Trust Policy
Prevention and Management of Pressure Ulcers Policy
Issue Date
Review Date
Version
3rd July 2019
31st June 2024
3
Purpose
This policy will enable compliance with current guidelines and recommendations for
prevention and management of pressure ulcers, including NHS improvement and NICE
guidance, High Impact Action “Your Skin Matters”. Effective implementation will reduce co-
morbidity enables patients to return their normal activity and home or place of care, reduce
inpatient time and health care costs. The application will improve communication and
ensure consistency of care across healthcare providers.
Who should read this document?
Nurses, Doctors, Health Care Assistants, Student Nurses, Physiotherapists, Therapists,
Dietician and other trust healthcare workers providing patient care
Key Messages
Pressure ulcers are largely avoidable if action is taken to prevent and manage patients appropriately
and at an early stage.
The following actions are needed:
Assessment of risk
Assessment of the skin condition
Planning patient care based on assessment findings
Implementation of prevention strategies with appropriate documentation
Evaluation of patient response to risk prevention and needs management
Consideration of safeguarding
Core accountabilities
Owner
Matron for Harm Free Care
Review
Nursing and Midwifery Operational Committee
Ratification
Chief Nurse
Dissemination
Matron for Harm Free Care
(Raising Awareness)
Compliance
Matron for Harm Free Care
Links to other policies and procedures
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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End of Life Care in Hospital Policy
Incident Management Policy
Intentional Care Record
Moving and Handling People and Objects Policy
Nutrition and Mealtimes Policy
Safe Operating procedures for moving and handling techniques of patients and objects
The Carers policy
The Management and Use of Medical Devices Policy
The Safeguarding Adults at Risk Policy
Waterlow, Skin Assessment
Version History
V1 May 2010
Initial document
V2 August 2012
Revised and reformatted
V3 July 2019
Revised
The Trust is committed to creating a fully inclusive and accessible service. Making equality and
diversity an integral part of the business will enable us to enhance the services we deliver and
better meet the needs of patients and staff. We will treat people with dignity and respect, promote
equality and diversity and eliminate all forms of discrimination, regardless of (but not limited to)
age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage/civil
partnership and pregnancy/maternity.
An electronic version of this document is available on Trust Documents.
Larger text, Braille and Audio versions can be made available upon
request.
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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Contents
Section
Description
Page
1
Introduction
4
2
Purpose, including legal or regulatory background
4
3
Definitions
5
4
Duties
5
5
Standards- Key Performance Indicators
5
6
Overall Responsibility for the Document
9
7
Consultation and ratification
9
8
Dissemination and Implementation
10
9
Monitoring Compliance and Effectiveness
10
10
References and Associated Documentation
10
Appendix 1
Dissemination Plan
12
Appendix 2
Review and Approval Checklist
13
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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1
Introduction
1.1. Pressure ulcers remain concerning and mainly avoidable harm associated with
healthcare delivery. In the NHS in England, 24,674 patients were reported to have
developed a new pressure ulcer between April 2015 and March 2016, and treating
pressure damage costs the NHS more than £3.8 million every day.
1.2. University Hospitals Plymouth NHS Trust (UHPNT) recognises that the
prevention and management of pressure ulcers are crucial to good patient
outcomes and improving the patient experience.
2
Purpose
2.1. The Trust will ensure that all inpatients undergo an assessment of their physical
condition on admission and all appropriate measures will be taken to prevent the
development of avoidable pressure ulcers while in the care of the Trust.
2.2. Where patients are admitted with pressure ulcers or develop them in our care,
treatment will be administered that prevents any further deterioration and promotes
healing.
2.3. This policy is intended to establish a standardised approach and framework for
healthcare professionals undertaking the care of patients including all ages with a
pressure ulcer, or at risk of developing one.
2.4. The policy and guidelines are based on current best practice statements, position
documents, expert opinion, National and European guidelines and research
evidence where it exists.
2.5. The development of pressure ulcers may in some instances be an indication of
neglect by the care provider. If there is a concern that an adult at risk may have
been abused or is at risk of abuse, a safeguarding adults referral must be made. It
must also be recognised that some pressure ulcers may not be preventable.
3
Definitions
3.1. A pressure ulcer is a localised damage to the skin and/or underlying tissue, usually
over a bony prominence (or related to a medical or other devices), resulting from
sustained pressure (including pressure associated with shear). The damage can be
present as intact skin or an open ulcer and may be painful
3.2. EPUAP/NPUAP Classification (2014)
Category 1
Non-blanchable erythema
Intact skin with non-blanchable redness of a localized
area usually over a bony prominence. Darkly pigmented
skin may not have visible blanching; its colour may differ
from the surrounding area. The area may be painful, firm,
soft, warmer or cooler as compared to the adjacent tissue.
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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Category 2
Partial thickness skin loss
Partial thickness skin loss of dermis presenting as a
shallow ulcer with a red pink wound bed, without slough.
May also present as an intact or open/ruptured serum-
filled or serosanguinous filled blister. Presents as a shiny
or
dry shallow ulcer without slough or bruising*. This stage
should
not be used to describe skin tears, tape burns,
incontinence-associated dermatitis, maceration or
excoriation.
* Bruising indicates suspected deep tissue injury.
Category 3
Full thickness tissue loss.
Subcutaneous fat may be visible but bone, tendon or
muscles are not exposed. Slough may be present but
does not obscure the depth of tissue loss. May include
undermining
and
tunnelling.
The
depth
of
a
Category/Stage 3 pressure ulcer varies by anatomical
location. The bridge of the nose, ear, occiput and
malleolus do not have (adipose) subcutaneous tissue and
Category/Category 3 ulcers can be shallow. In contrast,
areas of significant adiposity can develop extremely deep
Category/Category 3 pressure ulcers. The bone/tendon is
not visible or directly palpable.
Stage 4
Full thickness tissue loss with exposed bone, tendon
or muscle.
Slough or eschar may be present. Often includes
undermining
and
tunnelling.
The
depth
of
a
Category/Category 4 pressure ulcer varies by anatomical
location. The bridge of the nose, ear, occiput and
malleolus do not have (adipose) subcutaneous tissue and
these ulcers can be shallow. Category/Category 4 ulcers
can extend into muscle and/or supporting structures (e.g.
fascia, tendon or joint capsule) making osteomyelitis or
osteitis likely to occur. Exposed bone/muscle is visible or
directly palpable.
Unstageable
Full-thickness skin or tissue loss – depth unknown
Full thickness tissue loss in which actual depth of the
ulcer is completely obscured by slough (yellow, tan, grey,
green or brown) and/or eschar (tan, brown or black) in the
wound bed. Until enough slough and/or eschar are
removed to expose the base of the wound, the true depth
cannot be determined, but it will be either a
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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Category/Category 3 or 4.
Stable (dry, adherent, intact without erythema or
fluctuance) eschar on the heels serves as “the body’s
natural (biological) cover" and should not be removed.
Deep tissue damage-
Depth unknown
A purple or a maroon localized area of discoloured intact
skin or blood-filled blister due to damage of underlying
soft tissue from pressure and/or shear.
The area may be
preceded by tissue that is painful, firm, mushy, boggy,
warmer or cooler as compared to adjacent tissue. Deep
tissue injury may be difficult to detect in individuals with
dark skin tones. Evolution may include a thin blister over a
dark wound bed. The wound may further evolve and
become covered by thin eschar. Evolution may be rapid
exposing additional layers of tissue even with optimal
treatment.
3.1. Device Related Pressure Ulcer. A pressure ulcer that forms as a direct result of
pressure/friction/shear caused by a medical device. With the exception of mucosal
pressure ulcers, these should be ‘categorised’ as above.
3.2. Moisture Associated Skin Damage (MASD). Damage to the skin that occurs as a
direct result of excess levels of moisture at the skin surface (e.g. urine, faeces,
sweat, wound exudate)
3.3. SSKIN Bundle. A bundle of care that addresses Skin assessment, Surface, Keep
moving, Incontinence and Nutritional needs of the patient
3.4. .Present on Admission (POA) Pressure Ulcer. A pressure ulcer that is observed
during the skin assessment undertaken on admission to that service
3.5. New (acquired) Pressure Ulcer. The definition of a new pressure ulcer within a
setting is that it is first observed within the current episode of care
4
Duties
4.1. All clinical staff are responsible for the initial and ongoing assessment of patients
for the risk of acquiring pressure ulcers, escalating and reporting any incidence of
pressure ulcers or any safeguarding concerns, and for the delivery of preventative
measures and treatment of pressure ulcers.
4.2. All Ward/Departmental Managers are responsible for ensuring the policy is
implemented by staff in their area of responsibility, to monitor and investigate any
incidence of new hospital-acquired pressure ulcer and to implement an annual
action plan with specific actions if incidents occur to reduce overall
incidence/incidents.
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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4.3. All Matrons are responsible for ensuring the policy is implemented in the area of
responsibility and providing assurance to the Care Group and Service Line
Management Team of compliance with the policy.
4.4. Care Groups and Service Lines must review and monitor compliance with the
policy. They must identify any areas of concern and implement changes to practice
where required.
4.5. The Tissue Viability Team provides support for staff implementing the policy and
specialist advice where required for patient management. Monitor the effectiveness
of the policy and provide support for Matrons / Ward managers to develop and
implement action plans, report to the Nursing and Midwifery Operational
Committee on the effectiveness of the policy.
5
Standards- Key Performance Indicators
5.1. On admission
5.1.1. All patients will receive an assessment of their risk of developing pressure
ulcers and comprehensive skin assessment as part of the overall assessment
within six hours of admission and following any transfer of care i.e. ward to
ward, theatre to ward.
5.1.2. The risk assessment and the findings from the assessment of the patient’s
skin using the EPUAP tool must be recorded in the nursing admission
notes/record.
5.1.3. A clear plan of care and any interventions must be documented and should
take into account the care guidance available on the risk assessment form as
well as all elements of the SKIN bundle. (HIA, 2009) If indicated intentional
care rounding and appropriate documentation should be commenced
5.1.4. The site, extent and category of any skin damage should be documented
and if wound dressings are required a wound assessment/treatment chart must
be used.
5.1.5. All Patients admitted with skin damage must have a clinical incident (Datix)
form completed within 24 hours.
5.1.6. Consideration needs to be given to patients with skin damage and whether a
safeguarding concern should be raised with the local authority.
5.1.7. All pressure ulcers classified as category 2,3,4, unstageable or a DTI should
have a digital image taken, using either the SNAP technology or by requesting
through medical photography, which is then kept in the patient’s clinical record
5.2. Prevention
5.2.1. All unit/ward nurses will develop a plan of care for all patients considered at
risk of pressure damage. This plan will include the use of self-care strategies,
pressure relieving equipment, positioning schedules, skin care requirements
(including continence management), moving and handling needs and
nutritional requirements. (See NICE clinical guideline CG179 for further advice)
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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.Consideration needs to be given to all aspects of the SSKIN bundle and where
necessary ongoing use of intentional rounding.
5.2.2. The plan of care will take into consideration the findings of the risk
assessment, patient comfort and acceptability, critical care needs, patient
weight (BMI) and MUST assessment, general health, skin assessment,
continence issues and any safety issues.
5.2.3. If equipment required is not in place within 6 hours a clear plan of care must
be documented which includes actions taken to minimise the risk of damage
(eg. increased frequency of repositioning) and the plan for obtaining
equipment. All patients who are deemed at risk should as a
minimum preventative measure be placed upon a high specification foam mattress.
5.2.4. Staff will seek specialist advice as appropriate, e.g., manual handling,
dietician, tissue viability team. All Staff will document when they have referred
the patient in the nursing notes. When the specialist advice has been provided
with the nurse will ensure it is incorporated into the patient’s plan of care within
24 hours.
5.2.5. A Waterlow risk assessment and skin assessment will be documented daily
(and if the patient’s clinical condition changes significantly) and the care plan
updated to reflect any changes.
5.3. Treatment
5.3.1. All patients with pressure damage must have an incident form completed
within 24 hours. A referral to tissue viability using the internal referral form on
SALUS must be made for all patients with category 3, 4, or unstageable
pressure ulcers, or DTI and this should be accompanied by a digital image of
the wound.
5.3.2. Once pressure damage has been identified it must be reassessed on each
dressing change using the EPUAP grading tool, this should at the very least be
twice a week unless the patient is only having weekly dressing changes.
However, the patient’s overall skin condition should be examined each shift,
using the EPUAP tool as guidance. All findings must be recorded in the nursing
notes.
5.3.3. Wound documentation will include wound dimensions, using ruler
measurements. This can be supported by body mapping, medical photography
or SNAP photography images uploaded electronically at ward level. A wound
assessment chart must be completed.
5.3.4. The ward/unit nurse responsible for the patient must ensure a plan of care is
provided, detailing measures to prevent further damage and assist with the
treatment. This plan will include, for example, use of self-care strategies,
pressure relieving equipment, positioning schedules, skin care requirements,
moving and handling needs, nutritional and wound care requirements.
Specialist advice on treatments to be sought as required.
5.3.5. Ulcers on the feet that are a result of pressure must have a clinical incident
(Datix) form completed within 24 hours.
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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5.4 Patient and Carer participation
5.4.1 Staff will actively encourage patients/carers to participate in the prevention
and treatment of those at risk of pressure damage. This will encompass
strategies of repositioning, skin observation, safe use of the equipment and
passive exercises.
5.4.2 Staff will utilise a range of information resources to assist with this process,
for example, the tissue viability resource file or link nurses. All interventions
and education must be clearly documented in the nursing care record.
5.4.3 The carer’s policy should be referred to in all instances when pressure ulcer
prevention or treatment is delegated to a carer. That care remains the
responsibility of the registered practitioner, as does the communication and
support of that carer in their caring role on the ward. All agreed on care to be
delivered by the carer must be documented and evaluated in the patient’s
care plan.
5.5 Non Concordance
5.5.1 Each time a patient declines to be repositioned it must be clearly documented
in the nursing notes. Patients must continue to be offered to reposition in
accordance with their risk assessment.
5.5.2 A patient who declines to reposition more than 2 times in succession should
be reviewed by the ward manager or their delegated deputy.
5.5.3 Reasons for non-concordance must be addressed and dealt with if possible
i.e. pain when moving - patients may need analgesia to facilitate regular
repositioning.
5.5.4 The plan of care should also be discussed with the patient their family and or
carers, including an explanation of the risk and potential outcomes, with clear
documentation in the patient’s clinical record that this has been done and
that the patient, their family and carers where applicable understand those
risks and potential outcomes.
5.5.5 A referral to tissue viability should be made at an early stage for any patient
who is non-concordant with their repositioning care plan.
5.6 End of life care
5.6.1 For patients in the Last Days of Life, every effort should be made to continue
to undertake regular total skin assessment and full implementation of the
SSKIN bundle as part of an individualised care plan and taking into account
the wishes of the patient, their family and carers as applicable.
5.7 Education
5.7.1 Staff involved in caring for patients at risk of developing, or who have
developed a pressure ulcer have a professional responsibility to ensure that
they attend training in pressure ulcer prevention and treatment.
5.7.2 The Tissue Viability team offer update sessions in pressure ulcer
assessment and treatment on a regular basis which staff can book on to.
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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5.7.3 A designated registered nurse and unregistered nurse will act as ward link
nurses and attend the nurse link meetings.
5.8 Safeguarding
5.8.1 The guidance issued by the Department of Health and Social Care in
(January 2018) in the document Safeguarding Adults Protocol: Pressure
Ulcers and the interface with a safeguarding enquiry should be followed. The
adult safeguarding support tool within this document should be used to aid
any decision about whether to raise a safeguarding adults concern with the
local authority.
5.9 Discharging patients with pressure ulcers or other skin damage
5.9.1 A patient who is deemed ‘at risk’ of developing a pressure ulcer or other skin
damage should have a total skin assessment on the day of discharge.
5.9.2 A patient with a pressure ulcer or other skin damage should be discharged
with a documented wound care assessment and plan and this will be
recorded in the patient’s notes. An image should be taken of the wound,
either using SNAP or medical photography on the day of discharge.
5.9.3 A patient discharged with category 3, 4 or an unstageable pressure ulcer or a
deep tissue injury should be referred for further assessment by the
community team. This referral should be documented in the patient’s notes.
6
Overall Responsibility for the Document
6.1. The Matron for Harm Free Care has overall responsibility for developing this policy
in consultation with other relevant clinical staff.
6.2. Responsibility for implementation of this policy lies with clinical teams within Care
Groups.
6.3. This policy will be reviewed in line with Trust Policy of five years and earlier if any
significant changes are indicated.
7
Consultation and Ratification
7.1. The design and process of review and revision of this policy will comply with The
Development and Management of Trust Wide Documents.
7.2. The review period for this document is set as a default of five years from the date it
was last ratified, or earlier if developments within or external to the Trust indicate
the need for a significant revision to the procedures described.
7.3. This document will be approved by the Nursing and Midwifery Operational
Committee and ratified by the Chief Nurse.
7.4. Non-significant amendments to this document may be made, under delegated
authority from the Chief Nurse, by the nominated author. These must be ratified by
the Chief Nurse and should be reported, retrospectively, to the approving board.
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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7.5. Significant reviews and revisions to this document will include a consultation with
named groups or s across the Trust. For non-significant amendments, informal
consultation will be restricted to named groups, or categories that are directly
affected by the proposed changes.
8
Dissemination and Implementation
8.1. Following approval and ratification, this policy will be published in the Trust’s formal
documents library and all staff will be notified through the Trust’s normal notification
process, currently the ‘Vital Signs’ electronic newsletter.
8.2. Document control arrangements will be in accordance with The Development and
Management of Trust Wide Documents.
8.3. The document author(s) will be responsible for agreeing on the training
requirements associated with the newly ratified document with the Chief Nurse
and
for working with the Trust’s training function, if required, to arrange for the required
training to be delivered.
9
Monitoring Compliance and Effectiveness
9.1. Incident Reporting of New Pressure Ulcers (Hospital Acquired) category 2-4. This
information is available for Ward Managers / Matrons to review and trends will be
reported back to Ward areas and Harm Free Care Group on a monthly basis by the
Tissue Viability team.
9.2. Hospital Acquired Pressure Ulcers : All category 3 and 4 new hospital-acquired
pressure ulcers are subject to consideration as Serious Incidents Requiring
Investigation (SIRI), and following the Trust policy for investigation and reporting
will require and either a concise or full RCA determined by the level of harm to the
patient including the impact on their quality of life. As part of this process, an
interim review meeting will be undertaken with the Chief Nurse (or nominated
Deputy), Harm Free Care Matron and the Matron and Ward manager for the area
involved. The root cause analysis and learning points will be reviewed at the Harm
Free Care Group and disseminated across the trust.
9.3. Process monitoring will be undertaken by Ward Managers/Matrons as part of the
regular audits using Meridian. Ward managers/Matrons will be responsible for
implementing any remedial actions required, with support from the tissue viability
team as needed.
9.4. The Trust will meet any statutory requirements for data collection/audit to meet
external requirements (e.g. Patient Safety Thermometer) and action plans agreed
at ward level dependent on results.
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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10
References and Associated Documentation
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel
(2014)
Pressure Ulcer Guidelines. Washington DC: National Pressure Ulcer Advisory
Panel
DoH, Department of Health, (2010) Essence of Care; Benchmarks for Prevention &
Management of Pressure ulcers. The Stationary Office, London.
Plymouth Diabetes Health Community web site
: www.plymouthdiabetes.org.uk
National Institute of Clinical Excellence, NICE (cg119) March 2011 Diabetic Foot
problems Inpatient management
Pressure ulcers: prevention and management
(NICE) Clinical guideline [CG179]
Published April 2014
https://www.nice.org.uk/guidance/cg179/resources/pressure-
ulcers-prevention-and-management-pdf-35109760631749 (accessed 26/06/19)
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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Dissemination Plan and Review Checklist
Appendix 1
Dissemination Plan
Document Title
Prevention and Management of Pressure Ulcers
Date Finalised
July 2019
Previous Documents
Action to retrieve old copies
Dissemination Plan
Recipient(s)
When
How
Responsibility
All Trust staff
July 2019
Vital Signs
Information Governance Team
Tissue Viability Link Nurses
July 2019
Email & hard copy
Lead Nurse for Tissue Viability
for
Ward/Department
resource file
Matrons/Ward Managers
July 2019
Email
Lead Nurse for Tissue Viability
Review Checklist Title
Is the title clear and unambiguous?
Yes
Is it clear whether the document is a policy, procedure, protocol,
Yes
framework, APN or SOP?
Does the style & format comply?
Yes
Rationale
Are reasons for development of the document stated?
Yes
Development
Is the method described in brief?
Yes
Process
Are people involved in the development identified?
Yes
Has a reasonable attempt has been made to ensure relevant expertise
Yes
has been used?
Is there evidence of consultation with stakeholders and users?
Yes
Content
Is the objective of the document clear?
Yes
Is the target population clear and unambiguous?
Yes
Are the intended outcomes described?
Yes
Are the statements clear and unambiguous?
Yes
Evidence Base
Is the type of evidence to support the document identified explicitly?
Yes
Are key references cited and in full?
Yes
Are supporting documents referenced?
Yes
Approval
Does the document identify which committee/group will review it?
Yes
If appropriate have the joint Human Resources/staff side committee (or
Yes
equivalent) approved the document?
Does the document identify which Executive Director will ratify it?
Yes
Dissemination &
Is there an outline/plan to identify how this will be done?
Yes
Implementation
Does the plan include the necessary training/support to ensure
Yes
compliance?
Document Control Does the document identify where it will be held?
Yes
Have archiving arrangements for superseded documents been
Yes
addressed?
Monitoring
Are there measurable standards or KPIs to support the monitoring of
Yes
Compliance &
compliance with and effectiveness of the document?
Effectiveness
Is there a plan to review or audit compliance with the document?
Yes
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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Review Date
Is the review date identified?
Yes
Is the frequency of review identified? If so is it acceptable?
Yes
Overall
Is it clear who will be responsible for co-ordinating the dissemination,
Yes
Responsibility
implementation and review of the document?
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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Equalities and Human Rights Impact Assessment
Appendix 2
Core Information
Date
July 2019
Title
Prevention and Management of Pressure Ulcers Policy
What are the
To ensure compliance with the external guidance and recommendations for
aims, objectives prevention and management of pressure ulcers. Implementation will reduce co-
& projected
morbidity, enable patients to return their normal activity and home or place of care,
outcomes?
reduce inpatient time and health care costs. The application will improve
communication and ensure consistency of care across healthcare providers
Scope of the assessment
Pressure ulcer prevention forms a key part of clinical care for patients in all areas of the
Trust and all clinical staff are expected to take responsibility for ensuring all appropriate
measures are taken to minimise risk.
Collecting data
Race
There is no evidence to suggest that there is an impact on race regarding
this policy.
However, data collected from Datix incident reporting and complaints will
ensure this is monitored.
Consideration will be made if the information provided is required in a
different language.
Religion
There is no evidence to suggest that there is an impact on religion or
belief and non-belief regarding this policy.
However, data collected from Datix incident reporting and complaints will
ensure this is monitored.
The plan of care for patients includes nutritional requirements which may
relate to specific religious beliefs.
Disability
There is no evidence to suggest that there is an impact on disability
regarding this policy.
However, data collected from Datix incident reporting and complaints will
ensure this is monitored.
The document considers issues that may be identified in the plan of care
for patients and recommendations will be made as required
Consideration will be made if the information is required in different
formats or the translation services are required.
Consideration has been made for vulnerable adults and mental health and
learning disability issues will be highlighted within the care plan as
appropriate.
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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Sex
There is no evidence to suggest that there is an impact on sex regarding
this policy.
However, data collected from Datix incident reporting and complaints will
ensure this is monitored.
Gender Identity
There is no evidence to suggest that there is an impact on gender identity
regarding this policy.
However, data collected from Datix incident reporting and
complaints will ensure this is monitored.
Sexual Orientation
There is no evidence to suggest that there is an impact on sexual
orientation regarding this policy.
However, data collected from Datix incident reporting and complaints will
ensure this is monitored.
Age
There is no evidence to suggest that there is an impact on age regarding
this policy.
However, data collected from Datix incident reporting and complaints will
ensure this is monitored.
Socio-Economic
There is no evidence to suggest that there is an impact on socio-economic
regarding this policy.
However, data collected from Datix incident reporting and complaints will
ensure this is monitored.
Human Rights
The document has considered safeguarding issues which will be
addressed following the Trust safeguarding processes.
Informal carers will be encouraged to participate in the prevention and
treatment as required.
Data collected from Datix incident reporting and complaints will ensure this
is monitored.
What are the overall
No comparative data have been used to date which means that no trends
trends/patterns in the or patterns have been identified
above data?
Specific issues and
data gaps that may
No gaps have been identified at this stage but this will be monitored via
need to be addressed data collected from datix incident reporting and complaints.
through consultation
or further research
TRW.CLI.POL.457.3 Prevention and Management of Pressure Ulcers Policy
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Involving and consulting stakeholders
Internal involvement
Matrons
and consultation
Ward Managers
Specialist Staff – vascular, diabetes, plastic surgery
Tissue viability & link nurses
Chief Nurse
Equality & Diversity Lead
External involvement
and consultation
Impact Assessment
Overall assessment
Consideration will be made if the information provided is required in a
and analysis of the
different language.
evidence
The plan of care for patients includes nutritional requirements which may
relate to specific religious beliefs.
The document considers issues that may be identified in the plan of care
for patients and recommendations will be made as required
Consideration will be made if the information is required in different
formats or the translation services are required.
Consideration has been made for vulnerable adults and mental health and
learning disability issues will be highlighted within the care plan as
appropriate.
The document has considered safeguarding issues which will be
addressed following the Trust safeguarding processes.
Informal carers will be encouraged to participate in the prevention and
treatment as required.
Action Plan
Action
Owner
Risks
Completion Date
Progress update
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