Pressure Ulcer Prevention and Management - Sydney South West ...

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Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 20084. Performance Measures• Roles and responsibilities of the multidisciplinary team.4.1 Monitoring and Ongoing Reporting of Pressure UlcersIf a patient / client is identified as having a pressure ulcer the following mustoccur:(i)(ii)(iii)(iv)(v)A notification in the patient / client healthcare record via the pink notificationsticker must occur after the incident is notified in IIMS;Each month on a nominated day a prevalence audit is to be conducted bythe Nursing Unit Manager (NUM) or delegate. The results of this audit areto be sent to the Quality Unit and copies of the audit are to be kept by theNUM as evidence;The Quality Unit will then generate a monthly report for distribution to eachNursing Unit Manager, Department Head & Clinical Manager in order toupdate and monitor the pressure ulcer status of each patient / client with adocumented pressure ulcer;The Quality Unit will generate a trended monthly report from the aggregateddata; andBi-Annually Clinical Nurse Consultants will conduct a prevalence audit of allpatients in the facility.Incidence and prevalence of pressure ulcers by site, grade and intervention mustbe reported and discussed at the appropriate local clinical meetingMonthly aggregated reports are to be directed to the Facility Director of Nursingor Community Health Director of Nursing.An aggregated quarterly report from each Facility and Community Health QualityUnit indicating incidence and prevalence of pressure ulcers by site, grade andintervention must be tabled at the SSWAHS Nursing Clinical Practice CommitteemeetingAny incidence of grades 1 - 4 pressure ulcer must undergo a SeverityAssessment Code score in IIMS.Aggregated monthly incidence and prevalence rates on grade and site of allpressure ulcers are to be presented to relevant teams and committees.Identification of any contributing factors and recommendations on strategies toreduce the incidence are to be recorded and implemented with minimal delay.Review of the effectiveness of the strategies and actual outcomes is to beassessed and recorded by teams and relevant committees.4.2 Monitoring and EvaluationNursing managers are responsible for maintaining high standards of care andensuring the resources, educational programs and audit systems are in place tosupport an effective pressure ulcer prevention and management program.Regular evaluation is part of an ongoing process of monitoring and assessing.The monthly clinical audit forms an integral part of the organisations qualityCompliance with this policy directive is mandatory Page 10 of 20
Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 2008improvement plan. The principles and process ensure that agreedoutcome measures are achieved. Pressure ulcer monitoring must include:• Monthly incidence reports both at clinical and organisational level• Monthly clinical pressure ulcer prevalence audits5. DefinitionsBlanching Hyperaemia - reddened areas turn white following application of fingerpressure; this indicates that the microcirculation is intact.Epithelialisation - regeneration of the epidermis across the wound surface.Erythema - redness of the skin surface caused by vasodilation.Eschar - brown or black necrotic tissue.Exudate - any fluid that has exuded out of a tissue or its capillaries because of aninjury or inflammation and is high in protein and white cells.Friction - a force created by two surfaces in contact moving across each other.Granulation - healing tissue composed of newly formed capillaries and fibroblasts.Incidence - the frequency of occurrence of any event or condition over a period oftime and in relation to the population in which it occurs, as an incidence of a disease.Ischaemia - deficiency of blood, due to obstruction or constriction of a blood vessel.Necrosis - death of tissue.Non-blanching Hyperaemia - persistent redness when finger pressure is applied toan area of reactive hyperaemia indicating disruption to the microcirculation.Pressure - a perpendicular load or force.Pressure Reducing Support Surfaces - support surfaces that maintain tissueinterface.Pressure Support Surfaces - support surfaces that maintain tissue interface pressurePressure Ulcer - an area of localised tissue damage caused by unrelieved pressure,friction or shear. Pressure ulcers occur most commonly on the sacrum and heel butcan develop anywhere on the body including the coccyx, occiput, clavicle, ear andnose. Other terms for a pressure ulcer are pressure sore, bedsore and decubitus ulcer.Prevalence - the number of existing cases of a particular disease or condition in agiven population at a designated time.Reactive Hyperaemia - a normal compensatory mechanism following an episode ofreduced skin perfusion to the tissues as a result of pressure. Relief of pressure resultsin reddening of skin caused by blood returning back into ischaemic tissues.Compliance with this policy directive is mandatory Page 11 of 20
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Page 13 and 14: Appendix 1Waterlow Pressure Ulcer R
Page 15 and 16: Appendix 3Summary of Prevention Str
Page 17 and 18: Appendix 5Intervention GuidelinesPr
Page 19 and 20: Appendix 7Classification of Devices

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