Health and Social Care Diploma Workbook

Learner name………………….

Undertake agreed pressure area care.

Introduction

This workbook will support you to develop the required outcomes for the Level 2 Health and Social Care Diploma for Unit HSC 2024

Learning Outcomes

The learner will:-

1. Understand the anatomy and physiology of the skin in relation to pressure area care.

2. Understand good practice in relation to your own role when undertaking pressure area care.

3. Follow the agreed care plan.4. Understand the use of materials, equipment and resources available

when undertaking pressure area care.5. Prepare to undertake pressure area care.6. Undertake pressure area care.

Theory relating pressure area care will be covered during Health and Social care workshops.

Practical instruction will be given by experienced staff in your work place.

Learners will also need to complete a workbook and activities to demonstrate their understanding. These will be handed in to the health and social care assessor and feedback will be given. The workbook should then be kept in your portfolio as evidence for your Diploma.

Competence will be assessed in the workplace by health and social care assessors.

The Skin.

The skin weighs about 15% of total body weight and receives about a 1/3 of the blood supply. It varies in thickness from 1/50” on the eyelids to 1/3” on the soles of the feet.

Skin functions1. The skin provides a tough covering for the body and is naturally acidic.

This acidity helps to protect against infection.2. The skin is sensitive. Some areas such as the lips and finger tips have

greater numbers of nerve endings and are especially sensitive. The skin registers and distinguishes between touch, pain, itch, hot and cold sensation.

3. The skin helps to maintain body temperature. Blood vessels in the skin will dilate or constrict in response to temperature changes. When the body is hot the skin pores will open and release sweat. When the body is cold the skin constricts, the tiny muscles (erector pili) at the base of the body hairs are contracted and the hairs become erect forming ‘goose bumps’ on the skin.

4. Waste products can be excreted through the skin in the sweat.5. When the skin is exposed to ultraviolet light it manufactures vitamin D

which is essential for bone strength.6. The skin stores water and fat.7. The skin is able to absorb moisture. Cream is absorbed into the skin

and some medications are designed to be absorbed gradually into the circulation via the skin e.g. nicotine patches.

The top layer of the skin is the epidermis. This is a layer which has no blood vessels and regenerates every 4-6 weeks. On the surface there are dead cells which flake off or are washed off.

The lowest layer of the epidermis interlocks with the dermis. The dermis contains very small blood vessels called capillaries, pain touch receptors, hair follicles, sweat glands and sebaceous glands which secrete sebum (a substance rich in oil which lubricates the skin)

Next is the subcutaneous layer made of fatty tissue. Here there are larger blood vessels and the fat helps to cushion, insulate and protect the body.

Aging Skin As skin gets older it becomes thinner especially over the legs and

forearms. Less fat in the subcutaneous layer leaves bony prominences less

protected. The epithelial layer is more wrinkled. The dermal/epidermal junction flattens and the 2 layers are more easily

separated. ( Increased risk of skin tear) There are less sweat glands and the skin is drier. The blood vessels

are more fragile and easily damaged ( leading to skin haemorrhages called senile purpura)

The skin is less elastic. Aging skin is less able to manufacture vitamin D. There is less ability to resist infection. There is decreased pain perception. Circulation is decreased (leaving elderly people more prone to heat

stroke.) Over a life time there may have been damage by the sun. Healing may take longer.

Picture from davemoshe.com

Healthy Skin

There are lots of recommendations for how to maintain healthy skin. For example:-

Drinking plenty of water Regular skin cleansing Moisturiser Plenty of vitamins and minerals in the diet. Getting enough sleep. No smoking Limit exposure to the sun/ put on high factor sun block Regular exercise

However this list does not include something essential: - Blood Supply

If the skin does not have a blood supply it will die.Instead of healthy skin there will be a pressure sore.

Pressure sores, pressure ulcers, decubitus ulcers and bed sores are all names which are used to describe the same thing.

Definition of Pressure Ulcers.

Localised injury to the skin and /or the underlying tissue usually over a bony prominence, as a result of pressure, or pressure combined with shear and/or friction. A number of contributing factors are also associated with pressure ulcers.

Pressure Ulcer Advisory Panel 2007.

For tissues to be viable i.e. stay alive, they have a basic requirement for oxygen and nutrients to help growth and repair and for waste products to be removed.

The oxygen and nutrients are transported around the body in the blood by the arteries and then through tiny capillaries.

When there is disruption to the blood supply through the capillaries this area of tissue will die and this will result in a pressure sore.

Nursing and residential care. Nov.2007.Vol9.No 11 p.516

Pressure is when the body tissue is compressed or squashed so much that the blood cannot reach the skin. In an elderly frail person it might not take much pressure to stop the blood getting to the tiny surface blood vessels.

Picture from virtual.medicalcentre.com

Friction is when 2 rough or moist surfaces rub together and cause superficial skin damage. The rough skin on the heels is rubbing on the sheet.

Shear is when the skin is being pulled in 2 different directions. In the example the skin of the back is stuck to the sheet but the internal bones are moving further down the bed.

Picture from shema-pressure-ulcere.jpg

Great care must be taken when moving and positioning people not to drag them across rough surfaces or allow them to gradually slip down the bed

Pressure Sores.

Deep pressure damage

Superficial pressure damage

Muscle

Subcutaneous tissue

Skin

Bony

The first subtle sign you will notice of pressure damage is an area of skin which remains red 30 minutes or more after the pressure has been removed. At this stage the skin is not broken and will usually recover in a couple of days if pressure is kept off it. This is a Stage 1 Pressure sore

The diagram shows all 4 stages of the Stirling Pressure Sore Scale

Picture from spinal-injury.net

Stage 1. Discoloration of intact skin, light finger pressure will not alter the discoloration.

Stage 2. Partial thickness skin loss or damage involving the epidermis and/or dermis

Stage 3. Full thickness skin loss involving damage or necrosis (death) of the subcutaneous tissue, but not extending to underlying bone, tendon or joint.

Stage 4. Full thickness skin loss with extensive destruction and tissue damage or necrosis extending to underlying bone, tendon or joint.

Sites of Pressure SoresPressure sores are most likely to develop where there is a lot of pressure exerted over several hours at a place on the body where the bone is close to the surface of the skin and there is very little cushioning by subcutaneous fat. These sites are commonly the sacrum (bony area at the base of the spine), hips and the heels. There are also other sites which can be affected especially in people who are at very high risk of developing sores.

Sites of Pressure when lying down

People are also at risk of developing pressure sores in sitting positions and from pressure exerted by shoes or equipment.Care must be taken to ensure that vulnerable people are not sitting or lying on anything which will increase pressure on the skin such as creases in the sheets, zips, catheter tubing and buttons.

Assessing Risk Factors for Preventing Pressure Sores.

Everything possible must be done to prevent pressure sores from developing. All vulnerable people who receive care from a home care provider need to be assessed for their risk of developing sores so that appropriate equipment and care can be requested from the community occupational therapist or district nurse.

There are many different factors which will make a person more likely to develop sores. The assessment needs to take all of these into account.

Risk increases with age because of the changes which take place within the skin.

Women are at slightly increased risk of pressure sores due to anatomical differences making it more likely that their skin is wet.

Dry skin may crack and allow infection into the body. Someone with broken skin e.g. a person with eczema, is more likely to

have infected skin which weeps and the wetness may make the skin less strong.

Some people with poor circulation may have oedema in their legs or other parts of their body. This is when fluid collects in the tissues and is not pumped back to the heart properly. This skin is soft and delicate and prone to leaking. It is very easily damaged.

Very heavy people put more pressure on their tissues. Very thin people have very little padding over their bones which leads to

an increased risk of pressure damage. Urine on the skin will gradually weaken the skin and faeces will irritate

and break down the surface if left there. People with a poor appetite or people who are losing weight will not be

getting the balanced nutritious diet which is needed for skin repair and maintenance.

People with poor mobility are at increased risk. They may not be able to move because of physical disability or may be depressed and not want to move.

People with reduced or absent sensation are much more at risk because they cannot respond to the signals the body normally gives when pressure becomes too great. This would include people who have had strokes, people who are paralysed or people with nerve damage due to diabetes.

People who are near to the end of their life or dying can sometimes develop pressure sores very rapidly due to a combination of factors such as lack of food and fluids, immobility, very poor circulation and abnormal blood. This combination of factors is called terminal cachexia.

Anyone who smokes is at heightened risk of sores because smoking will cause narrowing of the arteries and problems with the blood circulation.

People who are anaemic have increased risk because their blood is carrying less oxygen which is essential for healthy skin and tissues.

There are several risk assessment tools used within the care sector. The Braden scale 1988, the Norton scale 1962 and the Waterlow scale 1995.

This assessment tool should be used to find out if people are risk. If they have a significant risk it must be repeated at regular intervals and used to design a care plan which will prevent any sores from developing.

Think of the people you care for and the risk factors they have for pressure sores. You need to be aware of these all the time. Even though there is a care plan to follow the situation can change very rapidly during episodes of ill health and the carer will be the first person to notice that the plan needs to be updated. Be sure to report any concerns to the person in charge and to document any changes in the daily records.

The care plan Should state clearly what the individual risks are. Describe the equipment which should be used to relieve pressure. Describe how to position the person in their chair or bed. Give guidance about how often an individual should be turned or

moved.

Nutritional factorsIf nutritional factors are identified such as poor diet, weight loss or lack of appetite then there needs to be a separate care plan outlining the action to take to improve the person’s nutritional status for example:-

Vitamin and mineral supplements Nutritional supplements Regular weighing Assistance to eat Pureed food

Education of the service user and their informal carers

It is important to explain to the service user and their informal carers how to prevent pressure sores from forming. They may need information about how to turn the person in bed or how to use specialist equipment

Skin Inspection

It is important for care staff to be very observant and to pick up subtle changes which may indicate skin damage. The signs to look for are:-

Purplish/bluish patches on dark skinned people Red patches on light skinned people Swelling Blisters Shiny areas Dry patches Cracks, calluses and wrinkles

The signs to feel for are:- Hard areas Warm areas Swollen skin over a bony prominence.

When a new person is accepted by a care provider, who is at risk of developing pressure ulcers, it may be possible to thoroughly check their skin during personal care This will enable prompt treatment and ensure that the staff do not get blamed for causing a sore which actually developed before the organisation was involved in giving care.If personal care is not normally given but there is a concern that a service user may be developing sores, the carer should ask for permission to check the appropriate areas. If permission is not given then he/she should pass on her concerns to her manager and the person’s GP.If a sore is found then the position and condition of the sore must be accurately described and recorded in the care records. The supervisor or manager must be informed and they will make a referral to the local district nursing service.

Wounds

Open wounds heal best if they are disturbed as little as possible and are kept in a warm moist environment. Try to handle the individual so that their dressings stay in place but if the dressing does come off cover the area with a non-stick sterile sheet until the district nurse is able to do the dressing. Sometimes when people have smaller superficial wounds they can bathe and shower as normal and care staff may be authorised to put on a small dressing. If you have been asked to clean and dress a small pressure sore/wound you will need to prepare yourself and read the care plan. Check you have the right dressing. Ensure that nothing touches the wound once the person comes out of the water. Dry gently around the wound using a clean dry wipe or gauze. Do not dry or touch the wound. Check that there are no obvious signs of

infection and then apply the dressing wearing clean gloves and holding the dressing at the edges to prevent any contamination.

Action to be taken by care staff to avoid sores People who are at risk will need to move at regular intervals e.g. by

being turned in bed or only sitting out for a few hours or changing position enough for the blood supply to recover. Some air mattresses are able to inflate and deflate to turn a person automatically.

A chart can be used to record turns and position changes. Padding may be used between limbs and in seating to protect bony

prominences. Appropriate equipment should be provided and used correctly The skin should be free of moisture. Wet skin will stick more to the

sheets and the skin will become softer and more easily damaged if it is wet. Incontinence pads must be changed before they overfill. Faeces must be removed from the skin as soon a possible as the enzymes will irritate the surface.

Skin should be kept in good condition by using gentle soaps and moisturising cream to avoid dryness.

Any signs of pressure damage must be reported immediately. There must be clear documentation and good teamwork to ensure that

pressure area care is done on time when needed. This may involve shared care with family members and district nurses so there must be excellent communication between the different group to ensure continuity of care.

An occupational therapist can be contacted to assess for new equipment.

Moving and handling must be done with great care to avoid friction and shearing forces. People must not be dragged up and down their beds

Their position in their bed or chair should be supported so they do not slip and cause shearing damage.

Risk assessment must be done monthly or whenever there are changes.

Teamwork is vital. Everyone must know what to do and play their part

Picture from hillrom.co.uk

N.B. Don’t!!

In the past it was recommended that staff rub the pressure area. This is no longer considered good practice. It may damage underlying tissues.

Staff should not be using water filled gloves, synthetic sheepskins or any doughnut shaped cushions for pressure relief.

The consequences of developing pressure sores.

The individualPressure sores can take a long time to heal which may impose enormous restrictions on a person’s lifestyle. They may need to spend many hours in bed during the daytime often lying on their side. This in turn can lead to social isolation, depression and loss of social skills. Their muscles will weaken and they will be at increased risk of developing a chest infection.

If sores become infected there is a risk that infective organisms could enter the blood stream and cause septicaemia and possible death. Antibiotics themselves can cause loss of appetite and unpleasant diarrhoea.

Pressure sores are often painful. The person may need to take regular analgesia (pain killers) which in turn could lead to constipation or drowsiness.

The sores may smell offensive which could put off family and friends from visiting and have a big impact on the person’s self esteem.

Picture from sci.washington.edu

The organisationIt is often a sign of poor care if people develop pressure sores so the reputation of the organisation could suffer.

Sores cost a lot to heal. It has been estimated that the cost of treating a grade 4 pressure ulcer in hospital is £40.000 per patient.

In a community setting the care package may need to be increased to spend more time attending to dressing sores and providing pressure relief.

Pressure sores may have been caused because of neglect. The care provider may be reported to the local authority SOVA (safeguarding of

vulnerable adults) department and be investigated by social workers and possibly even the police.The regulatory body for organisations providing care in the community is the Care Quality Commission. They publish reports on care providers and insist on essential standards of care. A poor report from the CQC will make it difficult to attract new customers and that could make the care provider financially unviable. If there is serious neglect and far too many people develop sores the CQC has the power to shut down a care organisation.

Education

All care staff and their supervisors need to be fully informed about the risks of pressure sores and how they can be avoided. It may also be appropriate to give an explanation to the individual who is at risk and their family carers about the care which is required, so that they can help to keep their skin in good condition. If family members are taking someone who is at risk of pressure sores out for the day they will also need information about how to prevent sores from occurring.Wherever the individual goes their risk of pressure sores must be considered. This might mean that there need to be special arrangements for an out patient appointment or the hospital may need to be contacted following admission to highlight the care which is needed to prevent sores.Pressure area care is something which must be continued 24hours a day, 7 days a week. All staff, formal and informal carers, new staff, bank staff, night sitters etc. have to play their part to ensure that the skin remains healthy.

EquipmentIn the community equipment can be obtained via the district nurses or occupational therapists. Profile beds and pressure relieving mattresses can be made available on loan. Families may wish to purchase specialist pressure relieving equipment from medical equipment suppliers but would be well advised to seek professional advice first.

Mattresses. A good pressure mattress will distribute pressure evenly so that bony areas are less likely to be damaged. Medium risk mattresses are often made of memory foam whereas high risk mattresses are normally air mattresses. These mattresses are made of alternating cells full of air with a continuous pump to keep them inflated. The pump must be set at the right pressure for the weight of the individual. The inflatable cells can sometimes be a little uncomfortable and the noise from the motor and the continuous movement may disturb sleep. There is usually a water resistant cover which must be kept clean and dry.

Picture from pressure-care.co.uk

Cushions. These come in many varieties from low to high risk. The high risk cushions are more likely to be air cushions which restrict seating to being near a socket. Extension leads should be used with extreme caution as they can be a hazard on the floor and lead to slips and trips and falls. As the air cushion inflates and deflates it can alter the individual’s seating position and care must be taken that the cushion does not cause the individual to slide out of the chair.

Pictures from healthandcare.co.uk, carehome.co.uk, hhproducts.ie

Pillows can be used to cushion bony prominences or to support under the leg while the heel hangs free.Joint protectors and padded boots may be useful to reduce pressure but sometimes they just add to pressure on another part of the body.

Pictures from squrrelmedicalshop.co.uk, vmmarketing.co.uk, squirrelmedical.co.uk

Legislation and Guidelines

Common Law requires people, “to take reasonable care to avoid acts and omissions which you can reasonably foresee would be likely to injure your neighbour”. Staff working for a care organisation could therefore be sued if they failed to give adequate pressure area care which resulted in a sore.

Health and social care act 2008. This act gave the CQC its powers to oversee and regulate the care given in care homes and by community care providers. There are 16 essential standards which must be met.

Outcome 4 : The care and welfare of people who use the service.It states that the registered person must take proper steps to assess the needs of the service user and to plan and deliver care to meet the service user’s individual needs. The registered person must also ensure the welfare and safety of the service user.The CQC expects that pressure sore risk will be assessed and that proper preventative measures will be put in place to prevent sores from occurring. The presence of sores will be considered an indication of poor care.

Outcome 7: Safeguarding people who use the service from abuse.The registered person must make suitable arrangements to ensure that service users are safeguarded against the risk of abuse and prevent it before it occurs. Abuse includes neglect and acts of omission which cause harm or place a person at risk of harm.If there are indications that an individual needs pressure area care and it is not done because of laziness, disorganisation or poor staffing levels then this individual has been ‘neglected’. The CQC would take firm action if this happened.

Outcome11: Safety and availability of suitable equipment.Equipment must be provided in sufficient quantities to meet the needs of people who use the service i.e. pressure relieving mattresses and cushions must accessed for anyone who needs them.

If the CQC finds that these outcomes are not being met it has the power to enforce improvements.

Mental Capacity Act 2005. This gives guidance about issues relating to capacity and consent.If, for example, a resident refuses to have pressure area care it is important to understand capacity issues.

All these documents can be found on the internet.

N.I.C.E. The National Institute of Clinical Excellence has produced guidelines on pressure ulcer risk management and prevention.

R.C.N The Royal College of Nurses has produced clinical practice guidelines on pressure ulcer risk management and prevention.

E.P.U.A.P The European Pressure Ulcer Advisory Panel has produced guidelines for the treatment and prevention of pressure sores.

The C.Q.C. Care Quality Commission (2009) Safeguarding Adults: Protocol and Guidance.

What do I do now?Once you have completed the activity book it will need to be returned to the assessor.

An assessor will also visit you at your place of work to assess your practical skills.