Blanching and non-blanching hyperaemia

Adapting a SSKIN bundle for carers to aid identification of pressure damage and ulcer risks in the community

If pressure damage is identified and addressed at an early stage, it may be reversed. Otherwise, it may quickly progress into a serious deep tissue injury. In the community, most daily skin care is undertaken by formal and informal carers. They therefore need to know how to identify signs that pressure ulcers may develop and what immediate actions to take. NICE guidance on pressure ulcer prevention is too extensive to be a simple tool for carers, so a SSKIN bundle was adapted for community use. This ensures carers know how to prevent and identify pressure damage, and includes skin care, repositioning and use of equipment. Carers need training. This is the responsibility of all involved with the patient, including health-care and local authority services.

Objective evaluation by reflectance spectrophotometry can be of clinical value for the verification of blanching/non blanching erythema in the sacral area

Early detection of non blanching erythema (pressure ulcer category I) is necessary to prevent any further skin damage. An objective method to discriminate between blanching/non blanching erythema is presently not available. The purpose of this investigation was to explore if a non invasive objective method could differentiate between blanching/non blanching erythema in the sacral area of patients undergoing hip fracture surgery. Seventy-eight patients were included. The sacral area of all patients was assessed using (i) conventional finger-press test and (ii) digital reading of the erythema index assessed with reflectance spectrophotometry. The patients were examined at admission and during 5 days postsurgery. Reflectance spectrophotometry measurements proved able to discriminate between blanching/non blanching erythema. The reliability, quantified by the intra-class correlation coefficient, was excellent between repeated measurements over the measurement period, varying between 0·82 and 0·96, and a significant change was recorded in the areas from day 1 to day 5 (P < 0·0001). The value from the reference point did not show any significant changes over the same period (P = 0·32). An objective method proven to identify early pressure damage to tissue can be a valuable tool in clinical practice.

Pressure ulcers: Back to the basics

Pressure ulcer in an otherwise sick patient is a matter of concern for the care givers as well as the medical personnel. A lot has been done to understand the disease process. So much so that USA and European countries have established advisory panels in their respective continents. Since the establishment of these organizations, the understanding of the pressure ulcer has improved significantly. The authors feel that the well documented and well publicized definition of pressure ulcer is somewhat lacking in the correct description of the disease process. Hence, a modified definition has been presented. This disease is here to stay. In the process of managing these ulcers the basic pathology needs to be understood well. Pressure ischemia is the main reason behind the occurrence of ulceration. Different extrinsic and intrinsic factors have been described in detail with review of literature. There are a large number of risk factors causing ulceration. The risk assessment scales have eluded the surgical literature and mostly remained in nursing books and websites. These scales have been reproduced for completion of the basics on decubitus ulcer. The classification of the pressure sores has been given in a comparative form to elucidate that most of the classifications are the same except for minor variations. The management of these ulcers is ever evolving but the age old saying of "prevention is better than cure" suits this condition the most.

Pressure ulcers: e-learning to improve classification by nurses and nursing students

AIMS AND OBJECTIVES

To detect problems when classifying pressure ulcers and to examine whether an e-learning program is able to increase the classification skills of qualified nurses and nursing students.

BACKGROUND

Both the distinction between pressure ulcer grades and the differentiation between moisture lesions is difficult. Misclassification and incorrect identification of the lesions results in inadequate preventive and therapeutic measures. Education and training are important for spreading evidence-based insights about this topic.

DESIGN

Repeated measure design, consisting of one pretest and three posttests.

METHODS

The experimental intervention consisted of a one-hour session during which the participants independently went over an e-learning program. The control intervention consisted of a one-hour lecture. Both interventions had the same learning contents. A convenience sample of 212 qualified nurses and 214 final-year nursing students was randomly assigned to an experimental-and a control group.

RESULTS

In the pretest, the classification skills were low. After the intervention, these skills improved significantly in both groups. The nursing students achieved better results when using the e-learning program. Among the qualified nurses, there was no difference between the learning methods. Although the classification skills decreased in the posttests, they did not drop under the level of the pretest.

CONCLUSION

The actual classification system does not provide the necessary information about the severity of a pressure ulcer. The differential diagnosis between a moisture lesion was complicated. The classification skills of the qualified nurses and nursing students increased by both learning methods. Repetition remains, however, necessary.

RELEVANCE TO CLINICAL PRACTICE

Both instruction methods are adequate to acquire the knowledge about the differences between moisture lesions and pressure ulcers. E-learning allows studying in one's own time and place, and could therefore be very suitable for repetition of the training. How to organise this training could be a subject for further research.

Reliability of the European Pressure Ulcer Advisory Panel classification system

AIM

This paper reports a study examining the interrater and intrarater reliability of classifying pressure ulcers according to the European Pressure Ulcer Advisory Panel classification system when using photographs of pressure ulcers and incontinence lesions.

BACKGROUND

Pressure ulcer classification is an essential tool for assessing ulcers and their severity and determining which preventive or therapeutic action is needed. Many classification systems are described in the literature. There are only a limited number of studies that evaluate the interrater reliability of pressure ulcer grading scales. The intrarater reliability is seldom studied.

METHODS

The study consisted of two phases. In the first phase 56 photographs, together with a random selection of nine photographs from the same set, were presented to 473 nurses. In the second phase, the 56 photographs were presented twice to 86 other nurses with an interval of one month and in a different order. All the nurses were familiar with the European Pressure Ulcer Advisory Panel classification. They did not receive any additional training on classification, and were asked to classify the lesions as normal skin, blanchable erythema, pressure ulcers (four grades, European Pressure Ulcer Advisory Panel classification) or incontinence lesions.

RESULTS

In the first phase, the multirater-Kappa for the 473 participating nurses was 0.37 (P < 0.001). Non-blanchable erythema was often confused with blanchable erythema and incontinence lesions. Also incontinence lesions were frequently not correctly classified. The intrarater agreement was low (kappa = 0.38). In the second phase, the interrater agreement was not significantly different in both sessions. The intrarater agreement was 0.52.

CONCLUSION

Both the interrater and intrarater reliability of the European Pressure Ulcer Advisory Panel classification of lesion photographs by nurses was very low. Differentiation between pressure ulcers and incontinence lesions seems to be difficult.

Perioperative analgesia: a factor in the development of heel pressure ulcers?

This article presents the incidence of heel pressure ulcers after an elective hip or a knee replacement. The majority of patients in the authors' institute receive either a neuraxial block (epidural and/or spinal) or peripheral nerve blocks (femoral and sciatic), depending on the anaesthetist's and surgeon's preference, and the patient's physical status. The past few years have seen increasing use of peripheral nerve blocks for knee replacement surgery. Patients with either the central or peripheral nerve blockade are at an increased risk of developing heel pressure ulcers. This article describes the experience at a tertiary referral centre and, in particular, highlights the risk of developing heel ulcers in patients receiving peripheral nerve blocks. Medical and nursing staff looking after these patients should be made aware of this complication and appropriate measures should be taken to prevent this avoidable complication.

Pressure-relieving equipment: promoting its correct use amongst nurses via differing modes of educational delivery

AIMS AND OBJECTIVES

To examine the impact of written and verbal education on bed-making practices, in an attempt to reduce the prevalence of pressure ulcers.

BACKGROUND

The Department of Health has set targets for a 5% reduction per annum in the incidence of pressure ulcers. Electric profiling beds with a visco-elastic polymer mattress are a new innovation in pressure ulcer prevention; however, mattress efficacy is reduced by tightly tucking sheets around the mattress.

DESIGN

A prospective randomized pre/post-test experimental design.

METHODS

Ward managers at a teaching hospital were approached to participate in the study. Two researchers independently examined the tightness of the sheets around the mattresses. Wards were randomized to one of two groups. Groups A and B received written education. In addition, group B received verbal education on alternate days for one week. Beds were re-examined one month later. One researcher was blinded to the educational delivery received by the wards.

RESULTS

Twelve wards agreed to participate in the study and 245 beds were examined. Before education, 113 beds (46%) had sheets tucked correctly around the mattresses. Following education, this increased to 215 beds (87.8%) (chi2 = 68.03, P < 0.001). There was no significant difference in the number of correctly made beds between the two different education groups: 100 (87.72%) beds correctly made in group A vs. 115 (87.79%) beds in group B (chi2 = 0, P = 0.987).

CONCLUSIONS

Clear, concise written instruction improved practice but verbal education was not additionally beneficial.

RELEVANCE TO CLINICAL PRACTICE

Nurses are receptive to clear, concise written evidence regarding pressure ulcer prevention and incorporate this into clinical practice.

Reducing the Incidence of PRESSURE ULCERS: Implementation of a Turn-Team Nursing Program

This study examined the effects a structured program designed to reduce pressure ulcers among patients in a midsized geriatric hospital. A select group of caregivers were organized into a "turn team that was responsible for preventive pressure ulcer care. Patient and staff data were collected during 6-month trial period. Subsequent analysis showed patient referrals to the staff enterostomal nurse and average length of stay, as well compensable musculoskeletal injuries among all staff declined. In addition, concerns the program might lead to an increased incidence of nosocomial infections were not substantiated.

Comparison of pressure ulcer grading scales: a study of clinical utility and inter-rater reliability

Pressure ulcer grading scales are subjective measures of pressure damage. This study measured inter-observer agreement of the Stirling scale (1-digit and 2-digit versions) and the European Pressure Ulcer Advisory Panel Scale, using Cohen's kappa and percentage agreement. Clinical utility was also assessed. Thirty-five observations were made by two Registered Nurses on 30 adult in-patients. The levels of agreement obtained were better than those reported previously and this may be related to the methodology used. The 2-digit Stirling scale gave the best level of chance corrected agreement (kappa=0.457) and was the scale preferred by raters. The 1-digit Stirling scale performed least favourably. Qualitative data identified problems with scale construction relating to visualisation of the base of the wound, discolouration of the skin, abrasions and shallow ulcers. Whilst refinements in scale construction may improve rater reliability, there is a need to develop objective measures of pressure induced tissue damage.

Controversies in classifying and assessing grade I pressure ulcers

There is more uncertainty on how to define a grade I pressure ulcer than any other type. The confusion will need to be dispelled and a consensus reached if a national grading system is to be implemented. This review explores the options.

Pressure ulcer classification: defining early skin damage

This article is the second of a two-part series. The first part (Russell, 2002) looked at various systems and pitfalls of pressure ulcer classification systems. This article focuses on the difficulties of defining early skin damage. Patients' quality of life suffers significantly with a pressure ulcer. The smell of the exudate may be an embarrassment to the patient. The pain and the distress the patient will experience will not easily be forgotten, i.e. the number of dressings required for a deep pressure ulcer, even after the pressure ulcer has healed, will be a memorable intrusion to the patient's daily routine. Early detection of pressure ulcers and timely intervention are essential in the management of patients with pressure ulcers. Controversy exists over the definition of the first three stages of pressure ulcers, but there is consensus on the definition of deep tissue damage. If the pressure ulcer is covered with black necrotic tissue it is difficult to establish depth of the tissue damage. Intact skin can cause problems, as a sacrum may be purple but intact. There is still considerable debate with regard to reactive hyperaemia, as the exact time parameters for persistent erythema to occur are unknown. Little is understood with regard to the exact pathophysiology of reactive hyperaemia and this area requires further investigation. Blistered skin and skin tone also cause confusion in grading of pressure ulcers. The problems associated with classification of pressure ulcers, using colour classification systems, are discussed and the implications for practice are considered. The confusion surrounding early classification of pressure ulcers is discussed and it is hoped that such confusion can be addressed by standardizing training using one national classification system.

Pressure ulcer classification: the systems and the pitfalls

The classification of pressure ulcers constitutes an essential part of patient assessment and forms a baseline on which to monitor patients' progress and measure the outcomes of care. Four classification systems - Torrance, National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Stirling - are discussed. Many classification systems have been adopted by trusts despite insufficient research in their use in clinical practice. Regardless of which classification system is implemented, nurses need to be familiar with the one they are using and how to stage accurately a pressure ulcer. This can only be attained through regular education.

Relieving the pressure in the radiology department

Interventional radiological procedures can be complex, requiring patients, many of whom already have compromised arterial circulation, to lie immobile for significant periods. X-ray table mattresses are designed to avoid radiation attenuation, which could degrade image quality or increase patient dose. Consequently, most mattresses do not have pressure redistribution properties. Skin changes, noted after lengthy radiological procedures, would appear to indicate that this unrelieved pressure places vulnerable patients at risk of sustaining pressure damage that could potentially initiate pressure ulcer development. This article examines the biomedical basis of pressure ulcer development, and discusses the suitability of alternative support devices for radiological examinations in an apparently under-researched environment.

Pressure ulcer classification: the Torrance system

A wide variety of pressure ulcer classification systems are in use but most have grading systems which are subjective and open to different interpretations. This review discusses the advantages and disadvantages of the Torrance classification system, and argues that this highlights the need for a national grading tool.