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aSSKINg
FRAMEWORK
ABDUL MANAN BIN OTHMAN
Supervisor Assistant Medical Officer
Primary Medical Care Sector
Family Health Development Division
Ministry of Health Malaysia
Tel: 03-8883 2248
H/P: 013-2634113
abdmanan@moh.gov.my
Prevention Strategies for Pressure Injuries
in Healthcare Setting.
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY
• A pressure injury is defined as localized damage to
the skin and / or underlying tissue, as a result of
pressure or pressure in combination with shear.
• Pressure injury usually occur over a bony
prominence but may also be related to a medical
devices or other object (EPUAP/NPIAP/PPPIA,2019)
• Why the word injury? :
o Stage 1 and Deep Tissue Injury were never
ulcers.
o An ulcer cannot be present without an injury, but
an injury can be present without an ulcer.
RISKFACTOR
STAGE 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 color may differ from the
surrounding area.
Further description:
The area may be painful, firm, soft, warmer or cooler as
compared to adjacent tissue. Stage I may be difficult to detect
in individuals with dark skin tones. May indicate "at risk"
persons (a heralding sign of risk).
STAGE 2
Partial thickness skin loss
Partial thickness loss of dermis presenting as a
shallow open ulcer with a red pink wound bed, without
slough. May also present as a serum-filled intact or
open/ruptured blister.
Further description:
Presents as a shiny or dry shallow ulcer without slough
or bruising.
*This stage should not be used to describe skin tears,
tape burns, perineal dermatitis, maceration or
excoriation.
*Bruising indicates suspected deep tissue injury
STAGE 3
Full thickness skin loss
Subcutaneous fat may be visible but bone, tendon or muscle
are not exposed. Slough may be present but does not
obscure the depth of tissue loss. May include undermining
and tunneling.
Further description:
The depth of a stage III pressure ulcer varies by anatomical
location. The bridge of the nose, ear, occiput and malleolus
do not have subcutaneous tissue and stage III ulcers can be
shallow. In contrast, areas of significant adiposity can develop
extremely deep stage III pressure ulcers. Bone/tendon is not
visible or directly palpable.
STAGE 4
Full thickness skin loss
Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar may be present on some parts of the wound
bed. Often include undermining and tunneling.
Further description:
The depth of a stage IV pressure ulcer varies by anatomical
location. The bridge of the nose, ear, occiput and malleolus do
not have subcutaneous tissue and these ulcers can be shallow.
Stage IV ulcers can extend into muscle and/or supporting
structures (e.g., fascia, tendon or joint capsule) making
osteomyelitis possible. Exposed bone/tendon is visible or
directly palpable
UNSTAGEABLE
Depth unknown, full thickness tissue loss in which the base of
the ulcer is covered by slough (yellow, tan, gray, green or
brown) and/or eschar (tan, brown or black) in the wound bed.
Further description:
Until enough slough and/or eschar is removed to expose the
base of the wound, the true depth, and therefore Category,
cannot be determined. Stable (dry, adherent, intact without
erythema or fluctuance) eschar on the heels serves as "the
body's natural (biological
DEEP TISSUE PRESSURE INJURY
Depth unknown, purple or maroon localized area of discolored
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.
MEDICAL DEVICE- RELATED
PRESSURE INJURY
Pressure injuries that result from the use of devices designed and
applied for diagnostic or therapeutic purposes. The resultant pressure
injury generally conforms to the pattern or shape of the device.
The injury should be categorized using the classification system.
MUCOSAL MEMBRANE PRESSURE
ULCERS
Pressure ulcers found on mucous membranes with a history of a
medical device in use at the location of the injuries.
Pressure ulcers on mucosal surfaces should be labeled as ‘Mucosal
pressure ulcers’ with no category identified.
MUCOSAL MEMBRANE PRESSURE
ULCERS
INTRODUCTION
The original five-step SSKIN care bundle approach to
preventing and managing pressure injury has been
established for many years and is widely used in
clinical practice with evidence showing it can help
improve clinical care
The original SSKIN care bundle focused on: Surface;
Skin Inspection; Keep your patients moving;
Incontinence/increased moisture; Nutrition/hydration
In 2018, the Improvement Pressure Injury Core
Curriculum document introduced two
important additional elements for preventing
pressure ulcers. These added to the existing 5-
step SSKIN care bundle with the letters: ‘
‘a’ for assess risk and ‘g’ for giving information
While the core SSKIN acronym remains unchanged
and represents the fundamental elements of care
delivery for the prevention and, when necessary,
management of pressure ulcers, the two new
additional elements of ‘assessing risk’ and ‘giving
information’ underpin and support the successful
implementation of care
Since its release in June 2018, there has been a
dedicated educational drive to raise awareness and
implementation of the aSSKINg framework, which is
now being adopted across a range of care settings
where it forms an essential part of patient care plans.
The aSSKINg care bundle is a tool which guides and
documents pressure injury prevention and many
associated interventions aimed at reducing the risk of
this often preventable patient harm
ASSESS RISK
Assess pressure injury risk using a validated tool
to support clinical judgment
Risk assessment identifies the patient’s
individual risk of pressure injuries
Appropriate care and interventions can be implemented
ensuring resources are used appropriately
Braden Scale
Braden Scale
Braden Scale
⮚ When Braden scale score is 16 or less,
implement pressure injury prevention
measures.
Why Braden Scale?
• As a wound care professionals, Braden Scale Risk Assessment Tools near and
dear to our hearts
• evidence-based tool
• the frequency of Braden Scale use may contribute to a multitude of different
scores
• a less frequent Braden Scale assessment yields more accurate results
• However, we should still complete a Braden Scale on admission, during transfer,
when receiving, and most importantly, with any change in condition.
• Wound Source International,2021
SKIN ASSESSMENT AND SKIN CARE
Early inspection means early detection
Perform regular skin inspections
Show patients and care takers what to look for
What is Skin Assessment
• Process of examining entire
skin for abnormalities
Requires looking at and
touching skin from head
to toe
Goals
Identify any pressure injuries
Find out if there are other lesions or skin related factors that predispose
the patient to develop pressure injuries.
Eg: Factors include excessively dry skin and moisture associated skin
damage (MASD)/ Incontinence Associated Dermatitis (IAD)
Parameters
1. Temperature
2. Turgor (firmness)
3. Colour
4. Moisture level
5. Skin integrity
– Skin intact
– Open areas, rashes, etc.
Bariatric patients/Obese
Inner aspect of thighs and skin folds
• Rash
• Maceration
• Infection (bacteria or candidiasis)
• Breakdown
Integrating skin assessment into
normal workflow
Each time you—
• Apply oxygen, check the patient’s ears for
pressure areas from tubing (prevent pressure injury cause
by medical devices)
• Check bowel sounds, look at skin folds
• Reposition the patient in bed, check the back
of the patient’s head
Integrating skin assessment into
normal workflow
Each time you—
• Auscultate lung sounds or turn the patient,
check the patient’s shoulders, back, and
sacral/coccyx region
• Check a male patient’s catheter, check his
penis
• Position pillows under the patient’s calves,
check the heels and feet
– Use a hand-held mirror to adequately visualize
the area.
Integrating skin assessment into
normal workflow
Each time you—
• Check IV sites, look at the patient’s
arms and elbows
• Lift the patient or provide care,
check exposed skin, especially on
bony prominences
• Remove equipment, check
adjacent skin
– This includes TENS units, restraints,
splints, oxygen tubing, and
endotracheal tubes.
Skin Care
•Keep the skin clean and dry
•Investigate and manage incontinence (Consider alternatives if
incontinence is excessive for age)
•Do not vigorously rub or massage the patients’ skin
•Use a pH appropriate skin cleanser and dry thoroughly to protect the
skin from excess moisture
Skin Care
•Use water based skin emollients to maintain skin hydration where possible
•Sudocream for healthy skin/nappy rash
•Calmoseptine Ointment for broken down skin in nappy region
•Orabase Protective Paste for broken down skin in nappy region
•Use chlorhexidine wipes daily only around tubing sites and open
wounds/open sternotomie
SURFACE SELECTION AND USE
Ensure the provision of appropriate pressure-
reducing or pressure-relieving devices
Ensure the patient is repositioned at regular
intervals to meet their individual healthcare
needs
Consider 30º tilt to position the patient
• Prevention strategies should involve the use of pressure relieving devices
appropriately chosen for the patient, regular skin inspection and
frequently redistributing the pressure by repositioning the patients
frequently and safely.
This non-powered pressure redistributing
mattress overlay, which comes with your choice of
a one-piece or two-piece cover, is made with 720
air cells divided into 4 independently adjustable
sections and includes drainage holes on the base
that draw moisture away from incontinent
patients
ROHO DRY FLOTATION
MATTRESS
This action relieves pressure under the body - particularly
in parts with less padding, like hips, shoulders, elbows, and
heels - and helps ensure proper air circulation, helping to
prevent, manage, and treat the occurrence of pressure
wounds
These bed mattress helps to prevent pressure injury. To
avoid skin breakdown in the patients due to low blood flow,
medical air mattress uses alternating pressure and low air
loss therapy to stimulate the circulation in the patient's body
AIR FILLED MATTRESS
This action relieves pressure under the body - particularly
in parts with less padding, like hips, shoulders, elbows, and
heels - and helps ensure proper air circulation, helping to
prevent, manage, and treat the occurrence of pressure
wounds
These bed mattress helps to prevent pressure injury. To
avoid skin breakdown in the patients due to low blood flow,
medical air mattress uses alternating pressure and low air
loss therapy to stimulate the circulation in the patient's body
AIR FILLED MATTRESS
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
KEEP PATIENTS MOVING
Encourage mobility and regular movement to
relieve pressure over bony prominences
Assist patients who are unable to move independently
Patients at risk of pressure injury should be suitably positioned to
redistribute pressure, repositioned regularly by minimising shear and
friction forces on the skin.
•For the patient to do so independently if able
•Equipment can be used to promote independent mobility. E.g.
overhead bed pole, side rails, walking frame.
•Patient and/or carers may need reminders to reposition
•For patients who are unable to assist moving themselves, it is
recommended that they be repositioned every two hours
Reposition tubes and face masks every two hours for pressure area care. Use barrier
dressings such as:
Hydrocolloid for nasogastric tubes. (DO NOT remove hydrocolloid that is placed within
twenty-four hours as it will cause shear of the skin).
Foams for BIPAP and CPAP masks, elbows and wound drain sites.
Barrier Wipes underneath tubing/masks, particularly on the face, to reduce the risk of a
pressure injury developing.
For high risk patients, limit time spent sitting in bed with
head elevated > thirty degrees to no more than two hours
due to the increased pressure on the sacrum.
Positions may include: prone, seated in bed, seated in
chair, left side lying, right side lying and supine.
Consider Physiotherapy consultation for assistance/advice
on transferring patients and repositioning.
INCONTINENCE ASSESSMENT
Keep skin clean and dry
This may include the use of barrier creams
incontinence products and/or emollients.
Moisture-associated skin damage (MASD) is not a direct cause of pressure injuries, but its
presence contributes to weakening of the skin and increases local friction (objects rubbing
together) and shear (forces moving in different directions).
As such, it is recognized that moisture on the skin greatly increases the risk of pressure injury ,
and MASD is now reported alongside them (NHS Improvement, 2018).
For these reasons, identifying through assessment and managing MASD is an integral part of
aSSKINg, the new educational framework for pressure injury prevention and management.
(Fletcher, 2019).
There are four main types of MASD:
• Incontinence-associated dermatitis (IAD);
• Intertriginous dermatitis (ITD), involving inflammation of
the skin folds relating to perspiration
• Periwound MASD due to wound exudate
• Peristomal MASD caused by leakage from stoma edges.
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
• Just as important is treating the cause of the excessive moisture – for example, identifying why a patient
is incontinent or why a wound is producing excessive exudate.
• A simple skin cleanser (with a neutral pH) should be used; soaps with perfumes or additives should be
avoided as they can strip the skin’s natural oils and alter the local pH balance.
• For patients with occasional incontinence, simple moisturisers (again, unperfumed and without
additives) may be sufficient to protect the skin but, in most cases, a skin barrier is also required, be it a
cream or film product.
• These should be applied according to the manufacturer’s instructions, allowing plenty of time for the
product to dry before replacing clothing or repositioning the patient on the affected area.
• If a fungal infection is suspected (characterised by a dry, pale-pink or white area that is frequently itchy)
a topical antifungal should be used. Moisturiser should be applied if the skin is dry.
Goals
Understanding the cause of MASD is important to instigate the appropriate treatment plan but,
whatever the cause, the following actions are crucial:
 Identify patients at risk from MASD;
 Relieve or reduce the source of moisture;
 Clean and dry the skin;
 Protect the skin.
Key points
Excessive moisture on the skin can cause damage, increasing the risk of pressure injury
The most common cause of moisture-associated skin damage is incontinence-associated
dermatitis
Pressure injury and incontinence-associated dermatitis are often confused with each
other but differ in location and shape
Identifying patients at risk from excessive moisture and instigating early skin protection
is key to preventing skin damage
Effective treatment also relies on identifying the underlying cause of the excessive
moisture
NUTRITION AND HYDRATION
ASSESSMENT/SUPPORT
Assess nutritional status.
Keep patients well hydrated
Implement prescribed diet/nutritional supplements
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
Role of nutrition in wound healing
•Pressure injuries
Wound
prevention
•Pre-surgical assessment
Wound
preparation
•Management of acute wounds
•Healing of chronic wounds
Treatment
of wound
•Adequate hydration is important in wound
healing as dehydrated skin is less elastic, more
fragile and more susceptible to breakdown.
•Dehydration will also reduce efficiency of blood
circulation, which will impair the supply of
oxygen and nutrients to the wound.
Fluid/ Water Intake
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
Diabetic plate
•Our diabetic plate is also a healthy
eating plate.
•It contains all the necessary
nutrients that we need.
•Extra calorie and protein could be
planned into diabetic diet plan.
•Cautions: when there is renal
insufficiency as the protein and
some minerals need to be
planned accordingly.
GIVING INFORMATION
Communicate effectively and provide information to
patients carers and the multidisciplinary team
regarding pressure injury prevention (e.g:
repositioning equipment nutrition/hydration)
Giving Information
01
Strategy
03
Evaluation
02
Objectives
04
Performance
Multidisciplinary Approach
Care takers
Patients
Colleagues
.
Tackle the issues
Aim
Empower the team
Education tools
Reading materials
Video
Soc-Med
Good Discussion
Be Clear
Focus on the key messages
Meet Your Wound Care Team
“Communication issues are one of the most
common areas identified in root cause analysis of
pressure injury incidents and patient complaints
about care”
Pressure Injury Tools Kit
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
WHY NPIAP
GUIDELINES2019
ISSO SPECIAL?
NPIAP
GUIDELINES
Evidence based guideline
International Experts
Information
• The evidence-based guideline was developed
under the leadership of the NPUAP, EPUAP
and PPPIA
• Continuous support from 14 international
wound care organizations, 250
international experts working in small working
groups and over 1000
international stakeholders.
• Information regarding needs,
concerns and goals for pressure
injury
prevention and management.
KeyRecommendation
General Skin Care (Berlowitz, 2020c; NPIAP, 2016b; EPUAP/NPIAP/PPPIA,
2019)
• •Obtain patient history: assess for connective tissue disorders and other
chronic diseases, previous surgeries, and factors limiting mobility; current
medications, allergies, past therapies (radiation or chemotherapy) and
tobacco and alcohol use.
• Perform physical examination: inspect all areas of the skin as soon as
possible upon admission for signs of pressure injury, especially non-
blanchable erythema. Examine entire skin surface for pressure ulcers,
epidermal excoriations, rashes, maceration, edema, and old scars.
• Assess skin temperature, color, turgor, moisture, and integrity. Record any
changes as soon as they are identified.
• In darkly pigmented skin, look for changes in skin tone, skin temperature
and tissue consistency compared to adjacent skin.
KeyRecommendation
• Assess pressure points, such as the sacrum, coccyx, buttocks,
heels, ischium, trochanters and elbows, and beneath medical
devices.
• Cleanse skin promptly after episodes of incontinence.
• Use skin cleansers that are pH balanced for the skin; avoid
hot water.
• Apply skin moisturizers daily on dry skin.
• Apply a barrier product to protect skin from moisture.
• Avoid vigorous massage over bony prominences.
• Avoid positioning the patient on an area of erythema or
pressure injury
KeyRecommendation
KeyRecommendation
Nutrition (Berlowitz, 2020a; NPIAP, 2016b; EPUAP/NPIAP/PPPIA, 2019)
• Hospitalized individuals are at risk for undernutrition.
• Use a valid tool to assess the patient’s risk for malnutrition.
• Assess oral, enteral and parenteral intake and refer at-risk patients to a
registered
dietitian/nutritionist; assessment includes protein and caloric intake,
hydration status, serum albumin and/or prealbumin, and total lymphocyte
count.
• Support patients with adequate fluid intake and a balanced diet and correct
any nutritional
deficiencies.
• Assess adequacy of oral, enteral, and parenteral intake. Target protein intake is
1.25 to 1.5 g/kg/day.
• Assess weight changes over time.
• Nutritional supplements are only recommended when deficiencies are
present, or if nutritional intake is not optimal.
KeyRecommendation
Repositioning and mobilization (Berlowitz, 2020a; NPIAP, 2016b;
EPUAP/NPIAP/PPPIA, 2019)
• Turn and reposition all at-risk patients, unless contraindicated; schedule
frequency based on the support surface in use, the tolerance of skin for
pressure and the patient’s preferences.
General recommendation is to reposition at least every two hours.
• Chair-bound patients who are weak or immobile should be repositioned
every hour.
• Lengthen the turning schedule at night to allow the patient to sleep.
• When turning, place the patient in a ≤ 30-degree side lying position, and
ensure the sacrum is off the bed.
• Assess the level of immobility, exposure to shear, skin moisture, perfusion,
body size and weight of
the patient when choosing a support surface.
KeyRecommendation
Repositioning and mobilization (Berlowitz, 2020a; NPIAP, 2016b;
EPUAP/NPIAP/PPPIA, 2019)
• Continue to reposition the patient when placed on any support surface.
• Use a breathable incontinence pad when using microclimate management surfaces.
• Use pressure redistributing cushions for patients sitting in chairs or wheelchairs.
• If the patient cannot be moved or is positioned with the head of the bed elevated
over 30
degrees, place a polyurethane foam dressing on the sacrum.
• Place pillows or foam wedges between the ankles and knees if patients have no
mobility in these areas.
• Elevate heels off bed or use polyurethane foam dressings on patients at high-risk for
heel ulcers.
• Place thin foam or breathable dressings under medical devices.
• Encourage mobility, provide physical therapy, and limit sedative medications, if
possible
2024???
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
PRESSURE INJURY CARE AND MANAGEMENT FOR HCW
1) National Pressure Injury Advisory Panel 2016
2) https://www.ncbi.nlm.nih.gov/books/NBK 333122/
3) MOH SINGAPORE-HEALTH PROMOTION BOARD
4) BergstormN,BradenBJ,LaguzzaA,HolmanV.The Braden Scale for predicting pressure sore risk. 1987;36(4):205-210
5) European Pressure Advisory Panel
6) Best Practice Information Sheets – Joanna Briggs Institute. (2008) Pressure ulcers – Prevention of Pressure related Damage.
12(2) 1-4.
7) Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury.
8) Prevention and treatment of pressure ulcers/ injuries: quick references guide 2019
9) Schindler, C.A., Mikhailov, T.A., Cashin, S.E., Malin, S., Christensen, M., & Winters, J.M. (2013). Under pressure: preventing
pressure ulcers in critically ill infants. Journal for specialists in Pediatric Nursing. 18, 329-34
References:
THANK YOU
FOR ATTENDING
SEKTOR PENJAGAAN PERUBATAN PRIMER
CAWANGAN KESIHATAN PRIMER
BAHAGIAN PEMBANGUNAN KESIHATAN
KELUARGA

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PRESSURE INJURY CARE AND MANAGEMENT FOR HCW

  • 1. aSSKINg FRAMEWORK ABDUL MANAN BIN OTHMAN Supervisor Assistant Medical Officer Primary Medical Care Sector Family Health Development Division Ministry of Health Malaysia Tel: 03-8883 2248 H/P: 013-2634113 abdmanan@moh.gov.my Prevention Strategies for Pressure Injuries in Healthcare Setting.
  • 5. PRESSURE INJURY • A pressure injury is defined as localized damage to the skin and / or underlying tissue, as a result of pressure or pressure in combination with shear. • Pressure injury usually occur over a bony prominence but may also be related to a medical devices or other object (EPUAP/NPIAP/PPPIA,2019) • Why the word injury? : o Stage 1 and Deep Tissue Injury were never ulcers. o An ulcer cannot be present without an injury, but an injury can be present without an ulcer.
  • 7. STAGE 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 color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk).
  • 8. STAGE 2 Partial thickness skin loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as a serum-filled intact or open/ruptured blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. *This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury
  • 9. STAGE 3 Full thickness skin loss Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
  • 10. STAGE 4 Full thickness skin loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable
  • 11. UNSTAGEABLE Depth unknown, full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological
  • 12. DEEP TISSUE PRESSURE INJURY Depth unknown, purple or maroon localized area of discolored 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.
  • 13. MEDICAL DEVICE- RELATED PRESSURE INJURY Pressure injuries that result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be categorized using the classification system.
  • 14. MUCOSAL MEMBRANE PRESSURE ULCERS Pressure ulcers found on mucous membranes with a history of a medical device in use at the location of the injuries. Pressure ulcers on mucosal surfaces should be labeled as ‘Mucosal pressure ulcers’ with no category identified.
  • 16. INTRODUCTION The original five-step SSKIN care bundle approach to preventing and managing pressure injury has been established for many years and is widely used in clinical practice with evidence showing it can help improve clinical care The original SSKIN care bundle focused on: Surface; Skin Inspection; Keep your patients moving; Incontinence/increased moisture; Nutrition/hydration
  • 17. In 2018, the Improvement Pressure Injury Core Curriculum document introduced two important additional elements for preventing pressure ulcers. These added to the existing 5- step SSKIN care bundle with the letters: ‘ ‘a’ for assess risk and ‘g’ for giving information While the core SSKIN acronym remains unchanged and represents the fundamental elements of care delivery for the prevention and, when necessary, management of pressure ulcers, the two new additional elements of ‘assessing risk’ and ‘giving information’ underpin and support the successful implementation of care
  • 18. Since its release in June 2018, there has been a dedicated educational drive to raise awareness and implementation of the aSSKINg framework, which is now being adopted across a range of care settings where it forms an essential part of patient care plans. The aSSKINg care bundle is a tool which guides and documents pressure injury prevention and many associated interventions aimed at reducing the risk of this often preventable patient harm
  • 19. ASSESS RISK Assess pressure injury risk using a validated tool to support clinical judgment Risk assessment identifies the patient’s individual risk of pressure injuries Appropriate care and interventions can be implemented ensuring resources are used appropriately
  • 22. Braden Scale ⮚ When Braden scale score is 16 or less, implement pressure injury prevention measures.
  • 23. Why Braden Scale? • As a wound care professionals, Braden Scale Risk Assessment Tools near and dear to our hearts • evidence-based tool • the frequency of Braden Scale use may contribute to a multitude of different scores • a less frequent Braden Scale assessment yields more accurate results • However, we should still complete a Braden Scale on admission, during transfer, when receiving, and most importantly, with any change in condition. • Wound Source International,2021
  • 24. SKIN ASSESSMENT AND SKIN CARE Early inspection means early detection Perform regular skin inspections Show patients and care takers what to look for
  • 25. What is Skin Assessment • Process of examining entire skin for abnormalities Requires looking at and touching skin from head to toe
  • 26. Goals Identify any pressure injuries Find out if there are other lesions or skin related factors that predispose the patient to develop pressure injuries. Eg: Factors include excessively dry skin and moisture associated skin damage (MASD)/ Incontinence Associated Dermatitis (IAD)
  • 27. Parameters 1. Temperature 2. Turgor (firmness) 3. Colour 4. Moisture level 5. Skin integrity – Skin intact – Open areas, rashes, etc.
  • 28. Bariatric patients/Obese Inner aspect of thighs and skin folds • Rash • Maceration • Infection (bacteria or candidiasis) • Breakdown
  • 29. Integrating skin assessment into normal workflow Each time you— • Apply oxygen, check the patient’s ears for pressure areas from tubing (prevent pressure injury cause by medical devices) • Check bowel sounds, look at skin folds • Reposition the patient in bed, check the back of the patient’s head
  • 30. Integrating skin assessment into normal workflow Each time you— • Auscultate lung sounds or turn the patient, check the patient’s shoulders, back, and sacral/coccyx region • Check a male patient’s catheter, check his penis • Position pillows under the patient’s calves, check the heels and feet – Use a hand-held mirror to adequately visualize the area.
  • 31. Integrating skin assessment into normal workflow Each time you— • Check IV sites, look at the patient’s arms and elbows • Lift the patient or provide care, check exposed skin, especially on bony prominences • Remove equipment, check adjacent skin – This includes TENS units, restraints, splints, oxygen tubing, and endotracheal tubes.
  • 32. Skin Care •Keep the skin clean and dry •Investigate and manage incontinence (Consider alternatives if incontinence is excessive for age) •Do not vigorously rub or massage the patients’ skin •Use a pH appropriate skin cleanser and dry thoroughly to protect the skin from excess moisture
  • 33. Skin Care •Use water based skin emollients to maintain skin hydration where possible •Sudocream for healthy skin/nappy rash •Calmoseptine Ointment for broken down skin in nappy region •Orabase Protective Paste for broken down skin in nappy region •Use chlorhexidine wipes daily only around tubing sites and open wounds/open sternotomie
  • 34. SURFACE SELECTION AND USE Ensure the provision of appropriate pressure- reducing or pressure-relieving devices Ensure the patient is repositioned at regular intervals to meet their individual healthcare needs Consider 30º tilt to position the patient
  • 35. • Prevention strategies should involve the use of pressure relieving devices appropriately chosen for the patient, regular skin inspection and frequently redistributing the pressure by repositioning the patients frequently and safely.
  • 36. This non-powered pressure redistributing mattress overlay, which comes with your choice of a one-piece or two-piece cover, is made with 720 air cells divided into 4 independently adjustable sections and includes drainage holes on the base that draw moisture away from incontinent patients ROHO DRY FLOTATION MATTRESS
  • 37. This action relieves pressure under the body - particularly in parts with less padding, like hips, shoulders, elbows, and heels - and helps ensure proper air circulation, helping to prevent, manage, and treat the occurrence of pressure wounds These bed mattress helps to prevent pressure injury. To avoid skin breakdown in the patients due to low blood flow, medical air mattress uses alternating pressure and low air loss therapy to stimulate the circulation in the patient's body AIR FILLED MATTRESS
  • 38. This action relieves pressure under the body - particularly in parts with less padding, like hips, shoulders, elbows, and heels - and helps ensure proper air circulation, helping to prevent, manage, and treat the occurrence of pressure wounds These bed mattress helps to prevent pressure injury. To avoid skin breakdown in the patients due to low blood flow, medical air mattress uses alternating pressure and low air loss therapy to stimulate the circulation in the patient's body AIR FILLED MATTRESS
  • 44. KEEP PATIENTS MOVING Encourage mobility and regular movement to relieve pressure over bony prominences Assist patients who are unable to move independently
  • 45. Patients at risk of pressure injury should be suitably positioned to redistribute pressure, repositioned regularly by minimising shear and friction forces on the skin. •For the patient to do so independently if able •Equipment can be used to promote independent mobility. E.g. overhead bed pole, side rails, walking frame. •Patient and/or carers may need reminders to reposition •For patients who are unable to assist moving themselves, it is recommended that they be repositioned every two hours
  • 46. Reposition tubes and face masks every two hours for pressure area care. Use barrier dressings such as: Hydrocolloid for nasogastric tubes. (DO NOT remove hydrocolloid that is placed within twenty-four hours as it will cause shear of the skin). Foams for BIPAP and CPAP masks, elbows and wound drain sites. Barrier Wipes underneath tubing/masks, particularly on the face, to reduce the risk of a pressure injury developing. For high risk patients, limit time spent sitting in bed with head elevated > thirty degrees to no more than two hours due to the increased pressure on the sacrum. Positions may include: prone, seated in bed, seated in chair, left side lying, right side lying and supine. Consider Physiotherapy consultation for assistance/advice on transferring patients and repositioning.
  • 47. INCONTINENCE ASSESSMENT Keep skin clean and dry This may include the use of barrier creams incontinence products and/or emollients.
  • 48. Moisture-associated skin damage (MASD) is not a direct cause of pressure injuries, but its presence contributes to weakening of the skin and increases local friction (objects rubbing together) and shear (forces moving in different directions). As such, it is recognized that moisture on the skin greatly increases the risk of pressure injury , and MASD is now reported alongside them (NHS Improvement, 2018). For these reasons, identifying through assessment and managing MASD is an integral part of aSSKINg, the new educational framework for pressure injury prevention and management. (Fletcher, 2019). There are four main types of MASD: • Incontinence-associated dermatitis (IAD); • Intertriginous dermatitis (ITD), involving inflammation of the skin folds relating to perspiration • Periwound MASD due to wound exudate • Peristomal MASD caused by leakage from stoma edges.
  • 52. • Just as important is treating the cause of the excessive moisture – for example, identifying why a patient is incontinent or why a wound is producing excessive exudate. • A simple skin cleanser (with a neutral pH) should be used; soaps with perfumes or additives should be avoided as they can strip the skin’s natural oils and alter the local pH balance. • For patients with occasional incontinence, simple moisturisers (again, unperfumed and without additives) may be sufficient to protect the skin but, in most cases, a skin barrier is also required, be it a cream or film product. • These should be applied according to the manufacturer’s instructions, allowing plenty of time for the product to dry before replacing clothing or repositioning the patient on the affected area. • If a fungal infection is suspected (characterised by a dry, pale-pink or white area that is frequently itchy) a topical antifungal should be used. Moisturiser should be applied if the skin is dry. Goals
  • 53. Understanding the cause of MASD is important to instigate the appropriate treatment plan but, whatever the cause, the following actions are crucial:  Identify patients at risk from MASD;  Relieve or reduce the source of moisture;  Clean and dry the skin;  Protect the skin.
  • 54. Key points Excessive moisture on the skin can cause damage, increasing the risk of pressure injury The most common cause of moisture-associated skin damage is incontinence-associated dermatitis Pressure injury and incontinence-associated dermatitis are often confused with each other but differ in location and shape Identifying patients at risk from excessive moisture and instigating early skin protection is key to preventing skin damage Effective treatment also relies on identifying the underlying cause of the excessive moisture
  • 55. NUTRITION AND HYDRATION ASSESSMENT/SUPPORT Assess nutritional status. Keep patients well hydrated Implement prescribed diet/nutritional supplements
  • 57. Role of nutrition in wound healing •Pressure injuries Wound prevention •Pre-surgical assessment Wound preparation •Management of acute wounds •Healing of chronic wounds Treatment of wound
  • 58. •Adequate hydration is important in wound healing as dehydrated skin is less elastic, more fragile and more susceptible to breakdown. •Dehydration will also reduce efficiency of blood circulation, which will impair the supply of oxygen and nutrients to the wound. Fluid/ Water Intake
  • 60. Diabetic plate •Our diabetic plate is also a healthy eating plate. •It contains all the necessary nutrients that we need. •Extra calorie and protein could be planned into diabetic diet plan. •Cautions: when there is renal insufficiency as the protein and some minerals need to be planned accordingly.
  • 61. GIVING INFORMATION Communicate effectively and provide information to patients carers and the multidisciplinary team regarding pressure injury prevention (e.g: repositioning equipment nutrition/hydration)
  • 62. Giving Information 01 Strategy 03 Evaluation 02 Objectives 04 Performance Multidisciplinary Approach Care takers Patients Colleagues . Tackle the issues Aim Empower the team Education tools Reading materials Video Soc-Med Good Discussion Be Clear Focus on the key messages
  • 63. Meet Your Wound Care Team “Communication issues are one of the most common areas identified in root cause analysis of pressure injury incidents and patient complaints about care”
  • 69. NPIAP GUIDELINES Evidence based guideline International Experts Information • The evidence-based guideline was developed under the leadership of the NPUAP, EPUAP and PPPIA • Continuous support from 14 international wound care organizations, 250 international experts working in small working groups and over 1000 international stakeholders. • Information regarding needs, concerns and goals for pressure injury prevention and management.
  • 70. KeyRecommendation General Skin Care (Berlowitz, 2020c; NPIAP, 2016b; EPUAP/NPIAP/PPPIA, 2019) • •Obtain patient history: assess for connective tissue disorders and other chronic diseases, previous surgeries, and factors limiting mobility; current medications, allergies, past therapies (radiation or chemotherapy) and tobacco and alcohol use. • Perform physical examination: inspect all areas of the skin as soon as possible upon admission for signs of pressure injury, especially non- blanchable erythema. Examine entire skin surface for pressure ulcers, epidermal excoriations, rashes, maceration, edema, and old scars. • Assess skin temperature, color, turgor, moisture, and integrity. Record any changes as soon as they are identified. • In darkly pigmented skin, look for changes in skin tone, skin temperature and tissue consistency compared to adjacent skin.
  • 71. KeyRecommendation • Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters and elbows, and beneath medical devices. • Cleanse skin promptly after episodes of incontinence. • Use skin cleansers that are pH balanced for the skin; avoid hot water. • Apply skin moisturizers daily on dry skin. • Apply a barrier product to protect skin from moisture. • Avoid vigorous massage over bony prominences. • Avoid positioning the patient on an area of erythema or pressure injury
  • 73. KeyRecommendation Nutrition (Berlowitz, 2020a; NPIAP, 2016b; EPUAP/NPIAP/PPPIA, 2019) • Hospitalized individuals are at risk for undernutrition. • Use a valid tool to assess the patient’s risk for malnutrition. • Assess oral, enteral and parenteral intake and refer at-risk patients to a registered dietitian/nutritionist; assessment includes protein and caloric intake, hydration status, serum albumin and/or prealbumin, and total lymphocyte count. • Support patients with adequate fluid intake and a balanced diet and correct any nutritional deficiencies. • Assess adequacy of oral, enteral, and parenteral intake. Target protein intake is 1.25 to 1.5 g/kg/day. • Assess weight changes over time. • Nutritional supplements are only recommended when deficiencies are present, or if nutritional intake is not optimal.
  • 74. KeyRecommendation Repositioning and mobilization (Berlowitz, 2020a; NPIAP, 2016b; EPUAP/NPIAP/PPPIA, 2019) • Turn and reposition all at-risk patients, unless contraindicated; schedule frequency based on the support surface in use, the tolerance of skin for pressure and the patient’s preferences. General recommendation is to reposition at least every two hours. • Chair-bound patients who are weak or immobile should be repositioned every hour. • Lengthen the turning schedule at night to allow the patient to sleep. • When turning, place the patient in a ≤ 30-degree side lying position, and ensure the sacrum is off the bed. • Assess the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the patient when choosing a support surface.
  • 75. KeyRecommendation Repositioning and mobilization (Berlowitz, 2020a; NPIAP, 2016b; EPUAP/NPIAP/PPPIA, 2019) • Continue to reposition the patient when placed on any support surface. • Use a breathable incontinence pad when using microclimate management surfaces. • Use pressure redistributing cushions for patients sitting in chairs or wheelchairs. • If the patient cannot be moved or is positioned with the head of the bed elevated over 30 degrees, place a polyurethane foam dressing on the sacrum. • Place pillows or foam wedges between the ankles and knees if patients have no mobility in these areas. • Elevate heels off bed or use polyurethane foam dressings on patients at high-risk for heel ulcers. • Place thin foam or breathable dressings under medical devices. • Encourage mobility, provide physical therapy, and limit sedative medications, if possible
  • 80. 1) National Pressure Injury Advisory Panel 2016 2) https://www.ncbi.nlm.nih.gov/books/NBK 333122/ 3) MOH SINGAPORE-HEALTH PROMOTION BOARD 4) BergstormN,BradenBJ,LaguzzaA,HolmanV.The Braden Scale for predicting pressure sore risk. 1987;36(4):205-210 5) European Pressure Advisory Panel 6) Best Practice Information Sheets – Joanna Briggs Institute. (2008) Pressure ulcers – Prevention of Pressure related Damage. 12(2) 1-4. 7) Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. 8) Prevention and treatment of pressure ulcers/ injuries: quick references guide 2019 9) Schindler, C.A., Mikhailov, T.A., Cashin, S.E., Malin, S., Christensen, M., & Winters, J.M. (2013). Under pressure: preventing pressure ulcers in critically ill infants. Journal for specialists in Pediatric Nursing. 18, 329-34 References:
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