Braden Score
+
Skin Inspection
+
Interventions
+
Critical Thinking
Pressure Ulcer Prevention
Objectives:
 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
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.
B.
C.
D.
1 (Completely Limited)
2 (Very Limited)
3 (Slightly Limited)
4 (No Impairment)
Test Question
Using the Braden Scale, what is Mr.
W.G.’s sensory perception score?
A.
B.
C.
D.
1 (Completely Limited)
2 (Very Limited)
3 (Slightly Limited)
4 (No Impairment)
Test Question
Using the Braden Scale, what is Mr.
W.G.’s moisture score?
A.
B.
C.
D.
1 (Constantly Moist)
2 (Very Moist)
3 (Occasionally Moist)
4 (Rarely Moist)
Test Question
Using the Braden Scale, what is Mr.
W.G.’s moisture score?
A.
B.
C.
D.
1 (Constantly Moist)
2 (Very Moist)
3 (Occasionally Moist)
4 (Rarely Moist)
Test Question
Using the Braden Scale, what is Mr.
W.G.’s activity score?
A.
B.
C.
D.
1 (Bedfast)
2 (Chairfast)
3 (Walks Occasionally)
4 (Walks Frequently)
Test Question
Using the Braden Scale, what is Mr.
W.G.’s activity score?
A.
B.
C.
D.
1 (Bedfast)
2 (Chairfast)
3 (Walks Occasionally)
4 (Walks Frequently)
Test Question
Using the Braden Scale, what is Mr.
W.G.’s mobility score?
A.
B.
C.
D.
1 (Completely Immobile)
2 (Very Limited)
3 (Slightly Limited)
4 (No Limitations)
Test Question
Using the Braden Scale, what is Mr.
W.G.’s mobility score?
A.
B.
C.
D.
1 (Completely Immobile)
2 (Very Limited)
3 (Slightly Limited)
4 (No Limitations)
Test Question
Using the Braden Scale, what is Mr.
W.G.’s nutrition score?
A.
B.
C.
D.
1 (Very Poor)
2 (Probably Inadequate)
3 (Adequate)
4 (Excellent)
Test Question
Using the Braden Scale, what is Mr.
W.G.’s nutrition score?
A.
B.
C.
D.
1 (Very Poor)
2 (Probably Inadequate)
3 (Adequate)
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.
B.
C.
D.
E.
9 or less = Very high risk
10-12 = High risk
13-14 = Moderate risk
15-18 = Mild risk
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.
B.
C.
D.
E.
9 or less = Very high risk
10-12 = High risk
13-14 = Moderate risk
15-18 = Mild risk
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 Assessment
1. 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 Assessment
2. Identify high-risk settings, and groups to target
prevention efforts to minimize risk.
Settings
o
o
Pressure ulcers usually develop within the first 2 weeks of
hospitalization (Langemo et at., 1989)
15% of elderly patients will develop pressure ulcers within
the first week of hospitalization (Lyder et al., 2001)
Groups
o
o
Seniors (>65) and children (<5) are at highest risk
Individuals with SCI are considered high risk
PU Assessment
3. Inspect the skin regularly.
•
Assess all bony prominences of “at-risk” individuals
at least on a daily basis (Bergstrom & Braden, 1992).
o
o
o
•
Supine position: Occiput, sacrum, heels
Sitting position: Ischial tuberosities, coccyx
Side-lying position: trochanters
Special garments, shoes, heel and elbow protectors,
orthotic devices, restraints, and protective wear
should be removed for skin inspection.
PU Assessment
4. 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 Assessment
5. 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 Assessment
6. 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 Assessment
7. 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 Assessment
8. 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 proteincalorie malnutrion.
PU Assessment
9. 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 Assessment
11. Assess factors that impede healing status.
•
Comorbid conditions that complicate wound healing:
o
o
o
o
o
o
•
•
•
Malignancy
Diabetes
Cerebral vascular accident
Heart failure
Renal failure
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
o
o
Steroids
Immunosuppressive agents
Anti-cancer drugs
PU Assessment
12. 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????