Using Pressure Ulcer Risk Assessment Tools In Care Planning

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Using Pressure UlcerRisk Assessment Toolsin Care PlanningPresented by Elizabeth A. AyelloPh.D., RN, ACNS-BC, CWON, ETN, MAPWCA, FAANExcelsior College School of Nursing

Welcome!Thank you for joining this webinar about howto use pressure ulcer risk assessmenttools in care planning.2

A Little About Myself Board certified wound and ostomynurse Clinical editor of the journalAdvances in Skin and Wound Care Vice president of the World Councilof Enterostomal Therapists (WCET) Faculty member of Excelsior CollegeSchool of Nursing Author of numerous articles and twobooks on wound care Past president of the NationalPressure Ulcer Advisory Panel Former consultant to CMS on someskin conditions3

Today We Will Talk About Pressure ulcer risk factor assessment Pressure ulcer risk assessment tools Using pressure ulcer risk assessment tools incare planningThese topics were introduced in your 1-daytraining. Today, we will revisit them in depth.Please make a note of your questions. YourQuality Improvement (QI) Specialists will followup with you after this webinar to address them.4

Attributes of Risk Factor Assessment Multifaceted Ongoing StandardizedPhoto K. ZulkowskiStandardized risk assessment is a prerequisite to implementingan evidence-based pressure ulcer prevention protocol.5

Purpose of Risk Factor AssessmentRisk factor assessment facilitates— Clinical decisionmaking Selective targeting of preventive interventions Care planning Communication between health care workersand care settings6

Purpose of Risk Factor AssessmentRisk factor assessment identifies— Patients who are more likely to developpressure ulcers Different components of risk for pressureulcers7

When To Do Risk Assessment On admission– Within 8 hours Reassessment frequency– Based on patient’s acuity Significant change in patient’scondition8

Risk Assessment ToolsAdult tools used in the UnitedStates include— Norton ScaleBegins onPage 136 Braden ScaleBegins onPage 134Today, we will focus on theBraden Scale.9

Braden Scale Risk ityMobilityNutritionFriction/shear10

Braden ScaleBegins onPage 13411

How To Score Risk Factors Score risk factors from 1 to 4 except—– Score friction/shear from 1 to 3. Risk factor score of 1 is the lowest level offunctioning. If a category fallsbetween two numbers,choose the lower score.12

How To Interpret Braden Score Total score ranges from 6 to 23. Lower Braden score indicates higher level ofrisk for pressure ulcer development. In most cases, a score of 18 or less indicatesat-risk status. Tailor this number to fit yourhospital or unit. Low subscale score indicates risk from thatfactor. Address all deficits in care planning.Do not rely on the total score alone.13

With the Braden Scale14

Limits of Risk Scores Some assessment tools include a scoring systemto predict pressure ulcer risk:– No tool has perfect predictability.– Even patients with a low risk score may need intervention.– If you base a patient’s individualized care plan on the riskscore alone, the care plan will not be tailored to all of hisor her risk factors.– Instead, use a comprehensive approach to riskassessment to identify pressure ulcer risk factors.Don’t rely on scores alone.15

Comprehensive Pressure UlcerRisk Assessment History.Assess co-morbidities, medications.Look at the skin.Touch the skin. Ayello, 201216

History: It’s Not Just About Score Ayello, 200617

Assess Co-Morbidities & Medications Perfusion and oxygenation Nutritional deficits Higher rates of PU– Corticosteroid use– CHF– COPD– PVD– DM– Obesity18

Look at SkinSkin StatusBony prominences, especially sacrum and heelsUnder medical devicesSkin to skin19Photos 2014, Ayello

Touch SkinSkin temperature may predict pressure ulcer risk.20

Risk Assessment Critically ill patients– Number of hypotensiveepisodes, hemodynamicinstability– Medical devices Perioperative patients– Length of surgery– Number of hypotensiveepisodes during surgery– Low core temperatures duringsurgery– Amount of time immobilizedbefore and after surgery Ayello, 201421

Clinical Decision making Based on Pressure Ulcer RiskSkinassessmentBraden ScalescoresComorbiditiesIs my patient at risk for a pressure ulcer?What is the plan of care?22

Using Assessment ToolsAssessment tools should be used— By trained staff In conjunction with clinical judgment and reviewof other risk factors To identify a patient’s risk factors To plan care that addresses these factors– Prevention strategies should be consistent with thepatient’s preferences and care goals.If your hospital has an electronic health record system,integrate assessment tools into the system.23

Strategies for Using Risk Assessment Tools Use valid and reliable tools. Train staff in how to properly use riskassessment tools. Assess all patients. Tailor interventions based on patient-specificareas of risk.Patients who previously had pressure ulcers are at risk forgetting them again, especially under similar circumstances.Plan appropriately.24

Using Risk Assessment Toolsin Care PlanningTake these steps:1. Review areas of risk identified by the Braden Scalefor a specific patient and other risk factors includedas part of a structured comprehensive riskassessment.2. Select interventions to address each area of riskthat are consistent with patient preference and caregoals.3. Communicate a tailored pressure ulcer preventionplan to all staff who interact with the patient. Alsoshare it with the patient and their family members.25

Planning Care for Each CategoryBegins onPage 13826

Select Interventions Bariatric patients– Appropriate size and weight of equipment, includingpressure redistribution support surfaces.– Are staff trained to care for these patients? Critically ill patients– Choose pressure redistribution support surfaces based onindividual’s perfusion and ability to be turned.– “Slow, gradual turns”; allow time for hemodynamic andoxygenation stabilization. Perioperative patients– Facial pads for prone position.– Operating room support surfaces on table.– Heel suspension devices. Ayello, 201427

Case StudyYour hospitalized patient— Responds to verbal commands Reports no pain Can turn and reposition without assistance but needsfrequent reminders Needs encouragement to walk more than twice a dayoutside his/her room Eats some of the food on his/her tray Has not suffered any recent weight loss Has moist skin from urinary and fecal incontinenceWhat is the total Braden Scale score for this patient, andis he/she at risk for a pressure ulcer?28

Case Study Braden Scale Scores4243331929

Selected Care Planning ExamplesPlan care for pain. Assess using validated and reliable pain assessment scales;use specific tools or observe body language or other cuesfor nonverbal patients. Prevent and manage pain.– Do this when lifting or transferring patient.– Coordinate pain medication administration with care.Begins onPage 13830

Selected Care Planning Examples Plan care for moisture problems. Use pH balanced skin cleaning products. Don’t massage or vigorously rub skin at risk forpressure ulcers. Cope with dry skin.– Apply moisturizing products such as lotions and creams. Cope with wet skin (incontinence, perspiration).– Clean skin promptly.– Protect skin with products such as skin sealants, lotions,and creams.31

Selected Care Planning ExamplesPlan care for activity problems. Inability to move while sitting in a wheelchair– Use support cushion in properly fitted wheelchair.– Consider PT/OT referrals for evaluation.32

Selected Care Planning ExamplesPlan care for mobility problems. Heels on the mattress– Use heel suspension devices.33

Selected Care Planning ExamplesPlan care for nutrition problems. Encourage family to bring favorite foods. Offer nutrition supplements and water.34

Selected Care Planning ExamplesPlan care for friction and shear. Protect bony prominences prophylactically byapplying a polyurethane foam dressing. Use silk-like fabrics rather than cotton orcotton blend fabrics.35

Today We Talked About Pressure ulcer risk factor assessment Pressure ulcer risk assessment tools Using pressure ulcer risk assessment tools incare planning36

Any Questions?Thank you for being such great listeners. Pleaserefer any questions you have to your QISpecialists.37

Resources Berlowitz D, VanDeusen C, Parker V, et al. Preventing pressure ulcersin hospitals: a toolkit for improving quality of care. (Prepared byBoston University School of Public Health under Contract No. HHSA290200600012 TO #5 and Grant No. RRP 09-112.) Rockville, MD:Agency for Healthcare Research and Quality; April 2011. AHRQPublication No. 11-0053-EF.– Tool 3D: The Braden Scale for Predicting Pressure Sore Risk– Tool 3E: Norton Scale– Tool 3F: Care Plan Sprigle S, Linden, M, McKenna D, et al. Clinical skin temperaturemeasurement to predict incipient pressure ulcers. Adv Skin WoundCare 2001;14(3):133-7.38

Resources John A. Hartford Institute for Geriatric Nursing. Assessment Tools- Try This.http://www.hartfordign.org/practice/try this/Lyder CH, Wang Y, Metersky M, et al. Hospital-acquired pressure ulcers: resultsfrom the National Medicare Patient Safety Monitoring System Study. J Am GeriatrSoc 2012;60(9):1603-8.National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel,Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers:clinical practice guideline. Perth, Australia: Cambridge Media; 2014.Niederhauser A, VanDeusen Lukas C, Parker V, et al. Comprehensive programs forpreventing pressure ulcers: a review of the literature. Adv Skin Wound Care 2012;25(4):167-88.Rapp MP, Bergstrom N, Padhye NC. Contribution of skin temperature regularity tothe risk of developing pressure ulcers in nursing facility residents. Adv Skin WoundCare 2009;22(11):506-13.Shanks HT, Kleinhelter P, Baker J. Skin failure: a retrospective review of patientswith hospital-acquired pressure ulcers. World Council Enterostomal Ther J2009;29(1):6-10.Wong VK, Stotts N, Hopf HW, et al. Changes in heel skin temperature underpressure in hip surgery patients. Adv Skin Wound Care 2011;24(12):562-70.39

Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: clinical practice guideline. Perth, Australia: Cambridge Media; 2014. Niederhauser A, VanDeusen Lukas C, Parker V, et al. Comprehensive programs for preventing pressure ulcers: a review of the literature. Adv Skin Wound Care 2012; 25(4):167-88.

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