Unit 64: Undertake Agreed Pressure Area
1 Understand the anatomy and physiology of the skin in relation to pressure area care
1.1 describe the anatomy and physiology of the skin in
relation to skin breakdown and the development of pressure sores
Skin functions
The skin provides a tough covering for the body and is naturally acidic. This acidity helps to protect against infection.

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.

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.

Waste products can be excreted through the skin in the sweat.

When the skin is exposed to ultraviolet light it manufactures vitamin D which is essential for bone strength.

The skin stores water and fat.

The skin is able to absorb moisture.

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, meaning and increased risk of skin tears.

There are less sweat glands and the skin is drier. The blood vessels are more fragile and easily damaged.

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.

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.

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.
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

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.

1.2 identify pressure sites of the body
Areas where bones are close to the surface and areas that are under the most pressure are at greatest risk for developing pressure sores. The most common sites are the back of the head and ears, the shoulders, the elbows, the lower back and buttocks, the hips, the inner knees, and the heels.

1.3 identify factors which might put an individual at risk
of skin breakdown and pressure sores
Factors that may put an individual at risk could be:
Aging skin
Alcohol abuse
Drug abuse
High exposure to UV rays
Poor or unhealthy diet
1.4 describe how incorrect handling and moving
techniques can damage the skin
It is important to recognise the effect on the skin caused by the forces of incorrect moving and handling. It is important to minimise friction and shear forces by limiting the potential for rubbing or dragging an individual’s skin during turning, or rolling and repositioning. Shear forces can occur when the skin is pulled sideways over muscle or bone when moving, as this can stretch and block the blood vessels, which restricts blood flow to the skin.

1.5 identify a range of interventions that can reduce
the risk of skin breakdown and pressure sores
Devices that can assist with manual handling include:
Slide sheets
Turning and repositioning aids that enable independent movement
1.6 describe changes to an individual’s skin condition
that should be reported
Any open sores or areas of skin that have been red and non blanching for 24 hours plus should be reported to a healthcare professional or a district nurse. If you have noticed an individual’s skin is slightly red in an isolated area, it should be reported to the manager and all the correct documentation should be done.

2 Understand good practice in relation to own role when undertaking pressure area care
2.1 identify legislation and national guidelines affecting
pressure area care
Some of the legislation and national guidelines affecting pressure area care are:- Care standards act 2000- Human rights act- N.I.C.E guidelines- European pressure ulcer advisory panel- The national pressure ulcer advisory panel- CQC essential standards of quality and safety.

2.2 describe agreed ways of working relating to
pressure area care
To maintain good pressure area care for individuals we as carers should always maintain good health and safety practices. This can be done by performing regular checks on individuals, and using turning charts to document the repositioning process and to make sure that all of their pressure areas are intact. We must always use the correct protocol and manual handling techniques to ensure skin safety at all times. We can do this by using slide sheets or other moving aids to help maintain an individual’s skin integrity.

2.3 describe why team working is important in relation to providing pressure area care
Team work is important, as it provides consistency of care. This allows everyone to know how things should be managed, and everyone will be working exactly the same and this in turn will decrease mistreatment of pressure area care.

3 Be able to follow the agreed care plan
3.1 describe why it is important to follow the agreed care plan
It is important to follow the agreed care plan, as it forms the basis of what is considered to be the best interest for the individual; it is unique to them and details their needs and preferences. All care givers to the individual should check the care plan to ensure they are giving the best quality of care, and if any changes are recognised, the care plan should be updated.

3.3 identify any concerns with the agreed care plan prior to undertaking the pressure area care
It is important to identify any concerns with the agreed care plan before undertaking the pressure area care in order to complete a risk assessment. Any new concerns should be noted and changed in order for the best care to be provided to the individual.

3.4 describe actions to take where any concerns with the agreed care plan are noted
Once a risk assessment has been completed, and concerns with the care plan have been found, it is important to address these issues with authorised staff so that the care plan can be updated to reflect these issues. Changes can then be made to ensure a high level of care is maintained for the individual. Any concerns should be verbally addressed, discussed and finally recorded in the written care plan.

3.5 identify the pressure area risk assessment tools which are used in own work area
3.6 explain why it is important to use risk assessment Tools
4 Understand the use of materials, equipment and resources available when undertaking pressure area care
4.1 identify a range of aids or equipment used to
relieve pressure
Aids and equipment to relieve pressure can include:
Pressure cushions
Airwave mattresses
Slide sheet
Repositioning charts
4.2 describe safe use of aids and equipment
When using a slide sheet, ensure that the individual is fully on the material before any force is applied, as this can cause shearing or friction to the skin. Mattresses and cushions should be checked regularly to ensure that they are still safe to use and in a good working order. Carers should ensure that when using aids, the correct policies and procedures are followed.

4.3 identify where up-to-date information and support
can be obtained about:
– materials– equipment– resourcesThe materials and equipment that should be used for an individual will be detailed in the manual handling section of an individual’s care plan. For further support and information you should seek information from your team leader or manager, G.P or district nurse. Resources can be found on the National Institute for Clinical Excellence website .