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

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Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 2008• Interventions are to be documented and based on the SSWAHSPressure Ulcer Prevention and Management Policy InterventionGuidelines (Appendix 3 & 4).• Pain management must include adequate analgesia as appropriate.• Strategies implemented to promote pressure ulcer healing andprevent further breakdown must be documented in the patient /client’s health care record.• Current risk assessment, existing pressure ulcers of all grades andpresence of pressure relieving devices are to be documented in thepatient / client’s health care record on transfer or discharge.• Implement appropriate prevention strategies as per WaterlowPressure Ulcer Management Flowchart (Appendix 2)• All existing pressure ulcer must be reviewed and documented on thepatient/client’s discharge summary3.2.3 Pressure Ulcer Prevention StrategiesPressure injury prevention strategies, directed at reducing or modifyingpressure ulcer risk factors, should be incorporated into the patient / client’smanagement plan. All patients identified ‘at risk’ should have a plan of carethat incorporates measures such as pressure support systems, positioning,skin care and nutritional interventions. These strategies include:(i)(ii)(iii)(iv)maintenance of skin integrity;minimisation of pressure, shear and friction;implementing pressure relieving positions and a pertinent turningschedule, including repositioning intervals; andprovision of an appropriate support surface.3.2.4 Maintenance of Skin IntegrityMaintaining the integrity of the patient / clients skin is the key to anyprevention program. As skin has a normal pH of 4-6.8, the skin’s acidity,normal flora and the natural anti-bacterial substances found in sebum delaymicro-organism growth. Maintaining a stable skin pH discourages thecolonisation of bacteria and reduces the risk of opportunistic infection.Patients at risk should have a skin inspection daily, or more often ifwarranted, paying particular attention to skin over bony prominences andweight bearing areas. A systematic inspection is integral to the earlyidentification of skin damage and provides a baseline for care planning andevaluating interventions. Actions to maintain skin integrity include:(i)Routinely Assess Skin:• Conduct a skin assessment on admission and at regularintervals, especially skin over bony prominences which is notdesigned to support sustained external pressure eg. Sacrum,heels and greater trochanters.Compliance with this policy directive is mandatory Page 6 of 20
Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 2008• Assess patients carefully for compromised peripheral circulationand diabetes.• Use vigilance to assess patients with casts, traction and supportstockings.• Document pre-existing ulcers in the patient / client health carerecord in terms of location, severity, size, description of ulcerand surrounding skin.(ii)Prevent Exposure to Excessive Moisture or Dryness:• Implement continence training with toileting / bowelmanagement regimes where applicable.• Minimise skin exposure to urine or faeces, excessive sweatingor wound drainage as these can increase the pH of the skincausing chemical damage, maceration and denuding of the skin.• Consider medical assessment (eg. medication review) for highrisk patients to manage reversible cases of incontinence.(iii) Promote Optimal Skin Hygiene:• Cleanse the skin gently to improve overall hygiene and stimulatecirculation.• Treat dry skin with appropriate moisturising creams.• Avoid vigorous rubbing or massaging over bony prominences.(iv) Promote Optimal Nutrition:• Encourage a balanced diet to provide adequate protein andcaloric requirements.• Assess nutrition and hydration and other indicies of nutritionalstate, eg. body weight loss, muscle wasting or any signs ofvitamin or mineral deficiencies.• Consult a dietician when nutritional deficits compromise tissueintegrity.(v)Minimisation of Pressure Shear and Friction. Damage to the skin iscaused by pressure, shearing forces or friction, or a combination ofthese:• Patients / clients who are immobile, inactive and elderly are atgreatest risk.• Skin assessment is critical in providing an indication of the skin’stolerance to pressure shear and friction.• Correct positioning, transferring and handling techniques shouldbe employed(vi) Protect Against the Forces of Shear and Friction:• Use aids that eliminate dragging and friction eg. Hoists, slidesheets, slide boards and slings.• Take care when transferring patients / clients between bed andchair• Avoid the overuse of plastic sheets / kyliesCompliance with this policy directive is mandatory Page 7 of 20
Page 1 and 2: Policy DirectivePressure Ulcer Prev
Page 8 and 9: Sydney South West Area Health Servi
Page 10 and 11: Sydney South West Area Health Servi
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

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

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