About pressure ulcers

What is a pressure ulcer?

A pressure ulcer is damage that occurs to the skin and underlying tissues due to the lack of blood and oxygen supply.

There are different grades (1-4) depending on the severity of the pressure ulcer. It is important to identify pressure ulcers at early stages to prevent quick deterioration.

Grade 1 – non blanchable erythema – persistent discolouration of intact skin
Grade 2 – partial thickness skin loss – superficial broken skin or blistering
Grade 3 – full thickness skin loss – without exposure of deep tissues
Grade 4 – full thickness tissue loss – exposed or palpable bone, muscle or tendon.

Pressure Ulcer Classification Tool
Skin Damage Tool

What is the impact of pressure ulcers?

Developing pressure ulcers can have an impact not only on care home residents, but also on their relatives, on care home staff and have wider implications.

Impact of pressure ulcers on resident

  • Pain, discomfort and stress
  • Low mood and depression
  • Nutritional issues and weight loss
  • Quality of life
  • Embarrassment, for example odour, position
  • Additional health problems, such as chest infections and even death
  • Social isolation
  • Further medical interventions, for example catheters

Impact of pressure ulcers on family and friends

  • Family feel let down leading to loss of trust, anger and blame
  • Stress and worry
  • Social impact because of not being able to take the resident out
  • Embarrassment regarding odour
  • May avoid visiting

Impact of pressure ulcers on staff

  • Feeling of failure because they have let the resident down
  • Increased workload for all staff
  • Loss of confidence and questioning own professionalism and capability
  • Increased pressure from management
  • Blame among staff
  • Poor morale
  • Input from other agencies, asking questions
  • Impact of communication/training amongst staff

Wider impact of pressure ulcers

  • Cost implications of treatment, staff time, dressings, other agencies becoming involved.Pressure ulcers place a significant burden on the provision of healthcare within the NHS . The expected cost of healing a pressure ulcer in the UK varies with the grade of ulcer from £1,214 (grade 1) to £14,108 (grade 4). Dealey C, Posnett J, Walker A. The cost of pressure ulcers in the United Kingdom. Journal of Wound Care. 2012, 21(6): 261-2, 264, 266.
    The cost increases with ulcer grade partly because the time to heal is longer for a more severe ulcer and partly because the incidence of complications is higher in more severe cases.
  • Recording and reporting implications to Care Inspectorate, social services and to family
  • Multidisciplinary team involvement such as community health liaison nurse, pharmacy, tissue viability nurse, dietician, physiotherapist, occupational therapist, falls team
  • GP involvement and communication
  • Impact on other residents as less time available
  • Reputation
  • Impact on other staff, for example kitchen staff preparing meals and so on

Jill’s story describes how it feels to have a pressure ulcer and highlights what did not so well in her care.

Why do pressure ulcers occur in care homes?

In 2007, The Care Inspectorate published a report called Pressure for Change, where it looked at inspections, complaints and enforcement activity related to pressure ulcers in care homes. These were the main issues it found.

Policies and procedures:

  • not in place / out of date
  • not current good practice
  • staff hadn’t read them
  • no pre-admission / transfer process for prevention, care and treatment

Care planning

  • some ‘Waterflow’ risk assessments
  • evaluated monthly – routine task
  • residents at risk – no care plan or not tailored to individual’s needs
  • lack of resident / family involvement

Equipment

  • insufficient amounts
  • not allocated on clinical need
  • sheepskins / fibre filled overlays
  • poor staff training
  • contracts / cleaning procedures

Education and training

  • no regular updates
  • accessing appropriate staff training / support
  • lack of support from tissue viability & community nurses in most areas

Wound assessment

  • no formal wound assessment process
  • lack of knowledge about dressings
  • prescribing, storing, administration and disposal of dressings

Pain assessment 

  • pain featured strongly in complaints
  • no formal assessments in place
  • inadequate knowledge of pain assessment and management

More recently, the Care Inspectorate reviewed the complaints related to tissue viability (the health of skin and underlying tissue) that it received in 2015/2016. The main issues raised by the 29 complaints that were upheld out of 44 were:

  • poor assessment of pressure ulcer risk
  • no linking skin assessments appropriate products
  • not updating documents after changes in medication
  • not following referral pathway
  • lack of knowledge
  • inappropriate use of pressure relieving devices
  • incomplete or inaccurate assessments