Examples of Pressure UlcerRisk Assessment Tools

• Braden Scale• Norton Scale

Braden Subscales

• Sensory perception• Moisture• Activity• Mobility• Nutrition• Friction and shear

Braden Risk Assessment Scale(abridged version)

Sensory Perception

1 Completely limited

2 Very limited

3 Slightly limited

4 No impairment

Moisture 1 Constantly moist

2 Very moist

3 Occasionally moist

4 No impairment

Activity 1 Bedfast 2 Chairfast 3 Walks Occasionally

4 Walks frequently

Mobility 1 Completely immobile

2 Very limited

3 Slightly limited

4 No limitation

Nutrition 1 Very poor

2 Probably inadequate

3 Adequate

4 Excellent

Friction & Shear

1 Problem 2 Potential problem

3 No apparent problem

Copyright Barbara Braden and Nancy Bergstrom, 1988, reprinted with permission

Examine Braden scale

• Highest possible score is 23• Lowest possible score is 6

• Mild risk = 15-18• Moderate risk = 13-14• High risk = 10-12• Very high = <9

Norton Scale

• Physical condition• Mental condition• Activity• Mobility• Continence

Norton Subscales

Scale

Physical condition

Good 4 Fair 3 Poor 2 Very bad 1

Mental condition

Alert 4 Apathetic 3

Confused 2

Stupor 1

Activity Ambulant 4

Walk/help 3

Chair-bound 2

Bed 1

Mobility Full 4 Slightly limited 3

Very limited 2

Immobile 1

Continence

Not incontinent 4

Occasional 3

Usually Urine 2

Urine & Feces 1

Examine Norton scale

• Highest possible score is 20• Lowest possible score is 5

• Onset of risk = 16 or below• High risk = 12 or below

Pressure ulcer risk management

Develop a care plan based on subscale scores and other conditions Immobile = reposition q 2 hrs in bed Inactive = reposition q 1hr in w/c Incontinent = protect skin from exposure Malnourished = supplement oral intake Shearing = keep HOB as low as possible Limited awareness= assess skin daily

Reduce Shear

• Shear diminishes blood supply to skin

• Use positioning, transferring & turning techniques to minimize friction / shear injury

Repositioning

• Reposition bed-bound individuals at least every 2 hours

• Reposition chair-bound individuals every hour and encourage weight shifts every 15 minutes

• Reposition while on special beds/ overlays• Person must be turned 40 degrees to remove

pressure from sacrum

Positioning Devices

• Teach individual to reposition using the trapeze• Use lifting devices to move individuals who cannot

assist• Place pillows or wedges between knees and ankles

Head of Bed Elevation

• Limit amount of time head of bed is elevated to reduce friction and shear

• Maintain the lowest possible elevation• Avoid more than 30° head-of-bed elevation unless

medically needed

Side lying position

• Avoid positioning directly on the trochanters • Use the 30° lateral inclined position

Elevate Heels

• There must be space between bed and heels (float heels)

• Use pillows to elevate heels off the bed surface• Avoid hyper-extension of the knees• Check for injury from splints when used for

heel elevation

No Donuts

• Do NOT use plastic rings or donuts for pressure relief

• Can cause larger area of tissue injury because of intense pressure along the donut

X

Change Support Surfaces

General information• Most pressure reducing devices are more effective than standard hospital mattress

CONTROLLING IMMOBILITY

• Tilt • Recline • Cushion selection• Seat pan or sling• Sacral sitting• Armrests• Trunk supports• Footrests• Covers on cushions

Standing

• Circulation• Tone• Spasticity• Pressure sores• Bladder management • Community environments• Psycho-social indications

• Contraindications: Contractures Poor standing tolerance BMD loss Fractures Postural hypotension (dizziness)

Offloading

• Removes pressure from high risk areas or areas with ulcers

• Can be done with pillows, devices and/or beds

Elevate Heels• There must be space between the heel and bed• Use pillows to elevate heels off the bed surface• Avoid hyper-extension of the knees• Check for injury from splints when used for heel

elevation

Repositioning

• Reposition bed-bound individuals

(time should depend on patient (1 ½-3

hours)

• Reposition chair-bound individuals

every hour

• Reposition even while on special beds

Positioning Devices

• Teach individual to reposition using the

trapeze

• Use lifting devices to move individuals

who cannot assist

• Place pillows or wedges between

knees and ankles

Head of Bed Elevation

• Limit amount of time head of bed is elevated

to reduce friction and shear

• Maintain the lowest possible elevation

• Avoid more than 30° head-of-bed elevation

unless medically needed

Side lying position

• Avoid positioning directly on the

trochanters

• Use the 30° lateral inclined

position

No Donuts

• Do NOT use plastic rings or donuts for

pressure relief

• Can cause larger area of tissue injury

because of intense pressure along the

donut

Support Surfaces

• Most pressure reducing devices are more effective than standard hospital mattress

• Types– Overlays– Mattress replacements– Beds

Constant Low Pressure Support Surface Devices

Constant Low Pressure Support Surface Devices

Constant Low Pressure Support Surfaces

• Maximize skin contact area to reduce peak interface pressures– Foam– Gel– Fiber– Low Air Loss– Air Fluidized

Constant Low Pressure Support Surfaces

• The redistribution of skin interface pressure over as large an area as possible.

Constant Low Pressure Support Surfaces

Interface Pressure Measurement

Alternating Pressure Air Support Surface Devices

Changes the interface pressure on the skin over time by periodically inflating and deflating air cells under the body

Alternating Pressure Air Support Surfaces

Made up of interconnected air cells that cyclically inflate and deflate to periodically remove pressure from soft tissue

Alternating cellsHeadsection

Support Surfaces in Chair

• For individuals who spend majority of time in wheelchair:

– Use pressure reducing cushion– Instruct to also relieve pressure with hand

lifts if possible– Consider changing chair to

tilt/recline for more pressure

distribution