Pressure ulcers: prevention and management – NICE guideline

Adults: risk assessment

Carry out and document an assessment of pressure ulcer risk for adults:

• being admitted to secondary care or care homes in which NHS care is provided or
• receiving NHS care in other settings (such as primary and community care and emergency departments) if they have a risk factor, for example:
  • significantly limited mobility (for example, people with a spinal cord injury)
  • significant loss of sensation
  • a previous or current pressure ulcer
  • nutritional deficiency
  • the inability to reposition themselves
  • significant cognitive impairment.

Adults: skin assessment

Offer adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional. The assessment should take into account any pain or discomfort reported by the patient and the skin should be checked for:

• skin integrity in areas of pressure
• colour changes or discoloration (healthcare professionals should be aware that non-blanchable erythema may present as colour changes or discolouration, particularly in darker skin tones or types)
• variations in heat, firmness and moisture (for example, because of incontinence, oedema, dry or inflamed skin).

All ages: care planning

Develop and document an individualised care plan for neonates, infants, children, young people and adults who have been assessed as being at high risk of developing a pressure ulcer, taking into account:

• the outcome of risk and skin assessment
• the need for additional pressure relief at specific at-risk sites
• their mobility and ability to reposition themselves
• other comorbidities
• patient preference.

Adults: repositioning

Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every 6 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.

Adults: devices for prevention of pressure ulcers

Use a high-specification foam mattress for adults who are:

• admitted to secondary care
• assessed as being at high risk of developing a pressure ulcer in primary and community care settings.

Neonates, infants, children and young people: risk assessment

Carry out and document an assessment of pressure ulcer risk for neonates, infants, children and young people:

• being admitted to secondary care or tertiary care or
• receiving NHS care in other settings (such as primary and community care and emergency departments) if they have a risk factor, for example:
  • significantly limited mobility (for example, people with a spinal cord injury)
  • significant loss of sensation
  • a previous or current pressure ulcer
  • nutritional deficiency
  • the inability to reposition themselves
  • significant cognitive impairment.

All ages: healthcare professional training and education

Provide training to healthcare professionals on preventing a pressure ulcer, including:

• who is most likely to be at risk of developing a pressure ulcer
• how to identify pressure damage
• what steps to take to prevent new or further pressure damage
• who to contact for further information and for further action.

Provide further training to healthcare professionals who have contact with anyone who has been assessed as being at high risk of developing a pressure ulcer. Training should include:

• how to carry out a risk and skin assessment
• how to reposition
• information on pressure redistributing devices
• discussion of pressure ulcer prevention with patients and their carers
• details of sources of advice and support.

Adults: management of heel pressure ulcers

Discuss with adults with a heel pressure ulcer and if appropriate, their carers, a strategy to offload heel pressure as part of their individualised care plan.

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