- Use standardized assessment tools to gain a better understanding of risk factors for specific clinical settings and client populations
- The Braden Scale and the Norton Scale have been tested sufficiently for reliability and validity to be useful adjuncts to nursing assessments and care planning
- These tools, along with clinical judgment, increase the ability to identify risk factors that are then incorporated into a client specific prevention plan of care
- Ideally, the client should be assessed for risk on admission, again in 48 hours and as often as the level of morbidity indicates
- Site of care assessment schedule:
- Long-term care facilities – At admission, then every week for four weeks and quarterly thereafter
- Intensive Care Units – Daily
- General medical/surgical units – Every other day
- Community – Every home visit
- The potential to develop pressure ulcers may be influenced by intrinsic risk factors that relate to aspects of the client’s physical, psychosocial or medical condition.
- These factors should be considered when performing a risk assessment, and include:
- nutritional status (malnutrition and dehydration)
- reduced mobility or immobility
- repetitive stress syndrome (involuntary movements)
- posture/contractures
- neurological/sensory impairment
- incontinence (urinary and fecal)
- extremes of age
- level of consciousness
- acute illness
- history of previous pressure damage
- vascular disease,
- and severe chronic or terminal illness
- Extrinsic factors derived from the environment can also influence the development of pressure ulcers.
- These include factors such as:
- Hygiene
- living conditions
- medication
- pressure
- shearing
- friction
- garments
- transfer slings
- restraint use and
- the support systems used to relieve pressure
- The following risk factors specific to client populations are included for consideration:
Clinical Setting Risk Factors Intensive Care Unit - organ failure, sepsis
- interface pressure, skin moisture, smoking, body temperatur
- level of consciousness, activity, cooperation, bowel incontinence, length of stay, C-reactive protein level
- intermittent hemodialysis, mechanical ventilation, vasopressor therapy and pain
- impaired perfusion/hemodynamic instability, pharmacologic or mechanical support to maintain normal blood pressure or adequate cardiac output, global or regional perfusion that is not adequate to support normal organ function including the skin
Medical/Surgical - having two co-morbidities, neuropsychiatric disorder, infection
Medical client - Length of time of hospitalization
Surgical client - Weight, serum albumin
Acute cute (surgery, internal medicine, neurology, geriatric) - Age greater than 75 years, weight on admission, abnormal appearance of skin, planned surgery in the coming week
- Presence of malignant tumor, arterial obstructive disease of abdominal and pelvic arteries
Orthopedic - Age greater than 71 years, pulmonary disease, diabetes
- Cerebral vascular accident
- High body mass index (BMI) has been demonstrated to be a significant predictor for pressure ulcer development
- People with BMIs of more than 40 were almost three times more likely to have a pressure ulcer compared to those with BMIs of 40 or less
Clinical Management
Risk Assessment and Prevention of Pressure Ulcers
Point of Care Resources