 Hydi, wrth gwrs, dain i gwybod wedi gymrydol am gwybod a gwybod rwy'n ddechrau'n gwrs yn ystod. ac wedi gael ei fwy o wybod, dyw ei gwybod rwy'n i gwybod rwy'n gwybod i'w cysylltwyr i'r gwaith o'r fideo. So gydag rydyn ni'n gofod i mobod ddechrau'r mod i'r gawr ac felly rydyn ni'n gobeithio gael arbennig llunion arheredd warfodau'u oherwydd goeth ddim i gynnyddol diolch oedd o'r cael ei ddau'r hneud o hyffordd o'r is basically some damage or an injury caused to the skin that is stemmed from pressure to that area and the blood supply has been cut off basically so if you're lying flat on a hard surface for example it's going to block off the blood supply and cause damage and skin breakdown. So firstly before we go into the categories of pressure ulcers I just wanted to say that wherever you're working there should be a risk assessment in place already where they will risk assess each patient on admission if they're at danger of developing a pressure ulcer or a pressure sore or if their nutrition is status is really poor, fluid balance is really poor anything like that they could be at risk of pressure ulcers. So just have a look at your local trust policies and procedures how you assess patients and how you do things and just go from there. These pressure areas are usually seen in the more bony prominence of the human body so you will have elbows knees heels ankles you'll have the spine sacrum shoulder blades ears as well sometimes back of the head sometimes the big toe anywhere that is bony basically that hasn't got any fleshy meaty bit that's going to protect it as much as the rest of your body and these are usually due to actually prolonged pressure on that particular area this isn't just like a short term thing this is more of a prolonged pressure and it's going to result in that sore appearing but sometimes these can form over a few hours as well not necessarily days or months this can be over a few hours you might see some red blanchin areas which is the sign of the start of the pressure ulcer or sore starting to happen. So what does red blanchin even mean? So red blanchin is where if you've got a red area on the skin you press it like that and it should go white so you press it down it's white and then it goes back to the pink red colour but if you're pressing it and there's no blanchin at all then that means it's just gone that little bit stage up and the pressure damage has really started basically because red blanchin it's it's not good but it's not bad bad just might mean that that person's been lying in a certain position for far too long and they really need to be moved and they should be repositioned more frequently just to stop that pressure. So when it gets to that point where it's not blanching you're pressing it there's no white it's just completely red that is classed as a category one pressure sore. This means that person will have to be repositioned more frequently some extra steps will have to be put in place to protect that and stop the skin from breaking down further like a barrier cream and the skin around it and the skin covering it will be intact as well just to point that out it will just be red but it won't be broken there'll be no broken areas or anything like that there'll be no blisters it's just purely a red spot but you have to put those extra precautions in place to prevent that from happening. So if there is some skin loss so there'll be partial thickness of the pressure area there'll be some skin loss sometimes it can look like a small blister or a large blister but there'll be no bruising there'll be no redness no darkness underneath it'll just be a clear blister round in shape and that's even without the skin being broken as such and that sort of pressure also should be reported and it should be documented as well in the patient notes. But the tissue viability nurses don't need to be contacted at this point just your datex reporting however whichever guidelines or policies procedures for your local trust whatever they say to do do that basically. So catatigree three when there's full thickness skin loss included in this so then there will be some fat exposed but there's not going to be bone muscles tendons anything like that none of that will be exposed yet but there will be some fats may be exposed in this blister area or this open broken skin area and with the category three you must also report this fill in the datex and you should also refer to the tissue viability nurses in your local trust. So category four pressure ulcer this is a step up again you're going to have a full tissue loss you're going to have muscle exposed tendon exposed sometimes bone exposed this might also include what they call undermine in or tunneling which is where the pressure ulcer is quite deep but there's a little hole where it's tunneling underneath even further and you can't actually measure it and you don't know how deep that is actually going because you can't physically see it and that's when you have to get the probe and measure sort of into that area to sort of assess how deep this is. This also depends where this category four is if this is on the sacrum area the buttox somewhere that's got a bit of meat to it this might be a lot deeper but if this is on an ear or an elbow ankle then this can be quite a shallow grade four if that makes sense because there's not as much fatty tissue or muscle arranged like that around to break through but if it's going to be on the buttox or anything like that this is going to be so much but worse than it is and I think that's where the confusion between the categories might come in and you sort of might have a bit of debate with colleagues or nurses about what sort of category this actually is and you might have to get advice from the tissue viability nurse is as a result. So deep tissue injury is the one that I don't like this is the one that I hate the most because you have no idea what is going on underneath. This is going to look really red really like dark dark dark angry red colour it's going to look dark purple black it's going to be non-blanching at all this colouring might be under a blister as well so usually blisters are quite clear and there's fluid inside but sometimes you can have a blister and it'd be dark purple underneath that's going to be a deep tissue injury because that colouring is telling you that it's going deeper down. With this sort of category pressure ulcer you need to fill in a DTEC incident report again report this but you don't necessarily have to make a tissue viability referral to this just keep monitoring it and put your measures in place like hourly returning area creams things like that to try and stop this from breaking down further and hopefully it'll resolve but if in doubt you can always contact your tissue viability team who are a massive massive help and next is unstageable so I think this is the equivalent to ungradable back on the old grading systems so it'll be unstageable or ungradable because you're looking at it and you've got no idea you don't know how deep it is you don't can't really work out what's going on underneath because there's so much slough on top and as well as being sluffy this might be necrotic so there might be some dead black skin areas to this particular wound site and that again needs to be reported the DTECs has to be filled in and this absolutely must must have to refer to the tissue viability nurses so that extra measures can be put in place to minimise this and resolve and if you're out in the community so if you're a community nurse this category and the unstageable category must be reviewed weekly by the district nurse or the community nurse so sometimes the oxygen masks can leave marks the tube in the nasal specs can leave marks behind the ears on the nose also people out there healthcare professionals out there who put the pulse oximeter supposedly for the finger who put it on the ear which it should not be on the ear at all because this is what it can cause it can cause burning it can cause pressure ulcers it can cause all sorts of problems because it's been put in the wrong place there are proper ear sats pulse oximeters that you can use on the ears and it's worth looking into that if you've got a patient that really needs that sort of level of monitoring if that makes sense just to prevent that prof pressure ulcer from happening also catheter tubing so sometimes if a catheter's been on a particular side of the leg for a long period of time and nobody's monitored it can leave really red markings so from maybe from toilet seats if they've been sat in a toilet seat for far too long it can cause that ring around it blood pressure cuff's been on too long it can leave markings i've seen photos of this as well i haven't luckily i haven't seen any of these happen out there in practice but it does happen i've seen photos and just from the training that i had just made me a lot more aware of these things that can happen and hopefully i'm going to prevent this when i go out there and practice and this type of pressure also also has to be datex reported and also the tissue viability nurses included if it's a category three four or unstageable and last but not least the wonderful wonderful moisture lesions so one of the most common types of moisture lesions i've seen are residents or patients that wear pads they're incontinent of urine so technically it's probably urine burns but it's obviously caused a moisture lesion but i have also seen moisture lesions in people they're completely incontinent they don't wear pads but they can still get it so they can get them under the breasts in the groin areas on the buttox so all sorts of areas you can get these moisture lesions whatever there's moisture basically and the big difference to tell what's a moisture lesion and what's a pressure sort is with moisture lesions they are usually like this they're not rounded they're completely jagered edges if it's on the buttox they're usually mirrored usually mirrored not always the case but they're usually mirrored on each buttox so say you've got the line of the buttox there so each side there'll be this a same sort of pattern and it's caused that pressure and it just sort of mirrors each other it's like a this they call it the butterfly effect i think from what i've heard from people saying and it's just this red rashy sort of looking area sometimes the skin's broken sometimes it's not broken it'll be red it'll be blanshing and sometimes it doesn't blansh and also as part of this you can have a combined categoryed pressure ulcer so you could have moisture lesion but then it could have like a category two inside of it so you could have your moisture lesion then a small ulcer inside of it so that would be a combined or mixed sort of pressure ulcer and for both of these so the moisture lesion or if it's a combined one that also has to be datex reported but for moisture lesions you don't need a tissue viability nurse to be included in this so that is it from me if you need any more information advice i'm going to post the links below so have a look at those links you can speak to your tissue viability nurses for any more advice or if you're unsure about categories anything like that or a patient if they're at risk the tissue viability nurses are absolutely amazing and they'll know exactly what to do what creams to use all of that so just inform them or go to them if you need any more help or information so always thank you so much for tuning in thanks for watching and i shall see you next time