐relieving support surfaces in use.
- Manual handling techniques and equipment should be used correctly in order to minimize shear and friction damage to the skin. After manoeuvring, slings, sleeves and other parts of the handling equipment should be removed from underneath individuals.
- In the community setting, patients and carers (both formal and informal) should be informed of the importance of repositioning (Royal Marsden NHS Foundation Trust [92]).
Incontinence and increased moisture
Excess moisture on the skin's surface causes softening and erosion of the epidermal layer, breaking the skin's barrier function. The link between excess skin moisture levels and pressure ulcers is widely acknowledged (Crook et al. [18]).
The source of excess moisture – whether incontinence, perspiration or wound drainage – should be eliminated where possible. When moisture cannot be controlled, interventions such as regular personal care using a pH‐neutral cleanser and an application of barrier products is recommended (Haesler [39]).
Nutrition
Malnutrition is an independent risk factor in pressure ulcer development (NICE [78]) and can impede healing in established pressure ulcers (Taylor [103]). Malnutrition causes a reduction in fibroblast activity and collagen synthesis, and it delays angiogenesis in the proliferative and maturation phases of healing (Neloska et al. [77]).
Individuals must be assessed for the risk of malnutrition using a valid and reliable screening tool within 24 hours of hospital admission (Haesler [39]) and at least weekly thereafter. This assessment should include factors influencing poor food or fluid intake and unintended weight loss (Posthauer et al. [86]).
Individuals at risk of pressure ulcers should be offered high‐calorie, high‐protein nutritional supplements in addition to their normal diet if their nutritional needs are not being met (ensure this is appropriate for the patient's renal function) (Haesler [39]). Individuals who have developed a pressure ulcer must be referred to a dietitian for assessment and intervention (Litchford et al. [62]). A referral to a speech and language therapist is advised in the case of actual or suspected chewing or swallowing difficulties (Posthauer et al. [86]).
Giving information
Healthcare professionals must provide tailored information and education about preventing pressure ulcers from developing for individuals at high risk and their family and/or carers, where appropriate (NICE [79]). Patient and carer education leaflets should be made available and include information on the following:
- the risk factors associated with developing pressure ulcers
- the sites that are at the greatest risk of pressure damage
- how to inspect skin and recognize skin changes
- how to care for skin
- methods of pressure relief and reduction
- where patients can seek further advice and assistance should they need it
- the need for immediate visits to a healthcare professional should signs of damage be noticed (Royal Marsden NHS Foundation Trust [92]).
If a patient declines an aspect of recommended care, this should be documented; additionally, evaluations of whether the patient is improving or deteriorating should be recorded to keep their care plan up to date (Royal Marsden NHS Foundation Trust [92]). Nurses should consult additional guidance if they are unfamiliar with the patient or regimen (NMC [82]).
