Pressure ulcer risk assessment

Tai Li Ling

Department of Anaesthesia & Intensive Care

Hospital Kuala Lumpur

 Most pressure ulcers are preventable if patient risk is recognised in time for  preventive actions to be initiated.

 Maklebust J., Sieggreen M.Y, (2001)

Pressure Ulcers: Guidelines for Prevention and Mangement, 3 ed.







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What is pressure ulcer risk assessment?

•  Standardised and ongoing process

•  To identify individuals at risk

–  not who will develop a pressure ulcer

–  who will more likely to develop a pressure ulcer, if no preventive measures are taken

•  To identify specific factors placing them at risk



What is pressure ulcer risk assessment?



A multifaceted process and includes

–  use of risk assessment scales

–  consider other risk factors not quantified in risk assessment scales

–  identify different levels of risk

–  develop a prevention care plan with more intensive interventions directed to patients at greater risk

 Why is risk assessment necessary? 

•  Aids in clinical decision-making

–  many HCWs are not skilled in identifying patients at risk

–  use of a standardised risk assessment helps to direct the process to identify those at risk and quantify the level of risk

 Why is risk assessment necessary? 

•  Allows the selective targeting of preventive interventions

–  pressure ulcer prevention is resource intensive

–  resources should be targeted towards those at greatest risk who would benefit most



 Why is risk assessment necessary? 

•  Facilitates care planning

–  care plans focus on the specific dimensions/ factors that place the patient at greatest risk

•  Facilitates communication between HCWs and care settings

–  HCWs have a common language by which risk is described

How is risk assessment performed?

•  More than determining an individual’s numerical score.

•  Pressure ulcer risk assessment involves:

–  using developed risk assessment scales

–  assessing other risk factors that are not captured in these scales

–  minimising those risk factors

When is risk assessment performed?

•  should be performed as soon as possible on hospital admission (within a maximum of 8 hours after admission)

•  repeated on a regular scheduled basis

•  repeated when there is a significant change in the patient’s condition, e.g. decline in health condition

Who is to perform risk assessment?

•  Training and skills are key to correct and consistent performance of risk assessment

•  Should be performed by HCWs who have undergone appropriate and adequate training



Risk factors

•  many of the risk factors, are captured by existing tools through the resulting immobility

•  several additional specific factors should be considered as part of the risk assessment process

Risk factors

•  Presence of a pressure ulcer

–  all patients with an existing pressure ulcer is considered at risk for an additional ulcer

•  Prior Stage III or IV pressure ulcers

–  Stage III or IV ulcers heal through a process of scar tissue formation and eventual epithelialisation

–  the healed skin lacks its former tensile strength and very prone to break down again

Risk factors

•  Hypoperfusion states

–  the skin is not adequately perfused in conditions e.g. sepsis, dehydration, or heart failure. Minimal amounts of pressure may cause ulceration.

•  Peripheral vascular disease

–  Because of the limited blood supply to the legs, these patients are predisposed to pressure ulcers of the feet, particularly the heels.

Risk factors

•  Diabetes

–  Diabetic macroangipoathy, microangiopathy, neuropathy contribute to risk of pressure ulcers of the feet

•  Smoking

–  interferes with oxygen delivery

–  associated with recurrence of pressure ulcers post surgery

–  increases risk of new pressure ulcers

Risk factors

•  Restraint use

–  physical restraints cause limited mobility

–  pressure is applied at the site of the restraints

–  chemical restraints with resulting sedation may lead to reduced in mobility

Risk factors

•  Spinal cord injury

–  Immobility, incontinence, and impaired sensation may combine to place these patients at exceptionally high risk.

–  The level and completeness of the spinal cord injury is critical.

Risk factors

•  Prolonged surgery/ transport

–  Prolonged time on a hard surface or in one position increases the risk of skin breakdown

–  Patients who undergo a procedure longer than 4 hours are at particularly high risk

Risk factors

•  End-of-life care

–  patients in the terminal stages of disease may have failure of multiple organ systems, including the skin.

Risk assessment scale

•  Instrument that serves as a standardised way to review some factors that may put a person at risk for developing pressure ulcer

•  Evaluate several different dimensions of risk e.g.

•  •  • 

Mobility

Nutrition

Moisture

•  •  •  • 

Demographics and chronic illness

Shear and friction forces being applied

Continence

Cognition & sensation

Risk assessment scale

•  Assigns points depending on the extent of any impairment

•  Especially helpful in identifying patients at mild to moderate risk

•  Nurses can identify patients at high risk or no risk

Risk assessment scale

•  Only a part of the risk assessment process

•  To be used in conjunction with clinical assessment, not in isolation

•  Not meant to replace clinical judgment

•  Use a risk assessment scale that is appropriate to the population e.g. elderly, adults, paediatrics, fair, dark skinned.

“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

 Risk assessment scales

•  Braden

•  •  •  •  •  • 

Norton

Waterlow

Douglas

Gosnell

Anderson

Knoll





Braden scale

•  •  •  • 

Developed in 1987 in USA

Most widely used

Translated into many languages

Evaluated extensively in acute care and long-term care settings

•  Good inter-rater reliability

Scores 15 - 18 indicate low risk, 13 -14 indicate moderate risk, 10 - 12 indicate high risk, ≤ 9 indicate very high risk.

Norton scale

•  •  •  • 

first pressure ulcer risk evaluation scale

created in 1962

developed in England

intended for use in geriatric hospital population

•  ease of use makes it still widely used today

Norton scale

Waterlow scale

•  Developed in 1985 in UK

•  Based on Norton scale

•  Large number of scored items and lack of operational definitions, may reduce its reliability.

Cubbin and Jackson scale

•  developed in 1991 for ICU patients

•  revised based on the Norton scale

•  consists of 10 items

–  Age

–  Weight

–  General skin condition

–  Mental condition

–  Mobility

–  –  –  –  – 

Haemodynamics

Respiration

Nutrition

Incontinence

Hygiene

Conclusion:

•  Four general scales (Norton, Waterlow, Braden and Braden Mod. Choi Song) have also been validated in ICUs

•  The Braden scale is recommended for assessing risk in critical care patients.

•  Other scales (e.g. Cubbin-Jackson, Jackson-Cubbin, Norton or BM by Choi Song) may be useful but further validation studies are required.

Hierarchy of risk factors

Moore Z et. al. (2011) J Clin Nurs, 20, 2633-44.

Hierarchy of risk factors

•  Pressure/shear is the prime cause of pressure ulcers

•  Those exposed to pressure/shear are those who are immobile and cannot relieve pressure from bony prominences

•  First question should be “Can the patient can move independently?”

•  If yes, unlikely to develop pressure ulcer

•  If no, perform risk assessment

Hierarchy of risk factors

•  Friction and shear are forces that come into play when a person has limited mobility.

•  It is not possible to have shear without friction, but it is possible to have friction without shear.

 Shear

•  combination of friction and gravity

•  occurs when the head of the bed is elevated and the patient slides downward

•  structures under the skin (muscle, bones) are pulled down by gravity, while the skin sticks to the surface due to friction

•  when the skin breaks, there is more damage than the opening would indicate, often with undermining tissue damage under the skin

Friction

•  Friction is caused by dragging the skin across the surface and only damages the epidermal and upper dermal skin layers

•  causes blisters and abrasions

Documentation of risk assessment

•  Documentation of findings is the key to accountability, responsibility, risk management and evaluation.

•  Record in patient’s medical record to form the basis for a care plan which is acted upon

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