Undertake Tissue Viability Risk Assessment

Understand the need for tissue viability risk assessment

The skin is an outside covering for the human body. It is an organ just like the heart, lung and liver. It provides layer of protection and plays a vital role in maintaining body temperature and by making you aware of external stimuli through the sense of touch. The skin has two layers, the epidermis and the dermis, although not part of the skin, the hypodermis lies beneath the dermis. When the skin is about to be damaged it shows signs of redness and warmth on the area. Skin gives protection against biological invasion, physical damage and ultra violet radiation. It also provides us sensation for touch, heat and pain. Thermoregulation is supported through sweating and regulation of blood flow through the skin and synthesis of Vitamin D occurs. As the body gets older, poor nutrition or disability occurs, the skin is under pressure of getting damage through pressure sores. Factors such as shearing, friction and compression are the major cause of a patient to have developed a pressure sore. A grading system has been developed in order to assess the damage of the skin. There are four recognised grades of pressure ulcers in the EPUAP Wound Classification system.

GRADE 1: Discolouration of intact skin not affected by light finger pressure (non blanching erythema)This may be difficult to identify in darkly pigmented skin .

GRADE 2: Partial-thickness skin loss or damage involving epidermis and/or dermis. The pressure ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.

GRADE 3: Full thickness skin loss involving damage of subcutaneous tissue but not extending to the underlying fascia.The pressure ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

GRADE 4: Full thickness skin loss with extensive destruction and necrosis extending to underlying tissue.

All patients that comes in to the ward for admission are checked and risk assess for pressure sores. Patients that are bed bound, incontinent, limited mobility, malnourished and severely ill are the most at risk, A tissue viability assessment form is being used and filled up. Using the waterlow score, the risk is identified and marked. High risk patient are to be prioritized to have a pressure relieving mattress or air mattress. Medium risk are to be in an air mattress if an equipment is possible or vigilant care to pressure areas are to be highlighted as well as pressure prevention creams used. (1.1, 1.2, 1.3, 1.4, 1.5, 1.6)

Understand when the risk assessment should be reviewed

Tissue viability risk assessments are updated every week per hospital policy. This is important in order to keep the patients pressure areas condition are monitored and maintained. This will give us idea whether the patients pressure sores have improve or have got worst. It will tell us that maybe additional intervention and prevention has to be done. This will also determine if the patient would still need further more specialist equipment or therapy or they are now at low risk and specialist equipment could now go to a patient who needed it most. Patients who show no sign of improvement will also be referred to the tissue viability specialist nurse for further help. The tissue viability assessment tool are no longer needed when the patient is totally independent and mobile and is ready to go home or when the patient is dying and is on a Liverpool Care Pathway. (4.1, 4.2)