Pressure ulceration is common. One study found that 4-10% of patients admitted to a UK district general hospital developed new pressure ulcers.1 But pressure ulcers don't just occur in hospital: anyone who is immobile for more than a short time is at risk regardless of the setting – even in their own home. So prevention of pressure ulcers should be the concern of those who care for patients in the community as well as in hospital.
The recent guideline on pressure ulcer assessment and prevention published by the RCN2 and adopted by NICE emphasises that pressure ulcers can be prevented by sound nursing and medical practice.
We live in the age of evidence-based medicine. However, the guideline states that its recommendations are 'evidence-linked' rather than 'evidence-based' because much of the small amount of research is of poor quality. In essence, we are presented with the distilled wisdom of experts who have reached consensus about best practice. But the advice is none the worse for that.
The substantive document is for the enthusiast. The 'Summary of Recommendations' is pithy, useful and should be read by every member of the primary healthcare team (see Figure 1, bottom). Many of the recommendations might seem obvious, but if pressure ulceration is so common then much that is 'obvious' is being ignored.
Recommendations include training personnel to identify patients who are at risk. Effective assessment depends on sound nursing practice rather than the use of any of the many assessment tools, none of which has been shown to be reliable.
All patients admitted to institutional care should have an informal risk assessment within 6 hours of arrival. Those who are acutely ill, immobile or unconscious should have a formal assessment and care plan to minimise their risk of developing pressure ulcers.
Patients should be encouraged to care for their own skin if they can, and be taught how to recognise suspicious changes.
Pressure-reducing devices should be used with care. Sheepskins are ineffective, although they may give comfort. Doughnut-type rings are positively dangerous. Pressure-redistributing mattresses for the bedbound are a good idea and there is evidence to support their effectiveness. Immobile patients should be repositioned frequently by staff trained in manual handling techniques. Good handling avoids the production of shearing forces that encourage ulcers to develop.
The authors make a plea for more, better-designed research. They recommend audit and make sensible specific suggestions about how to do it.
This is not cutting-edge high-powered technological medicine – but it is important. Perhaps we need to be reminded that our technical wizardry can only benefit patients if it is underpinned by good basic nursing care.
|Figure 1: Extract from the RCN guideline Pressure Ulcer Risk Assessment and Prevention – Recommendations2|
See also 'RCN aims to reduce prevalence of pressure ulcers' by Jo Rycroft-Malone in this issue.
- Clark M, Watts S. The incidence of pressure sores in a National Health Service Trust hospital during 1991. J Adv Nursing 1994; 20: 33-6.
- Royal College of Nursing. Pressure Ulcer Risk Assessment and Management. Recommendations. London: RCN, 2001.