Practice No.
139 / Version 3 / Page 1 of 8 / New Practice note
February 2008
Reference: 10/06 / 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. 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.

2. 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.

·  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.

3. 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)*
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 / MANAGE MOISTURE
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)*
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 / MANAGE NUTRITION
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)
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 / MANAGE FRICTION & 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)
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 / OTHER GENERAL CARE ISSUES
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

Yes No

Yes No

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.