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 functions
1. 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
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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.
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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
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If the skin does not have a blood supply it will die.
Instead of healthy skin there will be a pressure sore.
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.
Pressure sores, pressure ulcers, decubitus ulcers and bed
sores are all names which are used to describe the same
thing.
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.
Bony
Muscle
Deep pressure damage
Subcutaneous tissue
Superficial pressure
damage
Skin
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.
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 Sores
Pressure 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.
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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 factors
If 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
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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 individual
Pressure 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 organisation
It 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.
Equipment
In 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.