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Assessment of Pressure Ulcers and Trustworthiness of Risk Examination Tools

The reason for this task, is to recognize an individual, under the care and attention of the district nursing team, with a Quality 1 pressure ulcer, to their sacral area. To get started with, it will give a brief overview of the individual and their professional medical history. Through the entire assignment the individual will be known as Mrs A, to be able to protect the patients personal information and maintain confidentiality, in accordance with the guidelines lay out by the Nursing and Midwifery Council (NMC 2008). A short description of any Grade 1 pressure ulcer will be given, along with a description of the steps taken in evaluating the wound, making use of the Waterlow Range (1985). This task will discuss the books review that was completed, along with other methods of research used, to gather vital information on wound care, such as the different classifications of wounds and the various risk assessment tools available. This assignment, will include simple overviews, of some the other widely used pressure ulcer risk evaluation tools, that are put to make use of by practitioners and exactly how they compare to the Waterlow Range. This task will also seek to identify the value of using a combination of professional medical judgement, by carefully monitoring the patients physical and mental conditions, alongside the 'at risk' credit score calculated from the Waterlow Level, in order to deliver holistic care and attention to the patient.

Mrs A is a 84 time old lady that has been described the region nurses by her General Practitioner, as he has concerns regarding her pressure areas. Carrying out a recent show up she lost her self-confidence and is now house destined. She now spends additional time in her couch as she's become stressed when mobilising around the house and in her garden. She has a history of high blood pressure and occasional angina that she currently calls for Nicorandil 30mg b. d. as prescribed by her General Practitioner, Nicorandil has been recognised as an aetiological facet of non - recovery ulcers and wounds (Watson, 2002), this needs to be taken into consideration during the assessment and throughout the management of her wound. Mrs A has no history of prior falls or issues with her balance. She has always been a positive and independent girl, without current issues encircling continence or diet. She has always enjoyed a sizable network of friends who visit her regularly. It is strongly recommended by National Institute for Health insurance and Clinical Quality (NICE) that patients should acquire an Initial diagnosis (within the first 6 hours of inpatient care) and ongoing risk assessments and so referrals of this nature are seen on your day, if it is received if not within 24 hrs. To be able to create Mrs A's current threat of creating a pressure area, an analysis must take place. An initial alternative assessment, considering all contributing factors such as mobility, continence and nutrition will provide set up a baseline that will identify her degree of risk as well as figuring out any existing pressure harm.

A pressure ulcer is thought as, a localised injury to the skin and underlying cells usually over a bony prominence, therefore of pressure, or pressure in blend with shear. A number of contributing, or confounding factors, are also associated with pressure ulcers. Based on the European Pressure Ulcer Advisory Panel (EPUAP 2009).

Mrs A is more vulnerable to pressure destruction, as her skin area is becoming more delicate and thinner with years (NICE 2005). You will find risk factors associated to the integrity of the patient's pores and skin and also to the patients health and wellness. Skin that is already damaged, has an increased incidence of creating a pressure ulcer, than that of healthy pores and skin. Epidermis that becomes too dry, or is more moist anticipated to possible incontinence, is also at higher threat of creating a pressure ulcer than healthy skin. An seniors person's skin reaches increased risk, because it is more delicate and thinner than the skin of a younger person. Boore et al (1987) determined the following ideas in caring for the skin to avoid pressure damage, pores and skin should be held clean and dry and not remaining to remain wet. The skin should also not be left to dry to avoid any accidental harm. Due to Mrs A spending more time relaxing in her couch, she's become at a higher risk of developing a pressure sore, as she actually is less mobile. For the reason that It becomes difficult for the blood vessels to circulate leading to too little oxygen and nutrients to the tissues skin cells. Furthermore, the lymphatic system also begins to suffer from and becomes incapable, to properly remove waste material. In case the pressure is constantly on the increase and is not relieved by equipment or movements. The skin cells can get started to die, leaving an area of dead structure resulting in pressure damage. Nelson et al (2009) expresses, pressure ulcers can cause patients efficient limitations, emotional distress, and pain for people affected. The development of pressure ulcers, in various healthcare settings, is often regarded as a reflection of the grade of care which has been provided (Nakrem 2009). Pressure ulcer prevention is vital in everyday specialized medical practise, as pressure ulcer treatment is expensive and factors such as legalities have become more important. EPAUP (2009) have advised strategies, such as frequent repositioning the use of special support areas, or providing nutritional support to be contained in the prevention.

In order to assemble evidence based mostly research, to aid my assignment. I undertook a books overview of the Waterlow Size and Classifications of Grade 1 pressure sores. The databases used were the Culmulative Index to Medical and Allied Health Books (CINAHL) and OpenAthens. I used a number of search conditions including 'pressure sores', 'Quality 1 classification', 'Waterlow Level', and 'How pressure sore risk examination tools compare'. Throughout the literature review the info was obtained from sources utilizing a date range between the many years of 2000 - 2011, even though some recommendations were found from resources of information that are from a much later night out. This technique of research guaranteed a plethora of articles and recommendations were collated and analysed. The trust recommendations in wound attention were used, showing how we implement theory into practise locally, using the wound care formulary. There was a huge amount of information available, as pressure area good care is such a wide subject matter. The search conditions had to be narrowed down, occasionally to ensure the information accumulated was relevant rather than beyond the opportunity of the project. The data used throughout this task, is dependant on guidelines and suggestions given by NICE (2001), EPUAP (2001) and articles sourced in the Journal of Community Nursing (JCN). This is the most accurate information and help with pressure ulcer classifications and analysis although, some articles might not exactly have been the most recent.

The diagnosis tool used throughout my part of work, is the Waterlow Size. The Waterlow Size was developed by Judy Waterlow in 1985, while working as a professional medical nurse teacher. It was originally suitable for use by her scholar and can be used to evaluate a patient's risk of creating a pressure sore. It can also be used as helpful information, for the purchasing of effective pressure alleviating equipment. All Country wide Health Service (NHS) trusts have their own pressure ulcer protection policy, or recommendations and practitioners are anticipated to use the risk assessment tool, specified in their trust's policy. NICE (2003), information states, that all trusts must have a pressure ulcer plan, which should add a pressure ulcer risk assessment tool. However, it reminds professionals that the use of risk diagnosis tools, should be regarded as an help to the medical judgement of the practitioner. The usage of the Waterlow tool permits, the nurse to evaluate each patient regarding to their individual risk of producing pressure sores (Pancorbo-Hidalgo et al 2006). The level illustrates a risk analysis scoring system and on the slow area, provides information and guidance on wound assessment, dressings and preventative products. There is certainly information regarding pressure relieving equipment surrounding, the three degrees of risk highlighted on the range, and also provides assistance, concerning the nursing care given to patients. Although Waterlow score is utilized locally setting, when calculating the risk assessment report, it is vital that the nurse knows the difference in environment the tool was formerly developed for.

The tool runs on the combination of main and external risk factors that donate to the introduction of pressure ulcers. These are used to determine the risk level for a person patient. The fundamental factors include disease, medication, malnourishment, age, dehydration / fluid status, insufficient mobility, incontinence, condition of the skin and weight. The exterior factors, which refer to external affects which can cause pores and skin distortion, include pressure, shearing pushes, friction, and moisture. Gleam special risk section of the tool, which is often used if the patient is on certain medication or lately got surgery. This contributes to a holistic diagnosis of a patient and permits the practitioner to supply the most effective good care and appropriate pressure relieving equipment. The credit score is computed, by counting the results given in each category, which connect with your patient's current condition. Once these have been added up, you should have your 'at risk' report. This will then show the steps that require to be studied, to be able to provide the appropriate degree of care to the patient. Identification of any patients threat of creating a pressure sore is often considered the most crucial stage in pressure sore prevention (Davis 1994).

During the examination a pores and skin inspection takes place of the very most vulnerable areas of risk, typically these are heels, sacrum and areas of the body, where utter or friction could take place. Elbows, shoulders, back again of mind and toes are also regarded as more vulnerable areas (NICE 2001). With all the Waterlow tool to assess Mrs A's pressure risk, I came across she possessed a credit score of 9. Based on the Waterlow rating system she actually is not regarded as being at risk as her rating is less than 10. WHEN I had identified in my own assessment, she had a rating of 2, for her skin condition scheduled to Class 1 pressure ulcer to her sacrum. I believed it necessary, to spotlight her to be vulnerable. A grade 1 pressure ulcer on her sacral area, maybe anticipated to her recent lack of self confidence and reduced range of motion which has remaining Mrs A spending additional time in her seat.

Pressure ulcers are assessed and graded, according to the degree of damage to the

tissue. The Country wide Pressure Ulcer Advisory Panel (NPUAP), classifies pressure ulcers predicated on the depth of the wound. There are four classifications (Category/Stage I through IV) of pressure damage. In addition to these, two other categories have been described, unstageable pressure ulcers and profound tissue harm (EPUAP, 2009) Class 1 pressure harm is described, as a non-blanchable erythema of intact epidermis. Signals can be, discolouration of your skin, comfort, oedema, induration or hardness, especially in people with darker pigmentation (EPUAP, 2003). It really is assumed by some professionals, that blanching erythema reveals Level 1 pressure harm (Hitch 1995) although others suggest that, Level 1 pressure damage exists, when there is certainly non-blanching erythema (Maklebust and Margolis, 1995; Yarkony et al, 1990). The majority of practitioners, agree that temperature and coloring play an important role, in identifying class 1 pressure ulcers (EPUAP, 1999) and erythema, is a factor in almost all classifications (Lyder, 1991). The pressure destruction usually occurs, over boney prominences (Barton and Barton 1981). The skin in a Grade 1 pressure ulcer, is not broken, but it requires protection and monitoring.

At this stage, you won't be known how profound the pressure destruction is, regular

monitoring and evaluation is vital. The pressure ulcer may diminish, but if the

damage is deeper than the superficial tiers of your skin, this wound could eventually

develop into a much deeper pressure ulcer over, the next days and nights or weeks.

A Quality 1 pressure ulcer, is classed as a wound therefore i have commenced a

wound health care plan and also a pressure area attention plan. I will also ensure, Mrs A has

regular pressure area checks in order to stop the area wearing down. The

pressure area bank checks will take place weekly until the pressure relieving equipment

arrives, this will be reduced to 3 monthly assessments. Dressings can be applied to

a Quality 1 pressure ulcer. They must be simple and provide some degree of protection.

Also, to avoid any further skin surface damage a film dressing is often used, or a

hydrocolloid to protect the wound area (EPAUP, 2009). These dressings will help in

reducing further friction, or shearing, if these factors are involved. It really is considered

the easiest way to treat a wound, is to avoid it from ever before occurring. Taking away the

existing exterior pressure, lowering any moisture content, which may appear if the individual is

incontinent and utilizing pressure alleviation devices, may contribute to wound restoration.

Along with enough diet, hydration and dealing with any fundamental medical


The advice given to practitioners, on the change of the Waterlow tool is to provide a

100mm foam cushioning, when a patients risk credit score is above 10. As Mrs

A has an 'at risk' credit score of 9, with a Level 1 pressure sore visible, I feel it

appropriate to provide the pressure relieving mattress and cushion to avoid any

further pressure destruction developing. All individuals, assessed as being susceptible to

pressure ulcers should, as the very least provision, be placed on a high specification

foam mattress with pressure relieving properties (NICE, 2001). WHEN I am providing a

cushion and a bed, it isn't felt necessary to apply a dressing at this time.

However, the region will require regular monitoring, as at this time it is unknown how

deep the pressure harm is. If proactive attention is given in the protection and

treatment of pressure ulcers, by using risk assessments and providing

pressure relieving resources, the pressure area may resolve. Pressure ulcers can be

costly for the NHS, debilitating and painful for the patient. With basic and effective

nursing care offered to the patients, this may often be the key to success.

Bliss (2000) suggests that nearly all Quality I ulcers heal, or deal with without

breaking down if pressure comfort is put into place immediately. However, experiences

in a professional medical settings facilitates observations, that non-blanching erythema can often

result in irreversible destruction (Adam, 1998; Dailey, 1992).

McGough (1999) during a literature search, outlined 40 pressure ulcer risk

assessment tools, however, not all have be looked at ideal, or reliable for those clinical

environments. As there are various patient groups this often brings about a wide

spectrum of different patient needs. The three mostly used tools in britain (U. K. ) are, The Norton range, The Braden Size and The Waterlow Range.

The first pressure ulcer risk diagnosis tool was the Norton range. It had been devised by Doreen Norton in 1962. The tool was used for estimating a patient's risk for developing pressure ulcers by giving the patient a ranking from 1 to 4 on five different factors. A patients with a report of 14 or more, was identified to be at risky. In the beginning, this tool was aimed at elderly patients and there is little proof from research collected over the years, to support its use beyond an elderly treatment setting. Due to increased research over the years, concerning the recognition and risk of growing pressure ulcers, a customized version of the Norton scale was created in 1987.

The Braden Range was made in the mid 1980's, in the us and based on a conceptual schema of aetiological factors. Tissue tolerance and pressure where revealed, to be significant factors in pressure ulcer development. However, the validity of the Braden Scale is not regarded as saturated in all professional medical areas (Capobianco and McDonald, 1996). However, EPAUP (2003) talk about The Braden

Risk Assessment Level is known as by many, to be the most valid and reliable

scoring system for a wide a long time of patients.

The Waterlow Level, first devised in 1987, identifies more risk factors than the Braden and the Norton Scale. However, even though it is used generally over the U. K. , they have still be criticised for its ability to over predict risk and eventually result in the misuse of resources (Edwards 1995; McGough, 1999).

Although there are numerous tools, which have been developed to identify a patients specific risk, of producing pressure sores. The majority of scales have been developed, predicated on ad hoc viewpoints, of the value of possible risk factors, according to the Effective Healthcare Bulletins (EHCB, 1995). Franks et al, 2003; Nixon and Mc Gough, 2001, challenged the predictive validity of these tools, suggesting they could over predict the chance, cause expensive cost implications, as preventative equipment is put in place, when it might not exactly continually be necessary. Or they could under predict risk, so a patient maybe evaluated as not coming to high risk, evolves a pressure ulcer. Although the Waterlow rating system, now includes more target measurements such as Body Mass Index (BMI) and weight reduction after a recently available update. It is still unknown, due to no shared information, whether the consistency of the waterlow tool, has advanced since the changes that occurred. It has been recognised, as a fundamental flaw of the tools and due to this clinical judgement, should always be taken into consideration alongside the results that have been measure, from the utilization of the risk assessment. That is clearly recognised by NICE, as they guide their use as an aide-mmoire (2001). The aim of Pressure ulcer risk assessment tools, is to evaluate and quantify pressure ulcer risk. To determine the quality of the measurements the evaluation of validity and reliability would usually happen. The validity and consistency constraints, of pressure ulcer risk tools are greatly acknowledged. To defeat these problems, the perfect solution is that is recommended is to combine the results of pressure ulcer risk tools, with professional medical common sense (EPAUP 2009). This advice, which is often observed in the literature, however is inconsistent as Papanikolaou et al (2007) claims: "If pressure ulcer risk analysis tools have such limits, what contribution can they make to our confidence in clinical judgment, apart from prompting us about the things, which should be looked at when coming up with such judgments?". Investigations of the validity and dependability, of pressure ulcer risk tools are essential, in evaluating the product quality, but they are not sufficient to judge their professional medical value. In the research of pressure ulcer tools, there have been few attempts designed to compare, the various pressure ulcer risk diagnosis strategies. Referring to books until 2003, Pancorbo - Hidalgo et al (2006) discovered three studies, investigating the Norton range compared to scientific view and the effect on pressure ulcer incidence. From these studies, it was concluded that there is no evidence, that the chance of pressure ulcer incidence was reduced by the use of the risk examination tools. The Cochrane review (2008), attempt to determine, whether the use of pressure ulcer risk examination, in all healthcare options, reduced the occurrence of pressure ulcers. As no studies satisfied the conditions, the authors have been struggling to answer the review question. At present there is only weak evidence to aid the validity, of pressure ulcer risk assessment scale tools and obtained results contain varying amounts of measurement problem.

To improve our professional medical practise, it is suggested that although tools such as the

Waterlow Scale are being used to distinguish a patients pressure ulcer risk, other

investigations and tests, may need to be carried out to ensure a effective

assessment is occurring. Practitioners may consider, various blood checks and more

in depth history taking, including past pressure destruction and medications. Patients

lifestyle and diet also needs to be taken into consideration and where appropriate, a

nutritional analysis should be done if recent weight loss, or reduced desire for foods is

evident. Nutritional evaluation and verification tools are being used more easily and appearance to be becoming more relevant in controlling patients who are in threat of or have a pressure ulcer. The examination tools should be reliable and valid, so that discussed recently with other risk diagnosis tools they should not replace medical judgement. However, the utilization of nutritional diagnosis tools can help bring the dietary status of the patient to the interest of the practitioner, they need to then consider diet when examining the patients vulnerability to pressure ulcer development. The dietary status of the individual should be updated and re-assessed at regular intervals carrying out a examination plan which is individual to the individual and includes an evaluation date. The health of the individual will allow the practitioner to decide how consistent the assessments will arise. The EPUAP (2003) recommends that as the very least, assessment of dietary status will include regular weighing of patients, skin area assessment, documentation of food and fluid intake.

As Mrs A presently has a balanced diet, it isn't felt necessary to undertake, a

nutritional assessment at this point. Her weight can be updated on each review visit,

to examine any weight reduction during each visit. If there is any deterioration in her

condition, an diagnosis can be done when required. Continence should also be

taken into consideration and where necessary a continence diagnosis should take

place. Incontinence and pressure ulcers are common and often take place together.

Patients who are incontinent are usually more likely to obtain problems with their

mobility and elderly, both of which have a solid connection with the development

of pressure ulcers (Lyder, 2003).

The education of staff, encircling pressure ulcer management and elimination, is

also very important. NICE (2001) suggest, that health care pros, should

receive relevant training and education, in pressure ulcer risk diagnosis and

prevention. The info, skills and knowledge, gained from these training

sessions, should then be cascaded down, to other people of the team. The

training and education lessons, which are provided by the trust, are expected to

cover a number of topics. These should include, risk factors for pressure ulcer

development, skin assessment, and selecting pressure equipment. Staff are

also updated on policies, rules and the latest patient educational information

(NICE 2001).

Education of the patient, carers and family, is essential in order to achieve optimum

pressure area care. Mrs A is prompted to mobilise regularly, to be able to relieve

the pressure as a Quality 1 pressure sore has been diagnosed, she actually is at a significant

risk of developing a more serious ulcer. Interventions to prevent deterioration, are

crucial at this point. It is thought, that could avoid the pressure sore from

developing into a Grade 2 or worse. NICE (2001) have advised, that individuals

vulnerable to or at increased risk of growing pressure ulcers, who are able and

willing, should be up to date and informed about the risk examination and resulting

prevention strategies. NICE have devised a booklet for patients and relatives, called

Pressure Ulcers - Protection and Treatment (NICE Clinical Guidance 29), which gives

information and help with the treating pressure ulcers. It stimulates patients

to check their pores and skin and change their position regularly. As a part of good practise,

this booklet is directed at Mrs A at the time of assessment, for her to

develop some knowledge of her pressure sore. This booklet is also directed at the

care givers or relatives to allow them to also gain understanding, about the care and

prevention, of her pressure ulcer. An important part of nursing documents, is care

planning. It shows the care and attention, that the average person patient requires and can be

used to add patients and carers or family members in the patients good care. Involvement of

the patient and their comparative, or carer is beneficial, as this could be invaluable, to

the nurse planning the patient's care. The National Health Service Modernisation

Agency (NHSMA 2005) areas clearly see your face - centred good care is vital which care planning requires negotiation, discourse and distributed decision - making, between the nurse and the patient.

There were a number of advancements that Personally i think might have been designed to the holistic care of Mrs A. I feel that one of the essential factors that would have to be considered, were the sociable needs of the patient. As I feel they are a huge contributing factor, towards why the individual may have developed her pressure sore. The individual was previously known to be a very sociable woman, who little by little lost her assurance, resulting in her not going out of the house. There are various techniques and services available, which are provided by the neighborhood council or volunteer services, to allow older people or people unable to get around. For instance, an option that could of been suggested to Mrs A are services such as Ring and Ride, or Werneth Communicare. Using these services or being involved with these types of strategies, may have empowered Mrs A to leave the house on a far more regular basis. This might enable her to develop the confidence, she lost pursuing her fall. This might have also lead to positive effect on the patient's psychological care, as Mrs A could have had the opportunity to conquer her anxieties of leaving the home, enabling her to see friends and gain marketing communications lost. As mentioned in this project, although Mrs A got a score of 9, which is not considered an 'at risk' credit score. I still thought it essential to act on this score, even though the wound was a not considered to be critical. If it's felt the individual is at a higher risk than that shown on the examination tool, the practitioner should use their medical judgement, to make vital care decisions. It should also be looked at, by the specialist that risk analysis tools such as The Waterlow scale, might not exactly have been developed, for their section of practise. Throughout the duration of Mrs A's wound healing up process, a holistic assessment of her pressure areas and health and wellness assessment were taken and everything relevant factors, were taken into account. The diagnosis tool used to assess her pressure areas, is the most common tool used presently in practise and the tool advised by the Trust.

To conclude, there exists evidence to prove that pressure ulcer risk evaluation tools are of help, when used as a guide for the procurement of equipment. However, they can not be relied upon exclusively to provide all natural care to a patient. It has been highlighted, that to ensure a holistic diagnosis of patients, it is necessary to complete a variety of assessments, to make a complete picture. Although The Waterlow scale includes a number of factors that require to be considered, throughout the analysis, it has become evident that the 'at risk' rating, can often be over or under scored depending on the practitioner. Clinical judgement has became, an essential aspect of pressure ulcer prevention and treatment. The education of the individual, carer and family members in addition has been highlighted, as an important aspect of care. Empowering the patient with information regarding their condition, may decrease the treatment time and help prevent has further issues.

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