Braden Score+

Skin Inspection +

Interventions +

Critical Thinking Pressure Ulcer Prevention

Identify risks of pressure ulcer development Differentiate between skin assessment and skin

inspection Discuss interventions for pressure ulcer prevention Test your accuracy at scoring a Braden Scale

Objectives:

Most pressure ulcers are preventable if patient risk is recognized in time

for preventive actions to be initiated.

Maklebust J., Sieggreen M.Y, (2001) Pressure Ulcers: Guidelines for Prevention and Mangement, 3rd ed.

“Determining patient risk for pressure ulceration is greatly assisted by the availability of research-based

instruments such as the Braden Scale”

Maklebust, J., Sieggreen, M.Y., Sidor, D., Gerlach, M.A., Mauer, C., Anderson, C., (2005).

Computer-based testing of the Braden scale for predicting pressure sore risk. Ostomy/Wound Management; 51(4):40-52

The Evidence• Detroit Medical Center nursing audits raised

concern whether staff nurses accurately used the Braden Scale to calculate pressure sore risk.

• In 2002 a learning/assessment module was instituted

• 2,500 nurses at the facility were tested regarding their knowledge of pressure ulcer risk assessment and prevention using this module.

Case Study: Mr. W.G.• 75-year-old male with Non-Hodgkins lymphoma, Alert and oriented• Height 5’9”, Weight 160 lbs.• Spends most of the day in bed. Makes occasional slight changes in body or

extremity position but unable to make frequent or significant changes independently. Occasionally slides down to foot of bed, requiring some assistance to move back to the top.

• Able to walk a short distance to the chair with assistance• Incontinent of stool• Continent of urine – uses urinal as needed• Skin occasionally moist from incontinence• Hgb = 8.5, Serum Albumin 3.1• Admitting Orders:

– Tube feeding formula 400cc q 4 hours per PEG– Dietician consult for tube feeding recommendations– Up in chair daily

Test Question

Using the Braden Scale, what is Mr. W.G.’s sensory perception score?

A. 1 (Completely Limited)B. 2 (Very Limited)C. 3 (Slightly Limited)D. 4 (No Impairment)

Test Question

Using the Braden Scale, what is Mr. W.G.’s sensory perception score?

A. 1 (Completely Limited)B. 2 (Very Limited)C. 3 (Slightly Limited)D. 4 (No Impairment)

Test Question

Using the Braden Scale, what is Mr. W.G.’s moisture score?

A. 1 (Constantly Moist)B. 2 (Very Moist)C. 3 (Occasionally Moist)D. 4 (Rarely Moist)

Test Question

Using the Braden Scale, what is Mr. W.G.’s moisture score?

A. 1 (Constantly Moist)B. 2 (Very Moist)C. 3 (Occasionally Moist)D. 4 (Rarely Moist)

Test Question

Using the Braden Scale, what is Mr. W.G.’s activity score?

A. 1 (Bedfast)B. 2 (Chairfast)C. 3 (Walks Occasionally)D. 4 (Walks Frequently)

Test Question

Using the Braden Scale, what is Mr. W.G.’s activity score?

A. 1 (Bedfast)B. 2 (Chairfast)C. 3 (Walks Occasionally)D. 4 (Walks Frequently)

Test Question

Using the Braden Scale, what is Mr. W.G.’s mobility score?

A. 1 (Completely Immobile)B. 2 (Very Limited)C. 3 (Slightly Limited)D. 4 (No Limitations)

Test Question

Using the Braden Scale, what is Mr. W.G.’s mobility score?

A. 1 (Completely Immobile)B. 2 (Very Limited)C. 3 (Slightly Limited)D. 4 (No Limitations)

Test Question

Using the Braden Scale, what is Mr. W.G.’s nutrition score?

A. 1 (Very Poor)B. 2 (Probably Inadequate)C. 3 (Adequate)D. 4 (Excellent)

Test Question

Using the Braden Scale, what is Mr. W.G.’s nutrition score?

A. 1 (Very Poor)B. 2 (Probably Inadequate)C. 3 (Adequate)D. 4 (Excellent)

Test Question

Using the Braden Scale, what is Mr. W.G.’s friction and shear score?

A. 1 (Problem)B. 2 (Potential Problem)C. 3 (No Apparent Problem)

Test Question

Using the Braden Scale, what is Mr. W.G.’s friction and shear score?

A. 1 (Problem)B. 2 (Potential Problem)C. 3 (No Apparent Problem)

Test Question

Based on Mr. W.G.’s total Braden Scale Score, indicate his level of risk for developing a pressure ulcer.

A. 9 or less = Very high riskB. 10-12 = High riskC. 13-14 = Moderate riskD. 15-18 = Mild riskE. 19-23 = Generally not at risk

Test Question

Based on Mr. W.G.’s total Braden Scale Score, indicate his level of risk for developing a pressure ulcer.

A. 9 or less = Very high riskB. 10-12 = High riskC. 13-14 = Moderate riskD. 15-18 = Mild riskE. 19-23 = Generally not at risk

Detroit Medical Center Results• >2,500 nurses completed the computer-based Braden Scale learning module

during the third quarter 2002• Each of the 5 case studies took nurses between 6 and 10 minutes to complete• 75.5% of the nurses correctly rated the Braden Scale level• “Not at risk” and “severe risk” levels were rated correctly more often than

“mild risk”, “moderate risk”, and “high risk” levels• Subscales with the lowest percentage of correct answers were moisture and

sensory perception• Moisture: Nurses had a difficult time differentiating between a score of 3

(extra linen change once a day) and 2 (linen must be changed at least once a shift)

• Sensory perception: This subscale is based on patient communication of discomfort and the ability to feel pain over “half of the body”. Unless these description were spelled out exactly in the case studies nurses tended to score the patient higher (with less risk) than the test writer did.

“In addition to the Braden Scale pressure ulcer risk factors, evaluation of patients’ skin is an important concept for evaluating risk for pressure ulcers. Even if patients are rated “not at risk” according to the Braden Scale score,

Braden recommends placing them in an “at risk” category if they have actual pressure ulcers, healed pressure ulcers, or

persistently reddened areas of skin over bony prominences.”

Maklebust, J., Sieggreen, M.Y., Sidor, D., Gerlach, M.A., Mauer, C., Anderson, C., (2005).

Computer-based testing of the Braden scale for predicting pressure sore risk. Ostomy/Wound Management; 51(4):40-52

Skin Assessment

• Performed every shift• Included documentation of skin:

– Condition– Color– Turgor– Mucous Membranes

Skin Inspection• Performed at least daily, more often if indicated• Physical examination of the intactness of the skin, specifically on bony

prominences. Includes identification of the following abnormal skin conditions:– Abrasion– Blister– Bruising (due to pressure)– Burn– Denuded (missing the top layer of the skin)– Erythema (redness)– Hematoma– Laceration– Rash– Skin Tear– Wound

PU Management Goals:• Identify individuals at risk for developing pressure ulcers

and initiate early prevention programs• Implement appropriate strategies/plans to

– Attain/maintain intact skin– Prevent complications– Promptly identify or manage complications– Involve patient and caregiver in self-management

• Implement cost-effective strategies/plans that prevent and treat pressure ulcers

WOCN Guideline for Prevention and Management of Pressure Ulcers (2003)

PU Assessment1. Evaluate individual risk for developing pressure

ulcers.• Risk assessment is more than determining an

individual’s numerical score. It involves identifying the risk factors that contributed to the score and minimizing those specific deficits.

• Risk assessment should be performed on entry to a healthcare setting and repeated on a regularly scheduled basis or when there is a significant change in the individual’s condition, such as surgery or other decline in health status.

PU Assessment2. Identify high-risk settings, and groups to target

prevention efforts to minimize risk. Settings

o Pressure ulcers usually develop within the first 2 weeks of hospitalization (Langemo et at., 1989)

o 15% of elderly patients will develop pressure ulcers within the first week of hospitalization (Lyder et al., 2001)

Groupso Seniors (>65) and children (<5) are at highest risko Individuals with SCI are considered high risk

PU Assessment3. Inspect the skin regularly.

• Assess all bony prominences of “at-risk” individuals at least on a daily basis (Bergstrom & Braden, 1992).

o Supine position: Occiput, sacrum, heelso Sitting position: Ischial tuberosities, coccyxo Side-lying position: trochanters

• Special garments, shoes, heel and elbow protectors, orthotic devices, restraints, and protective wear should be removed for skin inspection.

PU Assessment4. Assess for immobility.

• Immobility is the MOST significant risk factor for pressure ulcer development

• Patients who have ANY degree of immobility should be carefully monitored for pressure ulcer development:

• Non-ambulatory• Confined to bed, wheelchairs, recliners and couches• Have paralysis or contractures• Wear orthopedic devices that limit function and range of motion• Require assistance in ambulating, moving, turning, repositioning,

getting out of bed or chairs

PU Assessment5. Assess for friction and shearing.

• Friction: the mechanical force of two surfaces moving across each other; it damages surface tissues, causing blisters and abrasions

• Individuals who cannot lift themselves with repositioning are at high risk for friction injuries.

• Shear: the mechanical force that is parallel rather than perpendicular to the skin, which can damage deep tissue such as muscle

• Occurs when the head of the bed is elevated and the individual slides downward (Makelbust & Sieggreen, 2001)

PU Assessment6. Assess for incontinence.

• Moisture from incontinence contributes to pressure ulcer development by macerating the skin.

• Fecal incontinence is a greater risk because the stool contains bacteria and enzymes that are caustic to the skin.

• In the presence of both urinary and fecal incontinence, fecal enzymes convert urea to ammonia, raising the skin pH. With a more alkaline skin pH, the skin becomes more permeable to other irritants (Ratcliff & Rodeheaver, 1999).

PU Assessment7. Assess nutritional status.

• Malnutrition is associated with overall morbidity and mortality.• Inadequate caloric intake causes weight loss and a decrease in

subcutaneous tissue, allowing bony prominences to compress and restrict circulation.

• Stage III-IV sacral ulcers in the elderly have been found to be associated with low body weight, low pre-albumin, and inadequate nutritional intake relative to needs

• Patients with pressure ulcers have been found to have lower serum albumin and Hgb compared to those without pressure ulcers

• Serum albumin levels < 3.5g/dL. have been associated with increased pressure ulcer incidence in individuals with spinal cord injury

PU Assessment8. Assess laboratory parameters for nutritional

status.• No single measurement or combination of nutritional

measurements has been determined to accurately predict the risk of developing pressure ulcers

• Standard measurements of protein:• Albumin (20 day half-life)• Pre-albumin (2-3 day half-life)• Transferrin

• Low serum albumin may reflect a chronic disease state rather than represent overall nutritional status.

• Total lymphocyte count is decreased in individuals with protein-calorie malnutrion.

PU Assessment9. Assess for history of prior ulcer and/or presence of

current ulcer, previous treatments, or surgical interventions.

• Presence of an ulcer or history of a prior ulcer puts a person at risk for additional pressure ulcers (Bergstrom & Braden, 1992; Berlowitz & Wilking, 1989).

10. Assess and monitor pressure ulcer(s) at each dressing change (van Rijswijk & Braden, 1989)

• Description: location, tissue type, drainage• Condition of periwound skin• Pain at ulcer site• Patient/caregiver’s ability and willingness to adhere to prevention

and treatment program.

PU Assessment11. Assess factors that impede healing status.

• Comorbid conditions that complicate wound healing:o Malignancyo Diabeteso Cerebral vascular accidento Heart failureo Renal failureo Pneumonia

• Limited or inaccessible resources may affect prevention and treatment

• Lack of compliance with pressure ulcer prevention measures complicates pressure ulcer healing

• Some medications interfere with wound healing:o Steroidso Immunosuppressive agentso Anti-cancer drugs

PU Assessment12. Assess/evaluate healing.

• Partial thickness ulcers (Stage II) should show evidence of healing within 1-2 weeks.

• Reduction of wound size following 2 weeks of therapy for Stage II-IV pressure ulcers has also been found to predict healing.

• If the condition of the patient or the wound deteriorates, reevaluate the treatment plan as soon as evidence of deterioration is noted.

• Routinely reassess wound dimensions, type of exudate, and tissue type when monitoring for wound healing.

PU Assessment 13. Assess for the following potential complications

associated with pressure ulcer(s):• Heterotopic bone formation• Fistula• Abscess• Osteomyelitis• Bacteremia• Cellulitis• Squamous cell carcinoma (Marjolin’s ulcer)

Interventions for PU Prevention• Mattress overlay• Low air loss bed• Fluid air bed• Boot/Splint• Heels off bed• HOB 30 deg or <• Bed trapeze• OOB/walk• PROM

• Chair reposition• Bed reposition• RD assess• Given supplement• Condom catheter• Barrier ointment• Rectal pouch• Flexi-Seal FMS• Moisturize skin• Turning Prompt

Critical Thinking

The key component needed to individualize a Pressure Ulcer Prevention

Protocol so as to incorporate the possible interventions

into a patient’s plan of care

QUESTIONS????