Risk Assessment
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Perform a risk assessment of each patient’s risk of pressure ulcer using a validated risk assessment tool. | Level of Evidence Not Assessed |
| 2 | Take a history and perform a physical examination, with thorough inspection of the skin to determine each patient’s comorbid condition. | Level of Evidence Not Assessed |
| 3 | Determine and document each patient’s risk status and recommended reassessment frequency. | Level of Evidence Not Assessed |
| 4 | Develop a plan of care based on a validated risk assessment instrument. Re-evaluate risk weekly or when patient factors change. | Level of Evidence Not Assessed |
| Address Patient-Centered Concerns | ||
|---|---|---|
| 5 | Inform and educate the patient about preventing his/her specific needs | Level of Evidence Not Assessed |
| Provide Local Wound Care | ||
|---|---|---|
| 6 | Follow TREATMENT recommendations | Level of Evidence Not Assessed |
| 7 | Establish and empower an interprofessional team to provide risk protection | Level of Evidence Not Assessed |
Background
It is important to assess an individual’s risk of developing pressure ulcers on admission. Risk assessment includes a careful history and targeted physical examination, use of a validated risk assessment tool, consideration of intrinsic and extrinsic risk factors, determination of risk status and appropriate frequency of reassessment and documentation of findings.• Inspection of the skin should include the entire body with a focus on bony prominences, searching for tissue damage. In light-skinned individuals, areas of non-blanchable erythema indicate a developing ulcer, whereas in dark-skinned persons, a developing pressure ulcer may appear blue or purple. Other parts of the body that may be vulnerable to pressure ulcers should also be carefully inspected, including areas in contact with equipment and those covered by restrictive garments, such as anti-embolic stockings, where normal activities may cause pressure, friction or shear.
• Risk assessment tools: Use of a risk assessment tool with demonstrated reliability and validity, such as the Braden Scale or the Norton Scale, is recommended to structure assessment and as a valuable adjunct to clinical judgment.
• Intrinsic factors associated with pressure ulcer risk include malnutrition; dehydration; decreased mobility or immobility; pain associated with chronic conditions that may decrease mobility; involuntary movements, posture or contractures; neurologic or sensory impairment or decreased level of consciousness; incontinence; extremes of age; acute, severe chronic or terminal illness; history of previous tissue damage from pressure; and vascular disease.
o Nutritional assessment: Evaluation may include consultation with a dietitian, identification of factors affecting dietary intake and potential need for supplementation
o Decreased mobility: Pressure, friction and shear should be evaluated in all positions and during transfers and repositioning for patients who are restricted to a bed or chair.
• Extrinsic factors include living conditions; hygiene; medication use; exposure to pressure, shearing forces and friction; garments, restraints and transfer and support systems; and surgery.
o Surgery: Risks include length of procedure; patient position and positioning devices; skin shearing and friction during positioning; intraoperative hypotension and circulatory changes due to position or blood loss pooling of prep solutions.
• Determination of risk status: Risk status is determined by the overall assessment, including the score derived from use of a risk assessment scale. Risk may be evaluated as none/minimal, mild, moderate, high or very high.
• Reassessment: The optimum frequency of risk assessment has not been determined. Initial findings, health status and changes in status should guide the reassessment frequency.
• Documentation: The findings of each assessment should be documented and made available to the interdisciplinary healthcare team.
A study in nursing homes found that, of patients who develop a pressure ulcer, 80% do so within 2 weeks and 96% do so within 3 weeks. In the acute care setting, assessment is often performed daily in intensive care and every second day on general medical/surgical floors. Homecare patients should be assessed at every nursing visit, as the visit schedule is usually determined by patient status.
Risk assessment tools supplement clinical judgment, as patients with the same risk score may have differing actual risks. A young patient recovering from surgery likely has a lower real risk than risk score indicates, whereas an elderly individual in declining health may have a higher real risk than suggested by a risk score.
References
| Essential Publications |
|---|
| 1 | Risk Assessment Scales |
Quality Indicator
|
Type: Systematic review |
| Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopex-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. Journal of Advanced Nursing 2006;54(1):94-110. | |||
| The purpose of this systematic review is to determine the effectiveness of various risk assessment scales used for the prevention of pressure ulcers. The Braden Scale provides the best balance between sensitivity and specificity and the best risk estimate compared to the Norton and Waterlow Scales. The Braden Scale was also found to be superior to nurses’ judgment and ability to predict pressure ulcers. | |||
| 1 | Validity of Braden Scale in LTC |
Quality Indicator
|
Type: Validation study |
| Bergstrom N, Braden B, Laguzza A, Holman V. The Braden Scale for predicting pressure sores. Nursing Research 1987;36(4):205-210. | |||
| In this paper, the development of the Braden Scale, which includes reliability and validity testing, is described. The scale is very reliable and is more sensitive and specific than previously developed scales. | |||
| 1 | Validity of Braden Scale in LTC |
Quality Indicator
|
Type: Validation study |
| Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Predicting Pressure Ulcer Risk: A Multisite Study of the Predictive Validity of the Braden Scale. Nursing Research 1998;47(5):261-269. | |||
| In this paper, the predictive validity of the Braden Scale is evaluated. Patients who developed ulcers had significantly lower Braden Scale scores than those who did not develop ulcers (p = 0.0001). Risk assessment completed 48 to 72 hours after admission was highly predictive of pressure ulcer development and a better indicator than a risk assessment completed at admission. | |||
| 1 | Validation of the Braden Scale in Home Care |
Quality Indicator
|
Type: Validation study |
| Bergquist S. Subscales, subscores, or summative score: evaluating the contribution of Braden Scale items for predicting pressure ulcer risk in older adults receiving Home Health Care. J WOCN 2001;28:279-89. | |||
| The purpose of this study was to determine if some Braden subscales are more important than others or the total score in predicting pressure ulcers. It was found that the summative score was a better predictor of pressure ulcer risk than the individual subscores. | |||