Pressure Ulcer Prevention

PATIENT/RESIDENT STATS

37.5%

Greater risk of pressure ulcers in individuals with both incontinence and immobility⁴

60,000

Approximate number of individuals who will develop a new pressure ulcer annually in the UK⁵

Incontinence-associated dermatitis (IAD) is prevalent to:

Double incontinence is

42% of hospitalised adults

83% of incontinent ICU patients

41% of residents in long-term care

50-70%

more common than urinary or fecal incontinence alone⁴

FACILITY STATS

£1,214 TO £14,108

£3 BILLION

Approximate cost of treatment per individual pressure ulcer

Estimated yearly cost of treating pressure ulcers⁵

Germ Transmission

According to the NHS professionals, the most common mode of transmission of disease is by pathogens, and 80% of those pathogens are transmitted by the hands.²

Escherichia Coli (E. Coli) can live on a surface for up to 16 months while Staphylococcus Aureus (MRSA) up to 7 months.³ These germs know no boundaries and can live anywhere including damaged skin.

Cuts, cracks or fissures are ideal places for microorganisms to plant themselves; it also makes it extremely easy to transfer from nurse to patient.

Discomfort Due to Damaged Skin

Hands that are dry, cracked, scaly or rough are especially sensitive to discomfort caused by alcohol based rubs.

However alcohol based rubs are less harmful to the skin than soap and water as they help retain natural lipids and incorporate vital emollients.³

Despite benefits of using the rub many users prefer hand washing in order to avoid the stinging or burning caused by the alcohol based product.

A reaction to an alcohol based hand antiseptic is typically a sign of pre-damaged skin, it is recommended that a caregiver who does experience this resist reverting to soap and water and should use the rubs in conjunction with professional grade hand lotions.

Allergic Reactions

In some extreme cases occupational related contact dermatitis can develop from the frequent and repetitive use of hand hygiene products.

Contact dermatitis as both an irritant and allergy can surface as dry, itchy, irritated areas around the hand or other areas that have been exposed to soaps, solvents, and cleansers.4

Even though this is an acute and very manageable allergy it is crippling to a career of anyone working as a healthcare provider.

Pressure

Pressure ulcers can occur when a large amount of pressure is concentrated on one part of the skin over a short period of time or in the contrary when a moderate amount of pressure is applied over a longer period of time. This can happen through the pressure from a bed or a chair for example.

The extra pressure disrupts the flow of blood through the skin which causes the skin to starve of oxygen and nutrients, and begins to break down, leading to the formation of an ulcer.¹

Friction

Friction is the resistance to motion in a parallel direction relative to the common boundary of two surfaces.³ Friction increases when skin rubs against a bed sheet or other surface.

Wet skin is easily abraded or blistered by friction so minimising or eliminating skin exposure to friction is important in preventing pressure ulcers as well as incontinence-associated dermatitis.⁴ A friction injury is visible because it occurs on the skin.

Shear Strain

Shear occurs when the bone moves in the opposite direction to the skin surface, for example when a patient or resident slides down in bed.

Shear forces distort deep tissues, especially those near bony prominences.² Incontinence and perspiration can intensify shear forces. A shear injury is less visible because it occurs underneath the skin.

Moisture-Associated Skin Damage

Moisture-associated skin damage encompasses distinct skin conditions caused by excessive and continued exposure to moisture: wound exudate, urinary and/or fecal incontinence, or perspiration.

Identifying the cause of skin damage helps ensure appropriate management and prevention interventions.⁵

Periwound Moisture- Associated Dermatitis

Drainage is normal during the inflammatory stage of wound healing. But excessive drainage can cause the periwound skin to macerate and even break down.

This is especially a concern with chronic wounds, which contain a higher concentration of proteolytic enzymes than acute wounds.⁵

Patients at Risk

There are many risk factors that can be associated with the development of pressure ulcers. Individuals that are immobile are patients at higher risk of pressure ulcer as they often stay in the same position for a while and cannot change position by themselves. This includes: paralised patients, fracture, coma, condition or disease that makes it difficult to move the body or parts of the body.

Incontinence is also a very important factor and patients who cannot control their bladder or bowels are at greater risk of acquiring pressure ulcers. Due to incontinence, the skin is exposed to moisture for a prolonged period of time and is more vulnerable. Other risk factors may include poor nutrition; health conditions such as diabetes, dementia, Alzheimer's, Parkinson's, schizophrenia; or age – ageing skin being more vulnerable.¹

Areas at Risk

If the circulation is cut off from too much pressure on a particular area of the body over a period of time, a pressure ulcer will occur. Certain parts of the body are at greater risk for pressure and pressure ulcers.

In general, the areas that are most at risk are those where there is a bony prominence and not much “cushion” for protection such as heels, knees, hips, elbows, occiput (back of the head), ischial tuberosities (sitting bones), shoulders, or sacrum.²

Redistributing Pressure

• Heels: If the patient is completely immobile, you can use a heel protection device to off load the heel and so that the heel no longer touches the bed. Heel protectors are a great solution to redistribute the pressure through the calf. An alternative option is to use a pillow under the calf. Be careful how the pillow is placed so it does not cause injury to the Achilles tendon or hyperextend the knee.
• Trochanter: When positioning a patient in the bed, avoid positions that place weight directly on the hip.
• Sacrum/Coccyx: The sacrum is one of the most common areas where pressure ulcers develop. Proper positioning can help relieve pressure on the sacrum and coccyx.

Repositioning

One of the most important ways to help prevent pressure ulcers is to redistribute pressure with frequent repositioning.

• Bedbound: Bedbound individuals may need to be turned every one to four hours, depending on their condition.
• Chairbound: Chairbound individuals should be repositioned at least every hour. For individuals who are capable, encourage them to reposition themselves every 15 minutes.

Turning Schedule

A turning schedule tells caregivers when and into what position the individual should be placed. It can be a simple chart that for patients who spend most of their time in bed but who can sit in a chair for short periods of time.

Repositioning a patient sometimes requires a helper or assistive device. It is important to protect both you and your patient from injury.

Caring for Individuals with Incontinence

You should:

• Always monitor and record the patient’s pattern to help develop a care plan.
• Provide toileting opportunities by prompting the patient to go to the bathroom on a regular schedule. Could be as frequent as every hour with the goal to keep the patient dry.
• Provide gentle skin care with a no-rinse, ph-balanced cleanser daily and immediately after every episode of incontinence.
• Thourouhly inspect the skin folds for residual stool or urine.
  Protect the skin after each incontinence episode with a high-quality moisture barrier.

Use of Continence Management Products

There are a variety of absorbent disposable products available for continence management. Continence management products are designed for protection against moisture, managing odor, and prompting autonomy and dignity.

It is best to select continence management products that wick moisture away from the skin, providing a healthier skin environment that allows air flow while acting as a barrier to moisture.

Absorbent disposable continence management products may be appropriate to provide protection against moisture based on each individual’s need. The most appropriate product is based on the user’s mobility, mental capacity physical ability, severity of incontinence and preference.