229 Undertake agreed pressure area care

Undertake agreed pressure area care
Unit 4222/229
Andrea Nemcova
The skin is largest organ of the body which is a natural protection barrier helping to maintain body temperature and protection from the sun.
It is made up of two layers - epidermis which is top protective layer
Dermis which is second layer containing nerves, sweat and oil glands and also hair follicles
Underneath these two layers is subcutaneous tissue which contains fat
Pressure ulcer develops when the area of the skin or underlying tissue has been damaged by continuous pressure, friction, shearing or combination. This usually happens on the bony area of the body where there is less body fat and the skin is thinner.
Pressure ulcer occurs when layers of the skin are compressed for prolonged period of time between bone and the surface .Blood is unable to circulate and is lacking oxygen and nutrients .It pressure is not relieved it will cause skin cells to die causing pressure damage.
Any area of the body(see picture below) can develop pressure ulcer.

Development of the pressure ulcer vary depending on the age of person, illness, mobility, moisture, nutrition and fluid intake, prolonged periods spend in the bed, chair or wheelchair without pressure relieving equipment. People unable to move themselves or re-position are at much higher risk as they rely on others to help them and are left in the same position for long period of time. It is advisable to be re-positioned at least every two hours and keep skin clean and dry.
Pressure ulcer can also develop by incorrect moving and handling techniques, by using incorrect equipment or using equipment incorrectly which can cause friction and breakdown of the vulnerable skin.
To prevent developing of pressure ulcers person need to be encouraged to move as much as possible, if care is in place pressure areas need to be monitored and any changes(redness, tears, non blanching skin) recorded and reported as soon as possible. Skin has to be kept clean and dry ,barrier creams applied where needed. Moving equipment such as slide sheets and hoist has to be used in correct way, pressure relieving equipment such as air mattress or pro pad cushion should be in use. Good nutrition and fluid intake is also important and should be monitored and recordd if possible.
Legislation as stated in National Institute of Clinical Excellence(NICE) clinical guidelines on “Pressure ulcer prevention and management ”(2014)states that correct moving and handling techniques has to be used, equipment has to be checked if safe to use. It also states that correct infection prevention, ,staff protection equipment is used, individual’s personal hygiene , condition of skin, nutrition and fluid intake is monitored. Guidelines has to be set up in the care plan by relevant health professionals. Pressure ulcer prevention guidelines can also be find in Health and Safety Act ,COSHH and the Manual Handling, The Human Rights Act, The Mental Capacity Act, The Health and Social Care Act (Regulated activities), The Essential Standards and The RCN Guidelines.
Following policies and procedures as stated in the agreed ways of working regarding prevention ,monitoring and reporting and treatment is vital as and only team work can effectively prevent development of pressure ulcers .
I have recently visited client Mrs.B when I was working with community nurses. They have asked me to update Waterlow and MUST charts. Client has a mobility issues and was spending majority of the day sitting in the chair. Although she already had a ProPad cushion in situ I have noticed that due to the client’s increased incontinence of urine there was a higher risk of developing a pressure sore in the sacral area. To prevent putting the client in the risk of possible tissue damage I have documented this in her are plan and reported these changes immediately to Community Nursing team.

Following a care plan is also important as it gives us picture of what has been happening and what needs to be done regarding pressure ulcer prevention or control and treatment. Care plan has to be checked prior to attending to the client, check whether it’s up to date ,identify any concerns. Pressure risk assessment form( Waterlow scoring) should be filled in by health professionals, updated regularly and kept in the client’s file. This scoring is most common tool use in the UK
Part of my job role is to make an initial risk assessment when visiting new client but also to check vulnerable pressure areas every visit. I also work with community nurses and part of my clinical competences is to fill and update Waterlow and MUST charts. To prevent putting the client in the risk of possible tissue damage I report any changes to Community Nursing team.

Name: __________________________________________________________ Hospital No: _________________________________

Instructions for use:
1. Complete on admission and recalculate daily WATERLOW CHART
2. Add scores together and insert total score.
3. If total score is 10+ initiate SKIN bundle care plan.
4. If total score 15+ initiate SKIN Bundle form at Bed side WATERLOW SCORE CHART Date (Day/Month/Year)
Time

Gender
Male
1

Female
2

Age
14 - 49
1

50 - 64
2

65 - 74
3

75 - 80
4

81 +
5

Build
Average BMI 20 – 24.9
0

Above average BMI 25 – 29.9
1

Obese BMI > 30
2

Below average BMI < 20
3

VISUAL ASSESSMENT OF AT RISK SKIN AREA
(May select one or more options)
Healthy
0

Thin and fragile
1

Dry
1

Oedematous
1

Clammy (Temp ↑ )
1

Previous pressure sore or scarring
2

Discoloured Grade 1
2

Broken Grade 2 - 4
3

MOBILITY
(Select one option
ONLY)
Fully
0

Restless/fidgety
1

Apathetic
2

Restricted/Bed bound
3

Inert (due to ↓consciousness/traction)
4

Chairbound/Wheelchair
5

CONTINENCE
(select one option ONLY)
Continent/catheterised
0

Occasional incontinence
1

Incontinent of Urine
2

Incontinent of Faeces
2

Doubly incontinent
3

Tissue Malnutrition (select one or more options)
Terminal Cachexia
8

Multi Organ Failure
8

Single Organ Failure
(Respiratory/Renal/Cardiac)

5

Peripheral Vascular Disease
5

Anaemia HB < 8
2

Smoking
1

Appetite
(select one option)
Average
0

Poor
1

N.G Tube/
Fluids only

2

NBM/anorexic
3

Neurological Deficit
(score depends on severity
Diabetes, CVA, MS, Motor/Sensory
Paraplegia, epidural

4-6

Major Surgery Trauma
(up to 48 hours post surgery)
Above waist
2

Orthopaedic, below waist, spinal >

2 hours on theatre table
5

6 hours on theatre table
8

MEDICATION
Cytotoxics high dose/long term steroids
Anti-inflammatory
4

TOTAL SCORE

NURSE INITIALS

Mattress
(Please tick as appropriate)
Enter name of other mattress if used
Pentaflex

Alpha Xcell

Autologic

Nimbus

Other mattress:

Chair cushion

Pressure relieving equipment is very important part in pressure ulcer prevention and treatment. These are : pressure cushions or mattresses which can be used on chairs, wheelchairs and beds
These can be already made of condensed foam ,gel or combination of both, electric air wave which is designed to accommodate client’s weight and relieve pressure according to this, cell blow up or deplete giving constant pressure in slightly different areas of the body or simple repose which is blow up cushion and needs pumping up prior to the use..Using slide sheets and /or hoist for re-positioning can prevent pressure ulcers development.
All equipment needs to be checked prior to each use, clean regularly, check whether it is working correctly(airflow delivering correct amount of air),hoist need to be serviced on regular basis, hoist slings check for tears ,rips etc. If equipment is not working correctly or is not suitable for client, damaged or service is out of date ,this has to be reported immediately. Faulty or damaged equipment must not be used as this could potentially harm the client.