Pressure ulcers: prevention and management

National Institute for Health and Care Excellence


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Prevention: adults

Risk assessment

  • Be aware that all patients are potentially at risk of developing a pressure ulcer
  • Carry out and document an assessment of pressure ulcer risk for adults:
    • being admitted to secondary care or care homes in which NHS care is provided or
    • receiving NHS care in other settings (such as primary and community care and emergency departments) if they have a risk factor, for example:
      • significantly limited mobility (for example, people with a spinal cord injury)
      • significant loss of sensation
      • a previous or current pressure ulcer
      • nutritional deficiency
      • the inability to reposition themselves
      • significant cognitive impairment
  • Consider using a validated scale to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale) when assessing pressure ulcer risk
  • Reassess pressure ulcer risk if there is a change in clinical status (for example, after surgery, on worsening of an underlying condition or with a change in mobility)

Skin assessment

  • Offer adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional. 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
    • colour changes or discoloration
    • variations in heat, firmness and moisture (for example, because of incontinence, oedema, dry or inflamed skin)
  • Use finger palpation or diascopy to determine whether erythema or discolouration (identified by skin assessment) is blanchable
  • Start appropriate preventative action in adults who have non-blanching erythema and consider repeating the skin assessment at least every 2 hours until resolved

Repositioning

  • Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every 6 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required
  • Encourage adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required

Skin massage

  • Do not offer skin massage or rubbing to adults to prevent a pressure ulcer

Nutritional supplements and hydration

  • Do not offer nutritional supplements specifically to prevent a pressure ulcer in adults whose nutritional intake is adequate
  • Do not offer subcutaneous or intravenous fluids specifically to prevent a pressure ulcer in adults whose hydration status is adequate

Pressure redistributing devices

  • Use a high-specification foam mattress for adults who are:
    • admitted to secondary care
    • assessed as being at high risk of developing a pressure ulcer in primary and community care settings
  • Discuss with adults at high risk of developing a heel pressure ulcer and, where appropriate, their family or carers, a strategy to offload heel pressure, as part of their individualised care plan
  • Consider the seating needs of people at risk of developing a pressure ulcer who are sitting for prolonged periods
  • Consider a high-specification foam or equivalent pressure redistributing cushion for adults who use a wheelchair or who sit for prolonged periods

Barrier creams

  • Consider using a barrier preparation to prevent skin damage in adults who are at high risk of developing a moisture lesion or incontinence-associated dermatitis, as identified by skin assessment (such as those with incontinence, oedema, dry or inflamed skin)

Prevention: neonates, infants, children and young people

Risk assessment

  • Carry out and document an assessment of pressure ulcer risk for neonates, infants, children and young people:
    • being admitted to secondary or tertiary care or
    • receiving NHS care in other settings (such as primary and community care and
      emergency departments) if they have a risk factor, for example:
      • significantly limited mobility
      • significant loss of sensation
      • a previous or current pressure ulcer
      • nutritional deficiency
      • the inability to reposition themselves
      • significant cognitive impairment
  • Use a scale validated for this population (for example, the Braden Q scale for children), to support clinical judgement

Skin assessment

  • Offer neonates, infants, children and young people who are assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional. Take into account:
    • skin changes in the occipital area
    • skin temperature
    • the presence of blanching erythema or discoloured areas of skin
  • Be aware of specific sites (for example, the occipital area) where neonates, infants, children and young people are at risk of developing a pressure ulcer

Repositioning

  • Ensure that neonates and infants who are at risk of developing a pressure ulcer are repositioned at least every 4 hours
  • Encourage children and young people who are at risk of developing a pressure ulcer to change their position at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed
  • Consider more frequent repositioning than every 4 hours for neonates and infants who have been assessed as being at high risk of developing a pressure ulcer. Document the frequency of repositioning required
  • Encourage children and young people who have been assessed as being at high risk of developing a pressure ulcer to change their position more frequently than every 4 hours. If they are unable to reposition themselves, offer help to do so, using equipment if needed. Document the frequency of repositioning required
  • Ensure that repositioning equipment is available to aid the repositioning of children and young people, if needed
  • Ensure that healthcare professionals are trained in the use of repositioning equipment
  • Ensure that patients, parents and carers understand the reasons for repositioning. If children and young people decline repositioning, document and discuss their reasons for declining
  • Consider involving a play expert to encourage children who have difficulty with, or who have declined repositioning
  • Relieve pressure on the scalp and head when repositioning neonates, infants, children and young people at risk of developing a pressure ulcer

Skin massage

  • Do not offer skin massage or rubbing to neonates, infants, children and young people to prevent a pressure ulcer

Nutritional supplements and hydration

  • Do not offer nutritional supplements specifically to prevent a pressure ulcer in neonates, infants, children and young people with adequate nutritional status for their developmental stage and clinical condition
  • Do not offer subcutaneous or intravenous fluids specifically to prevent a pressure ulcer in neonates, infants, children and young people with adequate hydration status for their development stage and clinical condition

Pressure redistributing devices

  • Use a high-specification foam cot mattress or overlay for all neonates and infants who have been assessed as being at high risk of developing a pressure ulcer as part of their individualised care plan
  • Use a high-specification foam mattress or overlay for all children and young people who have been assessed as being at high risk of developing a pressure ulcer as part of their individualised care plan
  • Discuss with children and young people at high risk of developing a heel pressure ulcer and their parents and carers, where appropriate, a strategy to offload heel pressure as part of their individualised care plan
  • Offer infants, children and young people who are long-term wheelchair users, regular wheelchair assessments and provide pressure relief or redistribution
  • Offer neonates, infants, children and young people at risk of developing an occipital pressure ulcer an appropriate pressure redistributing surface (for example, a suitable pillow or pressure redistributing pad)

Barrier creams

  • Use barrier preparations to help prevent skin damage, such as moisture lesions, for neonates, infants, children and young people who are incontinent

Prevention: all ages

Care planning

  • Develop and document an individualised care plan for neonates, infants, children, young people and adults who have been assessed as being at high risk of developing a pressure ulcer, taking into account:
    • the outcome of risk and skin assessment
    • the need for additional pressure relief at specific at-risk sites
    • their mobility and ability to reposition themselves
    • other comorbidities
    • patient preference

Patient and carer information

  • Offer timely, tailored information to people who have been assessed as being at high risk of developing a pressure ulcer, and their family or carers. The information should be delivered by a trained or experienced healthcare professional and include:
    • the causes of a pressure ulcer
    • the early signs of a pressure ulcer
    • ways to prevent a pressure ulcer
    • the implications of having a pressure ulcer (for example, for general health, treatment options and the risk of developing pressure ulcers in the future)
  • Demonstrate techniques and equipment used to prevent a pressure ulcer
  • Take into account individual needs when supplying information to people with:
    • degenerative conditions
    • impaired mobility
    • neurological impairment
    • cognitive impairment
    • impaired tissue perfusion (for example, caused by peripheral arterial disease)

Healthcare professional training and education

  • Provide training to healthcare professionals on preventing a pressure ulcer, including:
    • who is most likely to be at risk of developing a pressure ulcer
    • how to identify pressure damage
    • what steps to take to prevent new or further pressure damage
    • who to contact for further information and for further action
  • Provide further training to healthcare professionals who have contact with anyone who has been assessed as being at high risk of developing a pressure ulcer. Training should include:
    • how to carry out a risk and skin assessment
    • how to reposition
    • information on pressure redistributing devices
    • discussion of pressure ulcer prevention with patients and their carers
    • details of sources of advice and support

Management: adults 

Ulcer measurement

  • Document the surface area of all pressure ulcers in adults. If possible, use a validated measurement technique (for example, transparency tracing or a photograph)
  • Document an estimate of the depth of all pressure ulcers and the presence of undermining, but do not routinely measure the volume of a pressure ulcer

Categorisation

  • Categorise each pressure ulcer in adults using a validated classification tool (such as the International NPUAP-EPUAP [2009] Pressure Ulcer Classification System). Use this to guide ongoing preventative strategies and management. Repeat and document each time the ulcer is assessed

Nutritional supplements and hydration

  • Offer adults with a pressure ulcer a nutritional assessment by a dietitian or other healthcare professional with the necessary skills and competencies
  • Offer nutritional supplements to adults with a pressure ulcer who have a nutritional deficiency
  • Provide information and advice to adults with a pressure ulcer and, where appropriate, their family or carers, on how to follow a balanced diet to maintain an adequate nutritional status, taking into account energy, protein and micronutrient requirements
  • Do not offer nutritional supplements to treat a pressure ulcer in adults whose nutritional intake is adequate
  • Do not offer subcutaneous or intravenous fluids to treat a pressure ulcer in adults whose hydration status is adequate

Pressure redistributing devices

  • Use high-specification foam mattresses for adults with a pressure ulcer. If this is not sufficient to redistribute pressure, consider the use of a dynamic support surface
  • Do not use standard-specification foam mattresses for adults with a pressure ulcer
  • Consider the seating needs of adults who have a pressure ulcer who are sitting for prolonged periods
  • Consider a high-specification foam or equivalent pressure redistributing cushion for adults who use a wheelchair or sit for prolonged periods and who have a pressure ulcer

Negative pressure wound therapy

  • Do not routinely offer adults negative pressure wound therapy to treat a pressure ulcer, unless it is necessary to reduce the number of dressing changes (for example, in a wound with a large amount of exudate)

Hyperbaric oxygen therapy and electrotherapy

  • Do not offer the following to adults to treat a pressure ulcer:
    • electrotherapy
    • hyperbaric oxygen therapy

Debridement

  • Assess the need to debride a pressure ulcer in adults, taking into consideration:
    • the amount of necrotic tissue
    • the grade, size and extent of the pressure ulcer
    • patient tolerance
    • any comorbidities
  • Offer debridement to adults if identified as needed in the assessment:
    • use autolytic debridement, using an appropriate dressing to support it
    • consider using sharp debridement if autolytic debridement is likely to take longer and prolong healing time
  • Do not routinely offer adults with a pressure ulcer:
    • larval (maggot) therapy
    • enzymatic debridement
  • Consider larval therapy if debridement is needed but sharp debridement is contraindicated or if there is associated vascular insufficiency

Systemic antibiotics and antiseptics

  • After a skin assessment, offer systemic antibiotics to adults with a pressure ulcer if there are any of the following:
    • clinical evidence of systemic sepsis
    • spreading cellulitis
    • underlying osteomyelitis
  • Discuss with a local hospital microbiology department which antibiotic to offer adults with infection to ensure that the chosen systemic antibiotic is effective against local strains of infection
  • Do not offer systemic antibiotics specifically to heal a pressure ulcer in adults
  • Do not offer systemic antibiotics to adults based only on positive wound cultures without clinical evidence of infection

Topical antimicrobials and antiseptics

  • Do not routinely use topical antiseptics or antimicrobials to treat a pressure ulcer in adults

Dressings

  • Discuss with adults with a pressure ulcer and, if appropriate, their family or carers, what type of dressing should be used, taking into account:
    • pain and tolerance
    • position of the ulcer
    • amount of exudate
    • frequency of dressing change
  • Consider using a dressing for adults that promotes a warm, moist wound healing environment to treat grade 2, 3 and 4 pressure ulcers
  • Do not offer gauze dressings to treat a pressure ulcer in adults

Heel pressure ulcers

  • Discuss with adults with a heel pressure ulcer and, if appropriate, their family or carers, a strategy to offload heel pressure as part of their individualised care plan

Management: neonates, infants, children and young people

Ulcer measurement

  • Document the surface area of all pressure ulcers in neonates, infants, children and young people, preferably using a validated measurement technique (for example, transparency tracing or a photograph)
  • Document an estimate of the depth of a pressure ulcer and the presence of undermining, but do not routinely measure the volume of a pressure ulcer in neonates, infants, children and young people

Categorisation

  • Categorise each pressure ulcer in neonates, infants, children and young people at onset using a validated classification tool (such as the International NPUAP-EPUAP [2009]) Pressure Ulcer Classification System) to guide ongoing preventative and management options. Repeat and document each time the ulcer is assessed

Nutritional supplements and hydration

  • Offer an age-related nutritional assessment to neonates, infants, children and young people with a pressure ulcer. This should be performed by a paediatric dietitian or other healthcare professional with the necessary skills and competencies
  • Discuss with a paediatric dietitian (or other healthcare professional with the necessary skills and competencies) whether to offer nutritional supplements specifically to treat a pressure ulcer in neonates, infants, children and young people whose nutritional intake is adequate
  • Offer advice on a diet that provides adequate nutrition for growth and healing in neonates, infants, children and young people with a pressure ulcer
  • Discuss with a paediatric dietitian whether to offer nutritional supplements to correct nutritional deficiency in neonates, infants, children and young people with a pressure ulcer
  • Assess fluid balance in neonates, infants, children and young people with a pressure ulcer
  • Ensure there is adequate hydration for age, growth and healing in neonates, infants, children and young people. If there is any doubt, seek further medical advice

Pressure redistributing devices

  • Consider using specialist support surfaces (including dynamic support surfaces where appropriate) for neonates, infants, children and young people with a pressure ulcer, taking into account their current pressure ulcer risk and  mobility
  • Use a high-specification cot or bed mattress or overlay for all neonates, infants, children and young people with a pressure ulcer
  • If pressure on the affected area cannot be adequately relieved by other means (such as repositioning), consider a dynamic support surface, appropriate to the size and weight of the child or young person with a pressure ulcer, if this can be tolerated
  • Tailor the support surface to the location and cause of the pressure ulcer for neonates, infants, children and young people

Negative pressure wound therapy

  • Do not routinely use negative pressure wound therapy to treat a pressure ulcer in neonates, infants, children and young people

Hyperbaric oxygen therapy and electrotherapy

  • Do not use the following to treat a pressure ulcer in neonates, infants, children and young people:
    • electrotherapy
    • hyperbaric oxygen therapy

Debridement

  • Consider autolytic debridement with appropriate dressings for dead tissue in neonates, infants, children and young people. Consider sharp and surgical debridement by trained staff if autolytic debridement is unsuccessful

Systemic antibiotics and antiseptics

  • Consider systemic antibiotics for neonates, infants, children and young people with a pressure ulcer with clinical evidence of local or systemic infection          
  • Discuss with a local hospital microbiology department which antibiotic to offer neonates, infants, children and young people with infection to ensure that the chosen systemic antibiotic is effective against local strains of bacteria

Topical antimicrobials and antiseptics

  • Do not routinely use topical antiseptics or antimicrobials to treat a pressure ulcer in neonates, infants, children and young people

Dressings

  • Consider using a dressing that promotes a warm, moist healing environment to treat grade 2, 3 and 4 pressure ulcers in neonates, infants, children and young people
  • Consider using topical antimicrobial dressings to treat a pressure ulcer where clinically indicated in neonates, infants, children and young people, for example, where there is spreading cellulitis
  • Do not use iodine dressings to treat a pressure ulcer in neonates
  • Do not offer gauze dressings to treat a pressure ulcer in neonates, infants, children and young people

Heel pressure ulcers

  • Discuss with the parents or carers of neonates and infants and with children and young people (and their parents or carers if appropriate), a strategy to offload heel pressure as part of their individualised care plan to manage their heel pressure ulcer, taking into account differences in size, mobility, pain and tolerance

References

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG179

National Institute for Health and Care Excellence. Pressure ulcers: prevention and management. April 2014
First included: Jul 14.


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