SSPN-checklist

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SSPN helps you with systematic pressure ulcer prevention

1 Pressure ulcer risk assessed in all at first contact/visit. Risk and skin assessment should be done within the first two hours after first contact.

2 The risk of pressure ulcers is reassessed:

on discharge from or admission to hospital
during and after acute illness
by changes in nutritional status
by changes in nutritional status

3 Persons at risk of pressure ulcers are assessed as needed and plans are developed for:

use of pressure-relieving and pressure-distributing devices
Positioning/posture change and mobilisation
nutrition (screening and diet plan).

4 Actions in people at risk of pressure ulcers – SSPN:

Skin

Is the skin checked for pressure sores or pressure marks all over the body?
Is the skin damp, perhaps due to incontinence or sweating?
Is the skin too dry?
Does the person express pain?

Is the skin checked for pressure sores or pressure marks all over the body?
Is the skin damp, perhaps due to incontinence or sweating?
Is the skin too dry?
Does the person express pain?

Supports/Aids

Are the aids correctly adjusted to the person?
Are the aids used correctly in the bed, chair or wheelchair?
Is there a need for re-evaluation of aids?

Position change/mobilisation

Is the person mobilised in the best possible way?
Is the person being transferred and positioned correctly?

Nutrition

Is the person eating and drinking as planned in the diet plan?

You can find a pocket-friendly version of the SSPN checklist in our green pocket book.

The first point is risk and skin assessment

The first point is risk and skin assessment
Rapid and accurate identification of patients/citizens at risk of pressure ulcers is an important element of pressure ulcer prevention, together with systematic recording of this.

Risk assessment is performed with a clinical assessment of the patient in combination with a risk rating scale. There are different risk assessment scales that can be used. The Norton and Braden scales are the most widely used, and also the most validated, risk assessment scales. For a review of the use of the two risk assessment scales, see the guide on Pressure Ulcer Risk Assessment Tools.

In addition to risk assessment, patients/citizens at risk of developing pressure ulcers should have frequent skin assessment. This is part of basic nursing care, where the healthcare professional observes if there are changes in the patient’s/citizen’s skin when helping to wash and dry the skin. Optimally, this is done daily. All changes in the skin are documented.

Assessment of the skin should include:

Particular observation of the skin around bone prominences, where the risk of developing pressure ulcers is greatest.
Observation of whether the skin is dry, whether there are cracks in the skin, whether the skin is fragile and thin, whether there is softening of the skin due to. increased moisture (maceration) or if there are other changes in the skin condition.

The second point is the reassessment of pressure ulcer risk

It is essential to reassess the patient’s/resident’s pressure ulcer risk because risk factors such as mobility, continence and nutritional status can change over time, and particularly with acute illness and changes in functional level. In addition to risk assessment;

on discharge from or admission to hospital
during and after acute illness
by changes in nutritional status
by changes in the level of function,
it is important to repeat the risk assessment within a defined time interval.

The pressure ulcer package recommends that pressure ulcer risk reassessment is carried out daily in patients/citizens found to be at risk of developing pressure ulcers. Ideally, healthcare professionals should have an established workflow that includes skin assessment every time they assess, transfer or care for patients/citizens anyway.
As a minimum, a skin assessment should be carried out daily, but it should be assessed in each organisation how often the risk assessment needs to be repeated. If in doubt, ask your manager or colleagues what the policy is at your workplace.

The third point is the preparation and reassessment of pressure ulcer prevention actions

Pressure ulcer prevention actions should at a minimum focus on;

use of pressure-relieving and pressure-distributing devices
positioning, change of position and mobilisation
nutritional screening and diet plan

Creating a plan for the use of pressure-relieving and pressure-distributing devices requires multidisciplinary collaboration between health professionals. It is particularly important to involve occupational therapists, as they have a great deal of knowledge in this area.

Making a plan for camp, shift and mobilisation also requires multidisciplinary collaboration between health professionals. It is particularly important to involve physiotherapists, who have a great deal of knowledge about movement and mobilisation.

Pressure ulcer prevention should be based on the functional level of the individual citizen/patient, and it is important that the functional level is maintained, or improved if possible, through mobilisation and training and the use of appropriate aids.

If the patient/resident is bedridden and unable to turn himself/herself, a plan for the frequency of position changes must be drawn up. This plan must be drawn up on the basis of the risk and skin assessments carried out. How long the patient/resident can lie in the same position is individual and depends on both functional level, degree of pressure ulcer risk, skin condition and the quality of the chosen surface.

Frequency of posture change is assessed by observation of skin condition; nutritional status; whether there is poor circulation; whether there is impaired sense of touch; and ability to perform posture change by oneself. The more risk factors, the more frequently a change of position is needed.

The frequency of position changes can be modified if changes in the skin are observed – if pressure is observed, the frequency increases, and conversely if pressure is no longer observed, the frequency of position changes may be reduced.

It is recommended to use 30 degree side bearing and bearing with maximum weight bearing surface, where the bearing material supports the whole body surface.

Position change can be done with frequent micromobilisation. For example, the movement pattern provided by the Turn All tilt system with a slow movement from 30 degrees lateral position on alternating right and left sides.

Involving the patient/citizen in risk and communicating prevention knowledge to him/her should be done as early as possible and at all stages of a prevention programme and when developing pressure ulcer prevention actions.

Factors such as sleep disturbance, pain, patient/resident preferences, and the overall treatment goal are of significant importance in choosing the method of encampment and selecting the frequency of position changes.

Nutritional status is a major risk factor for the development of pressure ulcers. Both underweight and overweight people have an increased risk of developing pressure ulcers. Therefore, it is essential to perform a nutritional screening in patients/citizens who are at risk of developing pressure ulcers. All older people should be nutritionally screened regardless of pressure ulcer risk. If you are unsure where to find nutrition screening forms in your workplace, ask your manager or colleagues. Alternatively, the Danish Society for Clinical Nutrition has both a form and a guide to nutritional screening on their website.

It is important that overweight people continue to meet their nutritional needs – especially in the context of illness. The goal for the obese patient/resident should be weight maintenance, with a particular focus on achieving protein needs and not reaching much above the recommended calorie intake.

Optimal fluid intake and nutrition have a major impact on the development of pressure ulcers. Weight loss and loss of muscle mass can increase pressure on bone prominences, and oedema and reduced blood circulation can contribute to tissue damage.

Patients/citizens who already have a pressure ulcer should;

have drawn up an individual diet plan
have initiated diet/fluid recording
weighed once a week to monitor weight loss
have the diet plan continuously reviewed if it cannot be adhered to or if weight loss continues to occur.

The fourth point is a checklist of actions for the patient/resident at risk of developing pressure ulcers, focusing on skin, support/assistive devices, postural change/mobilisation and diet

The skin should be checked all over the body for pressure marks and pressure ulcers. It is part of the daily skin assessment.

In this context, it must be observed whether there are places where the skin is moist or dry, and skin care must be implemented adapted to the skin condition of each patient/citizen. The aim is to keep the skin supple and soft, as this helps to protect the skin from external influences such as pressure.

Damp skin can lead to maceration, where the skin looks puffy and whitish and the skin’s barrier function is destroyed. Damp skin can lead to maceration, where the skin looks softened and whitish, and where maceration is caused by damp and warm skin, typically in the area around the genitals and anus in patients/citizens who are incontinent. But it can also occur elsewhere on the body with dense skin folds, such as under the breasts or arms. Macerated skin is more sensitive to the degradation of healthy tissue. Therefore, it is important to reduce the skin’s exposure to contact with sweat, urine, faeces and secretions from wounds. Washing of the skin should be done with cloths intended for body washing, preferably in a soft material that does not damage the skin. In many places, special body wash cloths are used that contain a mild washing lotion that does not need to be rinsed off and that has a pH value close to the skin’s own. This is an obvious choice for washing the skin, remember though that the skin must be left dry. So you may need to wipe gently with a dry cloth or towel. If it is not possible to use the body wash, it is recommended that the skin is washed in water only as much as possible, as soap helps to shift the skin’s natural pH, which is part of the skin’s barrier function. Therefore, washing with soap can also help to increase maceration of the skin. After washing and drying macerated skin, skin care products that act as a barrier to moisture on the skin – such as barrier creams or barrier films – should be used. In some cases, it may also be appropriate to use drying skin care products. This should not be used without first consulting the wound manager at your workplace.

Dry skin has reduced elasticity and is therefore less resistant to external influences. Older people have reduced fat production in the skin, which means that they greatly need to have moisture supplied to the skin through skin care products, and through optimal fluid intake per os.

The reduced oil production in the skin is another reason to save soap, as soap helps to degrease and dry out the skin. If you wash with soap, you should always apply a cream, lotion or ointment afterwards. Treating dehydrated skin with moisturiser is effective in preventing pressure ulcers. Therefore, it is important that patients/citizens with dry skin are helped to lubricate their skin at least twice a day.

Skin pain is a sign of tissue damage, and pressure ulcers up to category 3 are typically painful. Therefore, it is relevant to ask the patient/citizen about pain during the skin assessment.

In relation to supports and aids, assess whether aids are set and used correctly and whether there is a need to reassess the need for aids and/or pressure-relieving supports.

If a wheelchair is used with a pressure-relieving cushion, it is relevant that the wheelchair’s armrests and footrests can be adjusted in height so that the height of the armrest and seat remains appropriate. An occupational therapist can help to ensure the correct adjustment of the wheelchair.

The pressure-relieving device must ensure that, irrespective of the user’s position, there is approximately 1½ finger widths between the base and the part of the body to be relieved. Remember to check daily that the user is raised about 1½ finger widths above the surface where the pressure-relieving aid is placed. The pressure-relieving aid may consist of foam or air, for example, and may include heel lifts, seat cushions, pressure-relieving foam mattresses, air or alternating pressure mattresses and tilting systems.

When assessing whether aids are set up and used correctly, it is a good idea to refer to the product user manual. This helps to ensure that the aids are used as intended.

If it is difficult to assess whether the aids have been used correctly and whether other/further aids are needed, it is a good idea to start an interdisciplinary collaboration between the patient/citizen, the health professionals (nurse, assistant/help and physio/ergotherapists) and possibly the aid dealer.

In relation to position changes and mobilisation, it is of course relevant to take the patient’s/citizen’s functional level as a starting point. If an assessment of the patient’s/citizen’s functional level has not been carried out, it is appropriate to involve an occupational therapist who can carry out, for example, a Barthel Screening. The screening provides insights into basic ADL (activity of daily living) functions, physical functioning and level of care, and will help assess whether mobilisation, transfer and positioning are performed optimally.

In relation to diet, it is important to evaluate whether the patient/resident is eating and drinking optimally. If this is not the case, further action must be taken. For example, the patient/resident may need nutritional drinks to achieve his/her protein and calorie intake, or an energy-dense diet may be ordered for the patient/resident. If the patient/resident cannot be made to take sufficient fluids, subcutaneous fluid therapy may be appropriate. The indication for subcutaneous fluid therapy is elderly patients/citizens who need fluid supplementation and where there are no indications other than fluid therapy for placing a peripheral venous catheter. Subcutaneous fluid therapy should typically be prescribed by a doctor. Ask the nurse in charge about the procedure at your workplace.