Prevention of
Pressure Ulcers: Risk Assessment,
Skin Assessment, and Interventions
Patti Senk, BSN, RN, Doctoral Candidate
Research Associate
Center for Nursing Research and Practice
Aurora Health Care
patti.senk@aurora.org
414-219-5903
Aurora Health Care is a not-for-profit health care provider and
a national leader in efforts to improve the quality of health care.
Objectives
• Recognize the impact of a pressure ulcer to
the patient, family, and organization
• Identify components of a pressure ulcer risk
assessment and a comprehensive skin
assessment
• Describe interventions for pressure ulcer
prevention
• Determine your teams next steps for
implementing interventions
Patient’s Perspective
Development of a pressure ulcer impacts an
individual’s life:
“The limping about is so painful; I’m happier when
I am sitting out of the way. I used to be a soldier and
youth worker, now I can’t do anything at all” (Hopkins et al.,
2006, p. 349).
. . . . Other clients describe themselves as
“miserable, worthless, useless with feelings of
worry, depression, inadequate and powerless” (Hopkins
et al., 2006, p. 349).
Patient’s Perspective
Pain / discomfort
“ . . .when I am sitting in my chair like now, that also
hurts and if I move a little it hurts even more, so I sit very
still in the chair, but still it hurts” (Hopkins et al., 2006, p. 348).
Limitations with ADL’s (temporary or permanent)
“I have to lie on my side for as long as I can bear
[because of the ulcer], but actually my arms begin to
ache after a while because, laying on your side, you can’t
do anything” (Spilsbury et al., 2007, p. 499).
Patient’s Perspective
Emotional stress
“I noticed the nurses were changing the dressings:
they could hardly stand the smell of it. The smell is
terrible. It comes through the whole bandage, you
see, and to me it’s an embarrassment” (Spilsbury et al., 2007,
p.500).
Prolonged recovery time (short or long term)
“Obviously, when this situation develops [pressure
ulcer formation] you cannot see the end of the road”
(Hopkins et al., 2006, p.349).
Patient’s Perspective
Increased cost
. . . with the pressure ulcer the patient couldn’t work
the whole day, there were frequent doctor visits, and he
had to stay home to have the dressing changed;
sometimes the nurse was delayed and what would only
take an hour ended up taking his whole day (Gorecki et al., 2009).
Increased length of stay
. . . as a result of developing a pressure ulcer, the
patient stayed longer in the acute care setting, and
rehabilitation was limited due to restrictions from the
pressure ulcer (Hopkins et al., 2006).
Family Perspective
Extra worry and workload
“But when I’m at home as well I’m having to rely on
other people to do things for me. Well, it’s not very nice
for them. Because, I mean, I’m having to rely on my
sister to do that and she’s got a job to go to, she’s got a
son to look after, she’s got her own life to lead” (Spilsbury et al.,
2007, p. 498).
“. . . my wife, she was the one who did all the work and
all the worry. . . . . I used equipment that pleased my
daughter, not me” (Hopkins et al., 2006, p.349).
Organizational Perspective
Nurse quality indicator
• Reflects directly on nursing practice
Cost/reimbursement
• Increased risk of infection, delayed healing
• Exacerbation of underlying health problems (Spilsbury et al.,
2007)
• A single pressure ulcer may:
- Increase length of stay five fold
- Increase hospital charges by $2,000-11,000
• Facility acquired pressure ulcer no longer reimbursed
(NPUAP-EPUAP, 2009)
Why perform a pressure ulcer
risk assessment?
• Identifies patients who are susceptible to
the development of a pressure ulcer
• Allows appropriate allocation of
interventions to prevent a pressure ulcer
from developing
Components of a
Pressure Ulcer Risk Assessment
• Risk assessment tool
• Braden Scale for Predicting Pressure Sore Risk
• Norton Pressure Ulcer Risk Assessment Scale
• Comprehensive skin assessment
• Risk factors to consider:
• Advanced age
• Skin moisture
• Other factors, such as surgery time or acuity
Timing of a
Pressure Ulcer Risk Assessment
•
•
•
•
Admission
Regular intervals based on patient acuity
Change in patient condition
Other times
Braden Scale for Predicting
Pressure Sore Risk
Enables nurses to collect information needed to
identify patients at risk to develop a pressure ulcer
• Scale consists of 6 subscales
• Based on point system
• Ranges from no impairment or limitation to total
dependent care
(Braden, 1988, accessed at http://www.bradenscale.com/)
Review of Braden Scale
Includes these subscales:
•
•
•
•
•
•
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction & Shear
Comprehensive Skin Assessment
• Initial skin assessment provides baseline data
• Ongoing assessment identifies changes from
patient’s baseline
• Is key to determining if the prevention interventions
performed are effective
Comprehensive Skin Assessment
5 Components:
• Color
• Temperature
• Moisture
• Turgor
• Integrity
Occiput
Thoracic
Vertebrae
Lumbar
Vertebrae
Scapula
Elbow
Sacrum
Coccyx
Hip
Ischium
Medial Malleolus
(Inner Ankle)
Lateral Malleolus
(Outer Ankle)
Metatarsals
(Toes)
Calcaneus
(Heel)
Pressure Ulcer Prevention
A pressure ulcer will not be prevented unless
interventions are implemented
Interventions to
Prevent Pressure Ulcers
•
•
•
•
•
•
Support Surfaces
Reposition
Reduce friction and shear
Skin care
Nutrition
Education
Redistribution Surface
• Redistribution mattress, or overlay
• Seat cushion when in chair/wheelchair
• Devices for heels
Do not use:
• Donut devices
• Water filled gloves
• Sheepskin
Reposition
Consider:
• Patient condition
• Patient need
• Support surface used
Position
• Head of bed at or below 30 degree
• 30 degree side lying
Heels
• Elevate off bed
• Heel protection devices
Reduce Friction and Shear
•
•
•
•
Lift/transfer equipment
Trapeze
Avoid positioning on medical device
Avoid positioning on area with nonblanching erythema
• Avoid elevated head of bed
Skin Care
• Cleanse gently
• Skin barriers
-
Cream
Ointment
Paste
Film-forming protectant
• Toileting schedule
• Absorbent underpad, or brief
Nutrition
• Screen and assess nutritional status
• Goal is promote and maintain adequate
intake
• Consult dietician
• Provide supplement
Education
•
•
•
•
•
•
Pressure ulcer risk factors
How to minimize risk
Skin inspection
Skin care
Reducing friction and shear
Repositioning
Skin Assessment
• Continue to assess skin at regular intervals
• Determines if interventions are effective
Next steps:
• Create a team
- Interdisciplinary approach
• Clearly identify risk factors
• Include time frame for risk assessment and
skin assessment
• Communicate prevention interventions
• Follow up to evaluate interventions
• Evaluate the cause and contributing factors
of any pressure ulcer that develops
References
Braden, B., & Bergstrom, N. (1988). Braden Risk Assessment Scale.
Gorecki, C., Brown, J., Nelson, E.A., Briggs, M., Schoonhoven, L., Dealey, C., …
Nixon, J. (2009). Impact of pressure ulcers on quality of life in older patients: A
systematic review, Journal of American Geriatrics Society, 57(7), 1175-183.
Hopkins, A., Dealey, C., Bale, S., Defloor, T., & Worboys, F. (2006). Patient stories
of living with a pressure ulcer, Journal of Advanced Nursing, 56(4), 345-353.
METASTAR. Pressure Ulcer Bundle. Accessed at
http://www.metastar.com/web/Default.aspx?tabid=339
NPUAP-EPUAP (2009). Pressure ulcer prevention & treatment: Clinical practice
guideline.
Spilsbury, K., Nelson, A., Cullum, N., Iglesias, C., Nixon, J. & Mason, S. (2007).
Pressure ulcers and their treatment and effects on quality of life: Hospital
inpatient perspectives. Journal of Advanced Nursing, 57(5), 494-504.