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Pressure Ulcer Prevention for the Bariatric Patient Susan Morello BSN, RN, CWOCN, CBN Opening Statement Pressure ulcer prevention has always been a part of nursing care. However, with the changes in reimbursement for adverse events, it has become a major focus for all healthcare facilities. Patients and residents must be adequately assessed for any skin breakdown upon admission to ensure that the skin is intact or to document the presence of a pressure ulcer. Once the admission skin assessment has been completed and treatment initiated if necessitated, pressure ulcer prevention protocols are implemented as part of the daily nursing care plan. Re-assessment of the patient’s risk for skin breakdown is an integral portion of pressure ulcer prevention protocols. Although several skin risk assessment tools are available, the Braden Scale is frequently used in healthcare facilities. Objective The Braden Scale assesses six basic areas of concern or subscales. The clinician is guided by a set of questions which assign a point value to the subscale. Once all responses are completed and the values compiled, the final total indicates the at-risk level of the patient. When assessing the bariatric patient, the clinician may need more specific information than that obtained by using the standard comments as outlined in the traditional Braden Scale. The subscales of the Braden Scale which need greater attention when evaluating the bariatric patient are Mobility, Moisture, Activity and Friction/Shear. Armed with the appropriate list of questions and observations, the clinician an obtain a more accurate evaluation of the at-risk status of the bariatric patient and implement the most appropriate interventions for the prevention and/or treatment of pressure ulcers in this patient population. About the Author: Susan Morello has been a Clinical Coordinator for Sizewise since 2007. She has been a nurse for more than 40 years and has experience in all areas of nursing throughout the continuum of care. She has been an active member of the NABN since 2008. Currently she serves on the Education Committee of the NPUAP and the Wound Committee of the WOCN. Poster Development Team: Susan S Morello, Chris Thowe | Contact: Susan S Morello | [email protected] Conclusion Routine inspection of the skin, frequent turning and repositioning of the bariatric patient and a thorough skin care regimen will ensure that the bariatric patient’s skin will remain intact. When we learn to incorporate our routine observations based on information from simple questions, we will understand how the Braden Scale is not only a useful tool, but also an invaluable and simple method for the prevention of pressure ulcers. By evaluating each subscale the Braden Scale will become a source of information about the skin risk status of our patients and enable us to introduce the appropriate interventions to ensure healthy, intact skin. We will be better equipped to provide the highest level of pressure ulcer prevention in our bariatric patient population. Sensory perception ability to respond meaningfully to pressure-related discomfort Patient’s Name Evaluator’s Name Date of Assessment Total Score Braden Scale For Predicting Pressure Sore Risk Moisture degree to which skin is exposed to moisture Activity degree of physical activity Mobility ability to change and control body position Nutrition usual food intake pattern Friction & Shear 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel pain over most of body 1. Completely Limited Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 1. Bedfast Confined to bed. 1. Completely Immobile Confined to bed. 1. Very Poor Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IV’s for more than 5 days. 1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body. 2. Very Moist Skin is often, but not always moist. Linen must be changed at least once a shift. 2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair 2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 2. Probably Inadequate Rarely eats a complete meal and generally eats only ½ of any food offered. Protein intake includes only 3 servings of meat or diary products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding 2. Potential Problem Moves feebly or requires minimum assistance. During a move skin probably slides into some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. 3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. 3. Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day. 3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. 3. Slightly Limited Makes frequent though slight changes in body or extremity position independently. 3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, diary products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs 3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals. 4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours. 4. No Limitation Makes major and frequent changes in position without assistance. 4. Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and diary products. Occasionally eats between meals. Does not require supplementation. Subscale Sensory perception Moisture Activity Mobility Nutrition Friction/Shear Question Is there anything that prevents my patient from feeling discomfort or letting me know he is uncomfortable? Is my patient’s skin exposed to fluid of any kind? Perspiration? How much time does my patient spend walking, sitting in a chair? Do I have to motivate my patient to do these activities? How well does my patient move in bed? Can he turn by himself? Is there enough room in the bed for him to turn? What is my patient’s albumin or pre-albumin? What does my patient actually eat every day? Is my patient’s skin going to move when he does? Considerations Think about wrinkled sheets, incontinent pads, tubing, and other medical devices under the patient. Think about items left in skin folds. Remember that perspiration is a fluid and many bariatric patients have perspiration problems, especially in skin folds. Examine the skin folds on a daily basis. Examine patient for Incontinence Associated Dermatitis and/or perineal skin irritation rather than asking the patient if he is incontinent. If either of these is noted, the Braden score should reflect this and should not be a 4. Ask your patient to transfer to a chair and walk a few steps…unassisted if possible. Monitor him as he walks to the bathroom. Evaluate activity daily. If patient only ambulates and sits in a chair when encouraged to do so, the Braden score should reflect this and should not be a 4. There must be sufficient extra space on the surface of the mattress to allow the patient to turn. Asking the patient to turn, move up in bed, etc. will let you know if the patient has the ability to complete these tasks as well as evaluate if the mattress is of adequate size to accommodate the patient. Estimating the patient’s intake on percentage of food eaten does not provide an adequate evaluation of the patient’s nutrition. Noting exactly was has been consumed by patient may help in the evaluation, but checking the albumin and/or pre-albumin is a much better resource for the dietary needs of the patient. Hydration must be evaluated. Consider monitoring the intake and output of the patient for at least 48 hours. Excess adipose tissue, inadequate tissue perfusion and lack of proper hydration all add to the patient’s susceptibility to skin tears and friction/shear injury. Moving in bed, sliding off the bed to stand or transfer adds to the risk. Even the most active and agile bariatric patient may be at risk for this type of skin damage.
