The affected area of skin appears discoloured and is red in a Caucasian person, and purple or blue in people with a darker complexion. Grade one pressure ulcers do not turn white when pressure is placed on them. The skin remains intact but it may hurt or itch, it may also feel either warm and spongy, or hard. In grade two-pressure ulcers some of the outer surface of the skin (the epidermis) or the deeper layer of skin (the dermis) is damaged, leading to skin loss. The ulcer looks like an open wound or a blister.
In grade three-pressure ulcers, skin loss occurs throughout the entire thickness of the skin. The underlying tissue is also damaged. However, the underlying muscle and bone are not damaged. The ulcer appears as a deep cavity like wound. A grade four-pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged and the surrounding tissue begins to die (tissue necrosis). The underlying muscles or bone may also be damaged. People with grade four pressure ulcers have a high risk of developing a life-threatening infection. Unit 229 Identify pressure sites of the body
For those individuals that are bed bound they are more likely to suffer with pressure ulcers on their: •Shoulders and shoulder blades •Elbows •Back of the head •Rims of the ears •Knees, ankles, heels or toes •Spine •Tailbone (coccyx’s) For those individuals that use wheelchairs maybe more prone to pressure ulcers on their: •Buttocks •Back of arms, legs •The back of the hip bones Identify factors which might put an individual at risk of skin breakdown and pressure sores •Mobility problems •Poor nutrition •Aged (over 70 ) •Incontinence (urinary or/and bowl )
Serious mental health conditions •Underlying health condition ( that disrupts blood supply and makes skin more fragile) Unit 229 Describe how incorrect handling and moving techniques can damage the skin Poor positioning can lead to the individual slipping/sliding on the bed this action can cause friction and shearing of the skin, this can also happen by not using the correct techniques or equipment for instance by using a sliding sheet and placing the individuals feet being flat on the bed can help with correct positioning and reducing the risk of friction or shearing.
Identify a range of interventions that can reduce the risk of skin breakdown and pressure sores •Relieving pressure •Promoting circulation (maintaining activity) •Allowing air to reach the skin •Reducing temperature and humidity and humidity •Avoiding incontinence •Allowing skin to being inspected •Good personal hygiene •Nutrition •Quit smoking Describe changes to an individual’s skin condition that should be reported You should report any new sore/ulcers or red areas to nurses or managers, or any changes to existing pressure sores should also be reported to nurses/doctors.
Once the sore as progressed to a grade two this should then be more thoroughly investigated by outside sources, (social workers, and health boards). It is important to do regular inspections of the individual’s skin and more frequently if sores are present. Unit 229 Understand good practice in relation to own role when undertaking pressure care area Identify legislation and national guidelines affecting pressure area care
The safe guarding or vulnerable adults – looks at our responsibility and accountability of keeping people safe and would include risk assessments to identify the skin breakdown •The care standards act – reinforces the importance of policies and procedures put in place by our organisations to protect the service users and this includes against skin care and prevention or pressure sores •The social care code of practice – also identifies roles and responsibilities of the care worker •NHS guidelines on wound care, tissue viability is relevant protocols that should be included in our organisations policies and procedures
Describe agreed ways of working relating to pressure area care Agreed ways of working related to pressure area care would be, by following your company’s policies and procedures, and that of the individuals care plan Describe why team working is important in relation to providing pressure area care Teamwork is essential as care can be given 24 hours a day and regular turning of the service user as well as good management needs to be given around the clock in order to prevent or stop the condition from worsening.
Most pressure ulcers can be predicted and prevented nursing assistants play a very important role in their prevention if a patient is at risk for getting a pressure ulcer all preventive measures, as stated by your facility must be done and documented. Preventing treating pressure ulcers needs the entire team to work together. Unit 229 Be able to follow the agreed care plan Describe why it is important to follow the agreed care plan The reason it is important to follow the agreed care plan as they are put together in the best interests of the individual based on what they wants, needs are .
It also covers all medical need and physical needs and will indicate the likelihood of pressure sores and where they are more likely to get them and by following the care plan will help greatly in prevention. Identify any concerns with the agreed care plan prior to undertaking the pressure area care As the care plan is updated regularly with changes to care that an individual will receive. Before you can help to provide care for that individual you should check for any changes i. e.
They start using different dressings or using pressure relief aids like a repose boot, make sure you understand your role and seek advice from seniors (nurses) as to what you need to do. Describe actions to take where any concerns with the agreed care plan are noted You should take note of your concerns and report to your seniors before you continue care make sure you document any concern on your paperwork as well if the concerns were serious then you should report to a manager or where necessary to outside sources, i.e. doctor , social worker or therapists depending on the concerns.
Maybe a change of diet is required as the individual has increasing trouble swallowing but the car plan still shows that a normal diet is required. Identify the pressure area risk assessment tools which are used in own work In our workplace we use the waterlow pressure ulcer risk assessment/prevention policy tool, which is said to be the easiest to use in the healthcare industry. Explain why it is important to use risk assessment tools.
Without the use of these tools there would be many more individuals suffering with preventable pressure ulcers as by the following guidelines of these tools you are better educated about the care that needs to be given thus reducing any unnecessary pain, infection or discomfort Unit 229 Understand the use of materials, equipment and resources available when undertaking pressure area care Identify a range of aids or equipment used to relieve pressure •Repose boots
Air flow mattresses •Pressure cushions •Permaflow elbow pads •Heel protectors •Leg support trough Describe safe use of aids and equipment For instance you may use joint protectors for the heels or elbows that come in the shape of a foam pad with a strap to hold them in place so you need to make sure they stay in place but also you must be sure that the straps do not exert excess pressure and cause more damage Identify where up to date information and support can be obtained