Practice No.
139
Reference: 10/06
Version 3
Page 1 of 8
New Practice note
February 2008
NMC Code of Professional
Conduct
GSCC Code of Practice for
Social Care Workers
Marsden Manual pf Clinical
Nursing Procedures
Management of Pressure Area Care
The ethos of care within Hampshire County Council Residential, Nursing and Day
Care Services, holds the safeguarding of the well being and independence of the
service user as a primary purpose of care.
This summarises the arrangements for maintaining the well being and independence
of vulnerable residents and other service users by managing the care of ‘pressure’
areas within the multi-disciplinary team.
Whilst elderly and disabled persons may be more vulnerable to developing pressure
injuries, these are generally preventable. Treating a pressure sore is far more difficult
than preventing one. The aim of pressure care is to identify factors that predispose to
the compromise of the tissue viability of an individual, and to eliminate or minimise
those factors.
A pressure sore is caused by unrelieved pressure on the skin, by friction or by
‘tearing/shearing’ forces. Pressure, the single most important factor in the
development of sores, occurs mainly when the individual remains unmoved for
inappropriate periods or exerts repeated pressure in one area, such as when using
poorly adjusted mobility aids. It mainly affects the skin. Friction and ‘tearing’ forces
are created by repetitive movement, such as sliding down in the bed or the use of
poor moving and handling techniques, and causes damage to and distortion of the
underlying tissue.
Almost half of all pressure sores develop over the sacrum and about a fifth on the
heels. Other areas at significant risk of damage are the buttocks and the hips. Whilst
an individual may not complain of discomfort, this does not necessarily indicate s/he
is not at risk, but may be the result of a lack of sensation or awareness which
increases the risk of developing pressure sores.
Factors which increase the vulnerability of a service user may include : Reduced mobility preventing normal adjustments to posture and position.
 Incontinence which can lead to skin damage and infection and will need to be
managed alongside pressure area care.
 Poor nutrition and / or hydration, affecting normal repair and replacement of
skin.
 Chronic ill health causing poor circulation, poor nutrition and damage to the
skin.
 Incorrect moving and handling techniques.
 Medication such as steroids which have the effect of decreasing the thickness
of the skin.
 Pain and stress which also compromise tissue viability and may be
particularly relevant to new residents and those recently hospitalised.
1.
2.
Care of potential pressure problems

The Registered manager will ensure that staff are trained in the
identification and care of pressure areas and the correct use of the
assessment tools and specialist equipment. (Copies of the Braden
assessment and wound care plan and pressure care checklist are
attached at the end of this document.)

The Registered manager may also delegate responsibility for tissue
viability care to a designated member of the management team.
Care of existing or developing pressure sores
Before Admission
 The pre admission assessment should determine the presence of existing
or potential sores and how they are being treated.
On Admission or on development of a sore
At all times it is necessary to obtain the consent of the service user to
assessment and treatment, to keep them, their advocate/family and all other
relevant persons, informed of progress and changes and to record all
discussions and actions in the service user’s personal file. Where this is not
possible all staff must comply with the requirements of the Mental Capacity
Act 2005. All decisions must be made in the best interests of the service user.

A Body Map should be completed to show the following :o The position and size of the sore – this can be indicated on paper,
but is best supported by a photograph of the sore which should
include a verifiable measuring scale. i.e. ruler
o The depth and severity of the sore
o The condition of the surrounding tissue
o If there is any exudate and of what type

A Risk Assessment must be made, using the Braden Scale for Predicting
Pressure Sore Risk. This tool is the most appropriate for use with older
persons and will inform decision making on the most appropriate action to
be taken to protect tissue viability. Staff should be aware that should they
need to refer to the PCT specialist, it may also be necessary to provide a
Waterlow score.

The Service User’s G.P. must be informed to enable a review of health
and medication.

A swab should be taken for analysis to determine the existence of any
infection.

An incident report must be completed, under ‘clinical incident’, upon
admission or as soon as the sore is detected, and the report copied to the
nurse advisor for attention.
3.

In residential care without nursing cover, it will be necessary to seek the
specialist advice of the PCT Tissue Viability Nurse.

In Day Care, it will be necessary to refer the situation to the Care Manager
for specialist advice, whilst ensuring that tissue viability is protected during
day care activities.

Occupational Therapy assessment will be part of the multi disciplinary
assessment, to identify the most suitable type of equipment to address the
specific needs of the service user.
Use of specialist equipment
Residential Care
For service users in residential care, the District Nurse assigned to the
service user will arrange the ordering of pressure relieving mattresses and
cushions.
Nursing Care
For service users in nursing care, pressure relieving mattresses and cushions
can be requested from the Joint Equipment Store. An order form can be
found online and requests emailed.
Day Care
For service users in Day Care, equipment should accompany the service user
following assessment arranged by the designated Care Manager.
4.
Care Planning

All assessments, multi disciplinary decisions and actions to be taken must
be recorded in the service user’s personal file.

Care planning should be holistic and address all areas of the service
user’s daily living activities.

Care plans must include wound care planning with regular monitoring and
review of pressure areas and sores.

Use of specialist equipment should be monitored for effectiveness and the
need for re-assessment.

The Care plan should be reviewed in all areas on a regular agreed basis
or as necessary as needs change.
AT RISK (15-18)*
MANAGE MOISTURE
FREQUENT TURNING
MAXIMAL REMOBILIZATION
PROTECT HEELS
MANAGE MOISTURE, NUTRITION
AND FRICTION AND SHEAR
PRESSURE-REDUCTION SUPPORT
SURFACE IF
BED- OR CHAIR-BOUND
* If other major risk factors are present
(advanced age, fever, poor dietary intake
of protein,
diastolic pressure below 60,
haemodynamic instability)
advance to next level of risk
USE COMMERCIAL MOISTURE BARRIER
USE ABSORBENT PADS OR UNDERWEAR
THAT WICK & HOLD MOISTURE
ADDRESS CAUSE IF POSSIBLE
OFFER BEDPAN/URINAL AND GLASS OF
WATER IN CONJUNCTION WITH TURNING
SCHEDULES
MODERATE RISK (13-14)*
MANAGE NUTRITION
TURNING SCHEDULE
USE FOAM WEDGES FOR 30E LATERAL
POSITIONING
PRESSURE-REDUCTION SUPPORT
SURFACE
MAXIMAL REMOBILIZATION
PROTECT HEELS
MANAGE MOISTURE, NUTRITION
AND FRICTION AND SHEAR
* If other major risk factors present,
advance to next level of risk
INCREASE PROTEIN INTAKE
INCREASE CALORIE INTAKE TO SPARE
PROTEINS.
SUPPLEMENT WITH MULTI-VITAMIN
(SHOULD HAVE VIT A, C & E)
ACT QUICKLY TO ALLEVIATE DEFICITS
CONSULT DIETICIAN
HIGH RISK (10-12)
MANAGE FRICTION & SHEAR
INCREASE FREQUENCY OF TURNING
SUPPLEMENT WITH SMALL SHIFTS
PRESSURE REDUCTION SUPPORT
SURFACE
USE FOAM WEDGES FOR 30E LATERAL
POSITIONING
MAXIMAL REMOBILIZATION
PROTECT HEELS
MANAGE MOISTURE, NUTRITION
AND FRICTION AND SHEAR
ELEVATE HOB NO MORE THAN 30E
USE TRAPEZE WHEN INDICATED
USE LIFT SHEET TO MOVE PATIENT
PROTECT ELBOWS & HEELS IF BEING
EXPOSED TO FRICTION
VERY HIGH RISK (9 or below)
OTHER GENERAL CARE ISSUES
ALL OF THE ABOVE
+
USE PRESSURE-RELIEVING SURFACE IF
PATIENT HAS INTRACTABLE PAIN
OR
SEVERE PAIN EXACERBATED BY
TURNING
OR
ADDITIONAL RISK FACTORS
*low air loss beds do not substitute for
turning schedules
NO MASSAGE OF REDDENED BONY
PROMINENCES
NO DOUGHNUT TYPE DEVICES
MAINTAIN GOOD HYDRATION
AVOID DRYING THE SKIN
Assessment of skin condition
when re-positioning a Service User
Consider all pressure areas
Including hands and elbows
knees and heels
Is there any redness of the skin ?
Is the skin broken ?
Yes
Ensure the skin is clean using
plain warm water and patting dry,
re-position the service user and
re-assess the pressure area in 30
minutes.
Ensure that any pressure relieving
equipment is functioning correctly.
No
Ensure the skin is clean using
plain warm water and patting dry
and re-position the service user.
Consider if the time between repositioning can be extended.
On re-assessment, is the skin still red ?
Yes



Check that any pressure relieving
equipment is functioning correctly
Reduce the time interval between repositioning
Ensure the skin is clean and dry as
before
No
Resume re-positioning at the
time intervals indicated in the
care plan.
TISSUE VIABILITY CARE PLAN
RESIDENT NAME
NAMED NURSE
PROBLEM NO.
WOUND ASSESSMENT DIAGRAM
Body Maps on reverse
indicate
Site of wounds
Wound depth (cm)
cm
AIM
DRESSING RATIONALE
ALLERGIES
PLAN
Cleansing Agent
Primary Care
Skin Care
Secondary Dressing
Frequency of dressing Change
If wound has not healed within 6 weeks, re-assess. Consider referral to district
nurse or tissue viability nurse and record actions.