This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the second two descriptors in the Skin domain, to help you assess your or your relative’s “level of need” in this important domain.
Don’t miss parts one, two, three, four, five, six and seven of this series!
Get Help Breaking Down The Decision Support Tool: An Overview
Get Help Breaking Down the Decision Support Tool: Breathing Part 1
Get Help Breaking Down the Decision Support Tool: Breathing Part 2
Get Help Breaking Down the Decision Support Tool: Nutrition Part 1
Get Help Breaking Down the Decision Support Tool: Nutrition Part 2
Get Help Breaking Down the Decision Support Tool: Continence
Get Help Breaking Down the Decision Support Tool: Skin (including tissue viability), Part 1
Following the 2018 revisions of the DST, Skin moved “up” from number 8 to number 4. As in the 2012 version, it still follows the Continence domain, highlighting the interaction between skin integrity and incontinence. Unlike the 2012 version, however, in the 2018 DST the Skin domain is followed by Mobility, emphasising the significant impact of immobility on skin integrity. Any interrelation between domains (complexity), and its potential impact on the delivery of care (intensity/unpredictability), should be considered in the analysis of the four Key Characteristics.
The assessed levels of need in the Skin domain range from ‘No Needs’ to ‘Severe’. There is no descriptor for a ‘Priority’ level of need in this domain, indicating that an issue with skin integrity is unlikely to present an immediate risk to life, in and of itself. That being said, the complications arising from pressure damage or other skin wounds can certainly be life threatening and swift. Skilled treatment is essential to prevent rapid deterioration. The vast majority of people being assessed for CHC will fall into the descriptors for a ‘Low’ or ‘Moderate’ level of need. The ‘High’ and ‘Severe’ levels of need are reserved for those suffering from extensive or non-healing wounds, which will usually require specialist treatment by the Tissue Viability Nurse (TVN), or vascular team.
The following clinical factors are relevant to the assessment of ‘High’ and ‘Severe ‘level needs in this domain:
- What is the extent of any existing skin damage – i.e., how deep are the wounds**?
- What treatment regime is required and who delivers it?
- Is the treatment effective – i.e., are the wounds responding/improving?
- Are any specialist dressing techniques required, e.g. compression?
- Is there any evidence of necrosis (white slough and/or dead, blackened tissue)?
**NOTE – Wounds are “graded” from 1-4 using a wound chart. Grade1 describes very superficial damage to the top layer of skin (epidermis), such as reddening or blanching. Grade 4 describes extensive damage to all three layers of the skin (epidermis, dermis, hypodermis). Extensive skin damage puts the underlying bones and joints at risk.
The main difference between the descriptors for a ‘High’ and ‘Severe’ level of need in this domain is the grading of the wound (depth/extent of damage) and whether it is showing signs of healing (“responding to treatment”).
Now that we’ve outlined the type of things the MDT will be considering in this domain, let’s take a look at the descriptors for ‘High’ and ‘Severe’ levels of need. For each level of need, we provide a case study to give you a better understanding of how the descriptors of need might be applied at your or your relative’s assessment.
HIGH
| Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is not responding to treatment
OR Pressure damage or open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’, which is/are responding to treatment. OR Specialist dressing regime in place; responding to treatment. |
Key FactorsGrade 2-3 wound, which is NOT showing signs of healing despite treatment. Grade 3-4 wound, which IS showing signs of healing. Specialist dressing regime, with good effect (e.g., compression to improve vascular flow). |
CASE STUDY – HIGH
Care Home Skin Care Plan
Mrs. X remains very fragile, immobile and requiring nutritional supplements, impairing skin healing. Waterlow assessment tool score 32, very high risk. Air-flow mattress and pro pad cushion provided for pressure relief. Pressure wound on right foot plantar of first metatarsal head referred to tissue viability nurse for appropriate support and dressing advice, which is ongoing. At high risk of skin breakdown due to incontinence, poor mobility and advanced age. Requires regular monitoring and repositioning to promote healing and prevent further skin breakdown. Barrier cream administered as needed to prevent skin breakdown and promote healing and protection. Repositioned every 2 to 3 hours. Make sure there is a cushion pad when seated on chair or wheelchair. Always ensure booties on both feet.
Tissue Viability Nurse Review
Wound on right foot 1cm x 1.5cm, grade 3. Centre of wound is sloughy but minimal exudate; Hydrogel dressing to aid debridement and healing. Edges of the wound are pink and epithelising. No sign of infection. Wound appears to be healing well and decreasing in size.
Mrs. X presents with a ‘High’ level of need as she has pressure damage or open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’, which is/are responding to treatment.
SEVERE
| Open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’ which are not responding to treatment and require regular monitoring/reassessment.
OR Open wound(s), pressure ulcer(s) with ‘full thickness skin loss with extensive destruction and tissue necrosis extending to underlying bone, tendon or joint capsule’ or above. OR Multiple wounds which are not responding to treatment.
|
| Key Factors
Grade 3-4 wound, which is NOT showing signs of healing despite treatment. Grade 4 wound; extensive damage and necrosis to all layers of the skin. Multiple wounds, grade 2-4, which are not showing signs of healing despite treatment. |
CASE STUDY 1 – SEVERE
Care Home Skin Care Plan
Mrs. X remains very fragile, immobile and requiring nutritional supplements, impairing skin healing. Waterlow assessment tool score 32, very high risk. Air-flow mattress and pro pad cushion provided for pressure relief. Pressure wound on right foot plantar of first metatarsal head referred to tissue viability nurse for appropriate support and dressing advice, which is ongoing. At high risk of skin breakdown due to incontinence, poor mobility and advanced age. Requires regular monitoring and repositioning to promote healing and prevent further skin breakdown. Barrier cream administered as needed to prevent skin breakdown and promote healing and protection. Repositioned every 2 to 3 hours. Make sure there is a cushion pad when seated on chair or wheelchair. Always ensure booties on both feet.
Tissue Viability Nurse Review
Wound on right foot 1cm x 1.5cm, grade 3. Centre of wound is sloughy, exudating and wet. Outer aspect of right big toe is black. Wound black/necrotic but looks white and appears to be infected. Swab taken. Smell is also offensive, referred to GP for antibiotics. Hydrogel dressing to aid debridement and healing. Wound does not appear to be healing well and is not decreasing in size.
Podiatrist Review
Right first metatarsophalangeal joint wound with infection 15mm diameter with surrounding callous. Seems painful as Mrs. X pulls away when touched. Already commenced antibiotics but suggest a check for diabetes due to rapid deterioration.
Mrs. X presents with a ‘Severe’ level of need as she has open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’ which are not responding to treatment and require regular monitoring/reassessment.
NOTE – This Mrs. X has the same wound, with the same treatment regime, as the Mrs. X in our example above for a ‘High’ level of need. However, in this case, the wound is not responding to treatment, has not reduced in size and has become infected. Blackened tissue indicates necrosis and Mrs. X shows signs of pain when the joint beneath the wound is touched. These factors make the difference between the ‘High’ and ‘Severe’ levels of need, although the location, size and grade of wound are the same. This is not a large wound, only 1 x 1.5cm, but the absence of healing and involvement of the underlying joint greatly increase the risk. If the joint becomes infected, there may be no option but to amputate the toe, or even the foot, to prevent the spread of infection which could rapidly lead to sepsis and death.
CASE STUDY 2 – SEVERE
Care Home Skin Care Plan
Mr. X is cognitively impaired, immobile and doubly incontinent, placing him at very high risk of skin breakdown. He is nursed in bed 24-hours a day; he is occasionally hoisted into a chair for a few hours. He is nursed on an alternating air pressure mattress and is dependent on staff to reposition him every 2 hours to reduce the risk of skin breakdown. Mr. X is prescribed barrier cream which staff apply to his skin following each episode of incontinence in order to reduce the risk of excoriation and moisture related lesions.
Relevant History
A rash was first documented to have been noticed on his back. It was initially treated as a fungal infection with numerous courses of topical and oral treatments to try to manage the symptoms. However, none of the treatments were effective and, over the following few months, the rash spread from his back to his shoulders, torso, arms and down his legs. What began as a florid rash became round scaly circular patches which were believed to be ringworm. These continued to grow and spread, with lesions joining together. They then began to breakdown, splitting open, scaling off and resulting in extensive areas of exposed flesh across his back, torso, arms and down his left leg, which have not responded to treatment. Despite numerous referrals to dermatology services, the GP has been unable to secure a domiciliary assessment of Mr. X’s skin, and he was considered too frail to attend an outpatient appointment. Mr. X was eventually admitted to hospital with extensive open skin from shoulder to wrist. He was discharged hours later with more topical creams which were applied with no effect.
Current Wound Care Plan
Mr. X’s skin on his back, shoulders and arms remains open and excoriated. The areas bleed periodically, and often ooze serous, yellow or green exudate. Staff try to manage this as best they can, under the supervision of Tissue Viability Service. As no viable treatment has been found, care centres on prevention of infection and excellent pain management. Mr. X is prescribed a Fentanyl patch 25mcg/hour, with as-required Oramorph for breakthrough pain/prior to dressing changes and repositioning.
In addition to the skin rash, Mr. X also suffers with numerous grade 2/3 wounds to both heels, left ankle, left knee and left elbow. All these wounds continue to be present, sometimes being noted to be ‘healing’ and other times with larger dimensions noted again and with purulent exudate. Currently dressed with Comfeel Plus and Hydrogel, depending on depth and amount of exudate. The Tissue Viability Nurse has been asked to review to see if there are any other treatments available.
Mr. X requires a very high level of care and management to prevent further tissue breakdown and ensure his pain is well-managed.
Mr. X presents with a ‘Severe’ level of need as he has multiple wounds which are not responding to treatment.
We hope this has helped you to understand the second two descriptors in the Skin domain. Don’t miss the next part of this series, Mobility, coming very soon!
For further reading around the subject on pressure sores:
The dangers of pressure sores, pressure ulcers and bed sores
Take a holistic approach to improve your chances of getting CHC Funding
Does the NHS Safety Thermometer’s findings impact on your relative’s entitlement to CHC Funded Care?
NICE Guidelines – Pressure ulcers: prevention and management https://www.nice.org.uk/guidance/cg179
If you need help assessing your relative’s level of need in any domain on the DST, don’t hesitate to contact one of our specialist Advice Lines to discuss your case today. If you need expert advocacy support with any stage of your assessment or appeal, visit our 1-2-1 support page.
If there is a particular topic you would like us to cover, we’d love to hear from you! Just send an email via our “Contact Us” page with the subject “blog request” and we’ll do our best to cover your suggested topic.
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