Pressure ulcers develop when capillaries supplying the skin and subcutaneous (fatty layer) tissues are compressed enough to impede perfusion, leading ultimately to tissue necrosis. Since 1930, we have understood that normal blood pressure within capillaries ranges from 20 to 40mm Hg; 32mm Hg is considered the average (Lyder & Ayello) less than 32 mm Hg should therefore be sufficient to prevent the development of pressure ulcers.
However, capillary blood pressure may be less than 32 mm Hg in critically ill patients due to haemodynamic instability and underlying conditions; meaning even lower applied pressures may be sufficient to induce ulceration in this group of patients where pressure ulcers can develop rapidly. Therefore, the key to preventing pressure ulcers is to accurately identify individuals with physical deterioration or reduced mobility rapidly so that preventative measures may be implemented.
Ways to prompt early detection of pressure damage in long term care
Early Identification with React to Red
‘React to red’ still remains the key prevention strategy you can teach everyone within the home. If a non blanching discoloured area (as demonstrated in picture) is picked up rapidly and immediate intervention implemented, such as simply offloading the area, this may halt the deterioration process and promote the aSSKINg reassessment process.
Ensuring mandatory training is incorporated in your care setting on induction, and repeated annually, will mitigate risk of pressure ulcers being left too late before action taken.
aSSKINg
aSSKINg still serves as the foundation for providing preventative pressure ulcer care.
A- assessment (Waterlow/Braden or Purpose T)
In many cases in long term care this will be repeated weekly or monthly along with weights and other measurements. However for anyone with a change of condition it is a key requirement that this should prompt a reassessment to revaluate risk.
S – surface
For someone who is physically deteriorating such as end of life, will likely have reduced mobility, they will require a further support surface equipment review to establish if enhanced offloading can be offered.
S – skin inspection
Given the speed a pressure ulcer can develop, the need to care plan for daily skin checks is vital so that prompt actions can be taken to prevent further deterioration. The SSKIN bundle may act as a prompt for this if used.
K – keep moving
Repositioning to maintain and increase capillary repercussion is key in preventing tissue hypoxia. The use of repositioning charts for those unable to self position must be used and are a full 30 or 90 degree turn can not be achieved, micro- movements must be promote and documented, or the use of Lateral tilt mattress.
I – incontinence
Anyone with incontinence must have a barrier cream/spray used to protect the skins PH level and prevent incontinence associated dermatitis or moisture lesions.
N – nutrition and hydration
Where indicated a food and fluid balance chart must be maintained.
G – giving information
Let the resident be part of their care plan and explain why and what you are doing.
Identifying rapid physical deterioration due to deep tissue injury.
The risk of septicaemia, osteomyelitis and necrotising fasciitis can be life threatening in those with deep tissue injury pressure ulceration.
The principles of identifying rapid deterioration using the National Early Warning Scoring system (click here) is worth including in your in-house training for nurses to act promptly if they suspect any of the above. Calling 999 in these cases is paramount to ensure rapid action is taken.
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References
Landis EM (1930) Micro-injection studies of capillary blood pressure in human skin. Heart. Issue (15) pp.209.
Lyder CH, Ayello E (2018) Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US);Chapter 12. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2650/
Young, T (2017) Back to basics: understanding the aetiology of pressure ulcers. Accessed online (22nd July 2019) available at : https://www.wwic.wales/uploads/files/documents/News%20Items/Understanding%20the%20Aetiology%20of%20Pressure%20Ulcers.pdf
