The intent of this assignment, is to place a patient, under the attention of the territory nursing squad, with a Grade 1 force per unit area ulcer, to their sacral country. To get down with, it will give a brief overview of the patient and their clinical history. Throughout the assignment the patient will be referred to as Mrs A, in order to protect the patients individuality and maintain confidentiality, in conformity with the guidelines set out by the Nursing and Midwifery Council ( NMC 2008 ) . A brief description of a Grade 1 force per unit area ulcer will be given, along with a description of the stairss taken in measuring the lesion, utilizing The Waterlow Scale ( 1985 ) . This assignment will discourse the literature reappraisal that was carried out, along with other methods of research used, to garner critical information on lesion attention, such as the different categorizations of lesions and the different hazard appraisal tools available. This assignment, will include brief overviews, of some the other normally used force per unit area ulcer hazard appraisal tools, that are put to utilize by practicians and how they compare to the Waterlow Scale. This assignment will besides seek to foreground the importance of utilizing a combination of clinical opinion, by carefully supervising the patients physical and psychological conditions, alongside the ‘at hazard ‘ score calculated from the Waterlow Scale, in order to present holistic attention to the patient.
Mrs A is a 84 twelvemonth old lady who has been referred to the territory nurses by her General Practitioner, as he has concerns sing her force per unit area countries. Following a recent autumn she lost her assurance and is now house edge. She now spends more clip in her chair as she has become nervous when call uping around the house and in her garden. She has a history of high blood force per unit area and occasional angina for which she presently takes Nicorandil 30mg b.d. as prescribed by her General Practitioner, Nicorandil has been recognised as an aetiological facet of non – mending ulcers and lesions ( Watson, 2002 ) , this has to be taken into consideration during the appraisal and throughout the direction of her lesion. Mrs A has no history of old falls or jobs with her balance. She has ever been a confident and independent lady, with no current issues environing continency or diet. She has ever enjoyed a big web of friends who visit her on a regular basis. It is recommended by National Institute for Health and Clinical Excellence ( NICE ) that patients should have an Initial appraisal ( within the first 6 hours of inpatient attention ) and ongoing hazard appraisals and so referrals of this nature are seen on the twenty-four hours, if it is received if non within 24 hour. In order to set up Mrs A ‘s current hazard of developing a force per unit area country, an appraisal must take topographic point. An initial holistic appraisal, looking at all lending factors such as mobility, continency and nutrition will supply a baseline that will place her degree of hazard every bit good as placing any bing force per unit area harm.
A force per unit area ulcer is defined as, a localized hurt to the tegument and / or implicit in tissue normally over a cadaverous prominence, as a consequence of force per unit area, or force per unit area in combination with shear. A figure of lending, or confusing factors, are besides associated with force per unit area ulcers. Harmonizing to the European Pressure Ulcer Advisory Panel ( EPUAP 2009 ) , the significance of these factors, is yet to be elucidated.
Mrs A is more vulnerable to coerce harm, as her tegument has become more delicate and dilutant with age ( Nice 2005 ) . There are risk factors associated to the unity of the patient ‘s tegument and besides to the patients general wellness. Skin that is already damaged, has a higher incidence of developing a force per unit area ulcer, than that of healthy tegument. Skin that becomes excessively dry, or is more damp due to possible incontinency, is besides at higher hazard of developing a force per unit area ulcer than healthy tegument. An aged individual ‘s tegument is at increased hazard, because it is more delicate and dilutant than the tegument of a younger individual. Boore et Al ( 1987 ) identified the undermentioned rules in caring for the tegument to forestall force per unit area harm, tegument should be kept clean and dry and non left to stay wet. The tegument should besides non be left to dry out to forestall any inadvertent harm. Due to Mrs A disbursement more clip sitting in her chair, she has become at a higher hazard of developing a force per unit area sore, as she is less nomadic. The ground being It becomes hard for the blood to go around doing a deficiency of O and foods to the tissue cells. Furthermore, the lymphatic system besides begins to endure and becomes unable, to decently take waste merchandises. If the force per unit area continues to increase and is non relieved by equipment or motion. The cells can get down to decease, go forthing an country of dead tissue ensuing in force per unit area harm. Nelson et Al ( 2009 ) provinces, force per unit area ulcers can do patients functional restrictions, emotional hurt, and hurting for individuals affected. The development of force per unit area ulcers, in assorted healthcare scenes, is frequently seen as a contemplation of the quality of attention which is being provided ( Nakrem 2009 ) . Pressure ulcer bar is really of import in mundane clinical practise, as force per unit area ulcer intervention is expensive and factors such as legal issues have become more of import. EPAUP ( 2009 ) have recommended schemes, which include frequent shifting the usage of particular support surfaces, or supplying nutritionary support to be included in the bar.
In order to garner grounds based research, to back up my assignment. I undertook a literature reappraisal of the Waterlow Scale and Classifications of Grade 1 force per unit area sores. The databases used were the Culmulative Index to Nursing and Allied Health Literature ( CINAHL ) and OpenAthens. I used a assortment of hunt footings including ‘pressure sores ‘ , ‘Grade 1 categorization ‘ , ‘Waterlow Scale ‘ , and ‘How force per unit area sore hazard appraisal tools compare ‘ . Throughout the literature reexamine the information was gathered from beginnings utilizing a day of the month scope between the old ages of 2000 – 2011, although some mentions were found from beginnings of information that are from a much later day of the month. This method of research ensured a overplus of articles and guidelines were collated and analysed. The trust guidelines in lesion attention were used, to demo how we implement theory into practise in the community, utilizing the lesion attention formulary. There was a huge sum of information available, as force per unit area country attention is such a wide topic. The hunt standards had to be narrowed down, in some instances to guarantee the information gathered was relevant and non beyond the range of the assignment. The grounds used throughout this assignment, is based on guidelines and recommendations given by NICE ( 2001 ) , EPUAP ( 2001 ) and articles sourced from The Journal of Community Nursing ( JCN ) . This was the most accurate information and counsel on force per unit area ulcer categorizations and appraisal although, some articles may non hold been the most recent.
The appraisal tool used throughout my country of work, is the Waterlow Scale. The Waterlow Scale was developed by Judy Waterlow in 1985, while working as a clinical nurse instructor. It was originally designed for usage by her pupil and is used to mensurate a patient ‘s hazard of developing a force per unit area sore. It can besides be used as a usher, for the ordination of effectual force per unit area alleviating equipment. All National Health Service ( NHS ) trusts have their ain force per unit area ulcer bar policy, or guidelines and practicians are expected to utilize the hazard appraisal tool, specified in their trust ‘s policy. NICE ( 2003 ) , counsel provinces, that all trusts should hold a force per unit area ulcer policy, which should include a force per unit area ulcer hazard appraisal tool. However, it reminds practicians that the usage of hazard appraisal tools, should be thought of as an assistance to the clinical opinion of the practician. The usage of the Waterlow tool enables, the nurse to measure each patient harmonizing to their single hazard of developing force per unit area sores ( Pancorbo-Hidalgo et al 2006 ) . The graduated table illustrates a hazard appraisal hiting system and on the rearward side, provides information and counsel on lesion appraisal, dressings and preventive AIDSs. There is information sing force per unit area alleviating equipment surrounding, the three degrees of hazard highlighted on the graduated table, and besides provides counsel, refering the nursing attention given to patients. Although the Waterlow mark is used in the community scene, when ciphering the hazard appraisal mark, it is critical that the nurse is cognizant of the difference in environment the tool was originally developed for.
The tool uses a combination of nucleus and external hazard factors that contribute to the development of force per unit area ulcers. These are used to find the hazard degree for an single patient. The cardinal factors include disease, medicine, undernourishment, age, desiccation / fluid position, deficiency of mobility, incontinency, skin status and weight. The external factors, which refer to external influences which can do skin deformation, include force per unit area, shearing forces, clash, and wet. There is besides a particular hazard subdivision of the tool, which can be used if the patient is on certain medicine or late had surgery. This contributes to a holistic appraisal of a patient and enables the practician to supply the most effectual attention and appropriate force per unit area alleviating equipment. The mark is calculated, by numbering the tonss given in each class, which apply to your patient ‘s current status. Once these have been added up, you will hold your ‘at hazard ‘ mark. This will so bespeak the stairss that need to be taken, in order to supply the appropriate degree of attention to the patient. Designation of a patients hazard of developing a force per unit area sore is frequently considered the most of import phase in force per unit area sore bar ( Davis 1994 ) .
During the appraisal a skin review takes topographic point of the most vulnerable countries of hazard, typically these are heels, sacrum and parts of the organic structure, where sheer or clash could take topographic point. Elbows, shoulders, back of caput and toes are besides considered to be more vulnerable countries ( NICE 2001 ) . When utilizing the Waterlow tool to measure Mrs A ‘s force per unit area hazard, I found she had a mark of 9. Harmonizing to the Waterlow marking system she is non considered as being at hazard as her mark is less than 10. As I had identified in my appraisal, she had a mark of 2, for her skin status due to Rate 1 force per unit area ulcer to her sacrum. I felt it necessary, to foreground her as being at hazard. A grade 1 force per unit area ulcer on her sacral country, possibly due to her recent loss of assurance and decreased mobility which has left Mrs A disbursement more clip in her chair.
Pressure ulcers are assessed and graded, harmonizing to the grade of harm to the
tissue. The National Pressure Ulcer Advisory Panel ( NPUAP ) , classifies force per unit area ulcers based on the deepness of the lesion. There are four categorizations ( Category/Stage I through IV ) of force per unit area harm. In add-on to these, two other classs have been defined, unstageable force per unit area ulcers and deep tissue hurt ( EPUAP, 2009 ) Grade 1 force per unit area harm is defined, as a non-blanchable erythema of integral tegument. Indexs can be, stain of the tegument, heat, hydrops, sclerosis or hardness, peculiarly in people with darker pigmentation ( EPUAP, 2003 ) . It is believed by some practicians, that paling erythema indicates Grade 1 force per unit area harm ( Hitch 1995 ) although others suggest that, Grade 1 force per unit area harm is present, when there is non-blanching erythema ( Maklebust and Margolis, 1995 ; Yarkony et Al, 1990 ) . The bulk of practicians, agree that temperature and coloring material play an of import function, in placing grade 1 force per unit area ulcers ( EPUAP, 1999 ) and erythema, is a factor in about all categorizations ( Lyder, 1991 ) . The force per unit area harm normally occurs, over boney prominences ( Barton and Barton 1981 ) . The tegument in a Grade 1 force per unit area ulcer, is non broken, but it requires protection and monitoring.
At this phase, it will non be known how deep the force per unit area harm is, regular
monitoring and appraisal is indispensable. The force per unit area ulcer may melt, but if the
harm is deeper than the superficial beds of the tegument, this lesion could finally
develop into a much deeper force per unit area ulcer over, the undermentioned yearss or hebdomads.
A Grade 1 force per unit area ulcer, is classed as a lesion and so I have commenced a
lesion attention program and besides a force per unit area country attention program. I will besides guarantee, Mrs A has
regular force per unit area country cheques in order to forestall the country interrupting down. The
force per unit area country cheques will take topographic point hebdomadally until the force per unit area alleviating equipment
arrives, this will so be reduced to 3 monthly cheques. Dressings can be applied to
a Grade 1 force per unit area ulcer. They should be simple and offer some degree of protection.
Besides, to forestall any farther tegument harm a movie dressing is frequently used, or a
hydrocolloid to protect the wound country ( EPAUP, 2009 ) . These dressings will help in
cut downing farther clash, or shearing, if these factors are involved. It is considered
the best manner to handle a lesion, is to forestall it from of all time happening. Removing the
bing external force per unit area, cut downing any wet, which can happen if the patient is
incontinent and employing force per unit area alleviation devices, may lend to injure healing.
Along with equal nutrition, hydration and turn toing any implicit in medical
conditions.
The advice given to practicians, on the contrary of the Waterlow tool is to supply a
100mm foam shock absorber, if a patients hazard mark is above 10. As Mrs
A has an ‘at hazard ‘ mark of 9, with a Grade 1 force per unit area sore evident, I feel it
appropriate to supply the force per unit area alleviating mattress and shock absorber to forestall any
farther force per unit area harm developing. All persons, assessed as being vulnerable to
force per unit area ulcers should, as a minimal proviso, be placed on a high specification
froth mattress with force per unit area alleviating belongingss ( NICE, 2001 ) . As I am supplying a
shock absorber and a mattress, it is non felt necessary to use a dressing at this point.
However, the country will necessitate regular monitoring, as at this phase it is unknown how
deep the force per unit area harm is. If proactive attention is given in the bar and
intervention of force per unit area ulcers, with the usage of hazard appraisals and supplying
force per unit area alleviating resources, the force per unit area country may decide. Pressure ulcers can be
dearly-won for the NHS, enfeebling and painful for the patient. With basic and effectual
nursing attention offered to the patients, this can frequently be the key to success.
Bliss ( 2000 ) suggests that the bulk of Grade I ulcers heal, or decide without
interrupting down if force per unit area alleviation is put into topographic point instantly. However, experiences
in a clinical scenes supports observations, that non-blanching erythema can frequently
consequence in irreversible harm ( James, 1998 ; Dailey, 1992 ) .
McGough ( 1999 ) during a literature hunt, highlighted 40 force per unit area ulcer hazard
appraisal tools, but non all have be considered suited, or dependable for all clinical
environments. As there are many different patient groups this frequently consequences in a broad
spectrum of different patient demands. The three most normally used tools in the United Kingdom ( U.K. ) are, The Norton graduated table, The Braden Scale and The Waterlow Scale.
The first force per unit area ulcer hazard appraisal tool was the Norton graduated table. It was devised by Doreen Norton in 1962. The tool was used for gauging a patient ‘s hazard for developing force per unit area ulcers by giving the patient a evaluation from 1 to 4 on five different factors. A patients with a mark of 14 or more, was identified as being at high hazard. Initially, this tool was aimed at aged patients and there is small grounds from research gathered over the old ages, to back up its usage outside of an aged attention puting. Due to increased research over the old ages, refering the designation and hazard of developing force per unit area ulcers, a modified version of the Norton graduated table was created in 1987.
The Braden Scale was created in the mid 1980 ‘s, in America and based on a conceptual scheme of aetiological factors. Tissue tolerance and force per unit area where identified, as being important factors in force per unit area ulcer development. However, the cogency of the Braden Scale is non considered to be high in all clinical countries ( Capobianco and McDonald, 1996 ) . However, EPAUP ( 2003 ) province The Braden
Risk Assessment Scale is considered by many, to be the most valid and dependable
hiting system for a broad age scope of patients.
The Waterlow Scale, foremost devised in 1987, identifies more hazard factors than the Braden and the Norton Scale. However, even though it is used widely across the U.K. , it has still be criticised for its ability to over predict hazard and finally consequence in the abuse of resources ( Edwards 1995 ; McGough, 1999 ) .
Although there are assorted tools, which have been developed to place a patients single hazard, of developing force per unit area sores. The bulk of graduated tables have been developed, based on ad hoc sentiments, of the importance of possible hazard factors, harmonizing to the Effective Healthcare Bulletins ( EHCB, 1995 ) . The prognostic cogency of these tools, has besides been challenged ( Franks et al, 2003 ; Nixon and Mc Gough, 2001 ) proposing they may over foretell the hazard, incurring expensive cost deductions, as preventive equipment is put in topographic point, when it may non ever be necessary. Or they may under predict hazard, so that person assessed as non being at high hazard develops a force per unit area ulcer. Although The Waterlow marking system, now includes more nonsubjective measurings such as Body Mass Index ( BMI ) and weight loss after a recent update. It is still unknown, due to no published information, whether the inter-rater dependability of the tool, has been improved by these alterations. It has been acknowledged, that this is a cardinal defect of these tools and due to this clinical opinion, must ever back up the determinations made by the consequences, of the hazard appraisal. This is clearly recognised by NICE, as they advise their usage as an aide-memoire ( 2001 ) . The purpose of Pressure ulcer hazard appraisal tools, is to mensurate and quantify force per unit area ulcer hazard. To find the quality of these measurings the rating of cogency and dependability would normally take topographic point. The cogency and dependability restrictions, of force per unit area ulcer hazard tools are widely acknowledged. To get the better of these jobs, the solution that is recommended is to unite the tonss of force per unit area ulcer hazard tools, with clinical judgement ( EPAUP 2009 ) . This recommendation, which is frequently seen in the literature, unluckily is inconsistent as Papanikolaou et Al ( 2007 ) provinces: “ If force per unit area ulcer hazard appraisal tools have such restrictions, what part can they do to our assurance in clinical judgement, other than motivating us about the points, which should be considered when doing such judgements? ” . Probes of the cogency and dependability, of force per unit area ulcer hazard tools are of import, in measuring the quality, but they are non sufficient to judge their clinical value. In the research of force per unit area ulcer tools, there have been few efforts made to compare, the different force per unit area ulcer hazard appraisal schemes. Mentioning to literature until 2003, Pancorbo – Hidalgo et Al ( 2006 ) identified three surveies, look intoing the Norton graduated table compared to clinical judgement and the impact on force per unit area ulcer incidence. From these surveies, it was concluded that there was no grounds, that the hazard of force per unit area ulcer incidence was reduced by the usage of the hazard appraisal tools. The Cochrane reappraisal ( 2008 ) , set out to find, whether the usage of force per unit area ulcer hazard appraisal, in all wellness attention scenes, reduced the incidence of force per unit area ulcers. As no surveies met the standards, the writers have been unable to reply the reappraisal inquiry. At present there is merely weak grounds to back up the cogency, of force per unit area ulcer hazard appraisal graduated table tools and obtained tonss contain changing sums of measuring mistake.
To better our clinical practise, it is suggested that although tools such as the
Waterlow Scale are used to separate a patients force per unit area ulcer hazard, other
probes and trials, may necessitate to be carried out to guarantee a effectual
appraisal is taking topographic point. Practitioners may see, assorted blood trials and more
in depth history pickings, including old force per unit area harm and medicines. Patients
life style and diet should besides be taken into consideration and where appropriate, a
nutritionary appraisal should be done if recent weight loss, or decreased appetency is
evident. Nutritional appraisal and showing tools are being used more readily and look to be going more relevant in pull offing patients who are at hazard of or hold a force per unit area ulcer. The appraisal tools should be dependable and valid, and as discussed antecedently with other hazard appraisal tools they should non replace clinical opinion. However, the usage of nutritionary appraisal tools can assist to convey the nutritionary position of the patient to the attending of the practician, they should so see nutrition when measuring the patients exposure to coerce ulcer development. The nutritionary position of the patient should be updated and re-assessed at regular intervals following a appraisal program which is single to the patient and includes an rating day of the month. The status of the person will so let the practician to make up one’s mind how frequent the appraisals will happen. The EPUAP ( 2003 ) recommends that as a lower limit, appraisal of nutritionary position should include regular deliberation of patients, skin appraisal, certification of nutrient and fluid consumption.
As Mrs A presently has a balanced diet, it is non felt necessary to set about, a
nutritionary appraisal at this point. Her weight can be updated on each reappraisal visit,
to measure any weight loss during each visit. If there is any impairment in her
status, an appraisal can be done when required. Continence should besides be
taken into consideration and where necessary a continency appraisal should take
topographic point. Incontinence and force per unit area ulcers are common and frequently occur together.
Patients who are incontinent are by and large more likely to hold troubles with their
mobility and aged, both of which have a strong association with the development
of force per unit area ulcers ( Lyder, 2003 ) .A
The instruction of staff, environing force per unit area ulcer direction and bar, is
besides really of import. NICE ( 2001 ) suggest, that all wellness attention professionals, should
receive relevant preparation and instruction, in force per unit area ulcer hazard appraisal and
bar. The information, accomplishments and cognition, gained from these preparation
Sessionss, should so be cascaded down, to other members of the squad. The
preparation and instruction Sessionss, which are provided by the trust, are expected to
cover a figure of subjects. These should include, hazard factors for force per unit area ulcer
development, skin appraisal, and the choice of force per unit area equipment. Staff are
besides updated on policies, guidelines and the latest patient educational information
( Nice 2001 ) .
Education of the patient, carers and household, is indispensable in order to accomplish optimum
force per unit area country attention. Mrs A is encouraged to call up on a regular basis, in order to alleviate
the force per unit area as a Grade 1 force per unit area sore has been identified, she is at a important
hazard of developing a more terrible ulcer. Interventions to forestall impairment, are
crucial at this point. It is thought, that this could forestall the force per unit area sore from
developing into a Grade 2 or worse. NICE ( 2001 ) have suggested, that persons
vulnerable to or at elevated hazard of developing force per unit area ulcers, who are able and
willing, should be informed and educated about the hazard appraisal and ensuing
bar schemes. NICE have devised a brochure for patients and relations, called
Pressure Ulcers – Prevention and Treatment ( NICE Clinical Guidance 29 ) , which gives
information and counsel on the intervention of force per unit area ulcers. It encourages patients
to look into their tegument and alter their place on a regular basis. As a portion of good practise,
this brochure is given to Mrs A at the clip of appraisal, in order for her to
develop some apprehension of her force per unit area sore. This brochure is besides given to the
attention givers or relations so they can besides derive apprehension, sing the attention and
bar, of her force per unit area ulcer. An indispensable portion of nursing certification, is attention
planning. It demonstrates the attention, that the single patient requires and can be
used to include patients and carers or relations in the patients attention. Engagement of
the patient and their comparative, or carer is advisable, as this could be priceless, to
the nurse be aftering the patient ‘s attention. The National Health Service Modernisation
Agency ( NHSMA 2005 ) states clearly that individual – centred attention is critical and that attention planning
involves dialogue, treatment and shared determination – devising, between the nurse and
the patient.
There were a figure of betterments that I feel could hold been made to the holistic attention of Mrs A. I feel that one of the cardinal factors that needed to be considered, were the societal demands of the patient. As I feel they are a big contributing factor, towards why the patient may hold developed her force per unit area sore. The patient was antecedently known to be a really sociable lady, who bit by bit lost her assurance, ensuing in her non go forthing the house. There are assorted strategies and services available, which are provided by the local council or voluntary services, to enable the aged or people unable to acquire around. For illustration, an option which could of been suggested to Mrs A are services such as Ring and Ride, or Werneth Communicare. Using these services or being involved in these types of strategies, may hold empowered Mrs A to go forth the house on a more regular footing. This would enable her to construct up the assurance, she lost following her autumn. This would hold besides led to positive impact on the patient ‘s psychological attention, as Mrs A would hold been able to get the better of her frights of go forthing the house, enabling her to see friends and addition communications lost. As antecedently mentioned in this assignment, although Mrs A had a mark of 9, which is non considered an ‘at hazard ‘ mark. I still felt it necessary to move on this mark, even though the lesion was a non considered to be critical. If it is felt the patient is at a higher hazard than that shown on the appraisal tool, the practician should utilize their clinical opinion, to do important attention determinations. It should besides be considered, by the practician that hazard appraisal tools such as The Waterlow graduated table, may non hold been developed, for their country of practise. Throughout the continuance of Mrs A ‘s lesion healing procedure, a holistic appraisal of her force per unit area countries and general wellness appraisal were carried and all relevant factors, were taken into consideration. The assessment tool used to measure her force per unit area countries, is the most common tool used presently in practise and the tool recommended by the Trust.
To reason, there is grounds prove that force per unit area ulcer hazard appraisal tools are utile, when used as a usher for the procurance of equipment. However, they can non be relied upon entirely to supply holistic attention to a patient. It has been highlighted, that to guarantee a holistic appraisal of patients, it is necessary to finish a assortment of appraisals, to make a complete image. Although The Waterlow graduated table covers a figure of factors that need to be considered, throughout the appraisal, it has become apparent that the ‘at hazard ‘ mark, can frequently be over or under scored depending on the practician. Clinical opinion has proved to be, a really of import facet of force per unit area ulcer bar and intervention. The instruction of the patient, carer and relations has besides been highlighted, as an of import facet of attention. Empowering the patient with information sing their unwellness, may diminish the healing clip and aid prevent has further issues.