By Aletha Tippett MD
I was recently asked to speak on best practices for prevention of pressure ulcers for a group of state surveyors. This is an excellent subject and here is how I would address it:
The first step is a thorough assessment of the patient. This includes a full body examination with special attention to pressure points, looking for any color changes, pain or bogginess. The assessment also looks at the patient’s overall health and comorbidities such as:
- Do they have heart disease, peripheral vascular disease, or edema?
- Are they paralyzed or weak?
- Are they obese?
Further assessment can use something like the Braden Scale system, or Norton Scale, both standardized tools for predicting risk of pressure ulcers. The Braden system is probably the most widely used, so will be discussed here.
Using the Braden Scale in Your Patient Risk Assessment
To use the Braden Scale, a patient is evaluated in six different systems: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each system is given a score from 1-4 and these points are totaled to give an overall score. A score of 12 or less represents high risk. Now, it is interesting that in 2008, the results of nine international pressure ulcer prevalence surveys from 1989 to 20051 revealed that the Braden Scale accurately predicted risk of a pressure ulcer 52% of the time. Now, that is about the same as flipping a coin.
Reasons for Inaccurate Pressure Ulcer Risk Assessment
After looking at many completed Braden scores, it is my opinion that this low accuracy is due to improper completion of the Braden Scale. For example, how would you score a 300 pound man who was recently paralyzed from the waist down, admitted to the hospital?
For sensory perception he is very limited due to his paralysis (and loss of sensation), so let’s give him a 2. For moisture he is often moist due to bowel and bladder incontinence from his paralysis, so let’s give him a 2. For activity, he is either bedfast or chairfast, depending on how early in his hospitalization this score is, which gives him either a 1 or 2. His mobility is very limited because he can’t move himself independently, so he gets a 2 for that. For nutrition we would have to know how much of his meals he is eating; he is probably a 2 or 3. For friction and shear he definitely has a problem because he requires maximum assistance in moving and complete lifting is difficult. Even with a trapeze, he will be sliding on the bed. So his score here is 1. This gives him a total score of 11 or 12, making him high risk. Compare this to the hospital scoring of 16-18.
Based on the risk assessment, certain interventions can be put in place. For high risk patients, a special support surface is needed for the bed and chair; special accommodations need to be made for moving the patient, such as a hoyer lift, and plans for turning/repositioning need to be made. Diet should be optimized with a nutrition consult. If a patient is determined to be low risk, then usually nothing special is done, so if the initial assessment was wrong, that’s when a pressure ulcer occurs even though the Braden Scale was used. If on the initial exam a spot of pressure ulcer was found, then appropriate interventions need to be put in place, with pressure support, turning and positioning plans and nutrition intervention. And that spot needs to have a care plan.
Overall, doing a proper pressure ulcer risk assessment can result in prevention of pressure ulcers and better treatment of a patient with a pressure ulcer.
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1. Vangilder C, Macfarlane GD, Meyer S. Results of Nine International Pressure Ulcer Prevalence Surveys: 1989 to 2005. Ostomy Wound Management. Feb 2008;54(2):40-54.
About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.