Risk Assessment

By the WoundSource Editors

The prevalence of pressure injuries among certain high-risk patient populations has made pressure injury risk assessment a standard of care. When utilized on a regular basis, standardized assessment tools, along with consistent documentation, increase accuracy of pressure injury risk assessment, subsequently improving patient outcomes. Conversely, inconsistent and non-standardized assessment and poor documentation can contribute to negative patient outcomes, denial of reimbursement, and possibly wound-related litigation.

By Susan M. Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary

As a Director of Nursing, your assessment skills must be tiptop. How are the skills of the staff you are entrusting with the care of our older residents in long-term care? Have you given the staff the tools and time required to accomplish comprehensive and compassionate assessments?

By Hy-Tape International, Inc.

Infants pose a major challenge for wound care professionals. Because neonatal skin is immature and thin compared with adult skin, it is more easily damaged and requires greater care. This makes it critical that health care professionals follow specialized best practices when caring for neonatal wounds to minimize skin damage and ensure optimal outcomes for patients.

Holly M. Hovan MSN, APRN, ACNS-BC, CWOCN-AP

Payne and Martin brought skin tears to the attention of wound and skin specialists and to the wound care community when they reported an incidence rate of 2.23% in individuals aged 55 years and older, living in a long-term care facility. A skin tear is "a wound caused by shear, friction, and/or blunt force resulting in a separation of skin layers." Skin tears may be partial- or full-thickness wounds, develop into chronic wounds without proper treatment and follow-up, and, most importantly, are preventable.

By Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN

A pilonidal cyst is a pocket located at the top of the cleft of the buttocks that usually results from an embedded or stiff hair. This area may remain dormant for years and cause no major issues; however, often the embedded or stiff hair may cause the cyst to become inflamed and infected, resulting in an abscess that requires incision to drain the infected material. These abscesses can recur, causing the patient to require surgical intervention to remove the cyst. After surgery, some patients tend not to heal well, resulting in a chronic tracking wound in an area that is difficult to heal.

by Heidi H. Cross, MSN, RN, FNP-BC, CWON

When looking at medical charts from a legal perspective, one of the areas closely scrutinized is the risk assessment for skin breakdown and pressure ulcer development. Completing a risk assessment is considered a standard of care. Was the patient adequately assessed, and was this done in a timely fashion? Was it repeated at regular intervals, with a change in condition, or on readmission? Do scores seem appropriate for the patient's condition? Is there consistency among health practitioners? Were the results used to institute evidence-based and appropriate prevention and treatment measures and care plans? Or do the results seem to simply languish in the chart? What are the standards of care related to this?

by the WoundSource Editors

By Samantha Kuplicki MSN, APRN-CNS, AGNCS-BC, CWCN-AP, CWS, RNFA, CFCN

By Holly Hovan MSN, APRN, CWOCN-AP

Friction and shear… what’s the difference and how do they cause pressure injuries? Are wounds caused by friction and shear classified as pressure injuries? What’s the easiest way to explain the differences between these critical components of the Braden Scale for Predicting Pressure Sore Risk® that are not always understood? How do I know if my patient is at risk?

By Holly Hovan MSN, APRN, CWOCN-AP

The Braden Scale for Predicting Pressure Sore Risk® category of activity focuses on how much (or how little) the resident can move independently. A resident can score from 1 to 4 in this category, 1 being bedfast and 4 being no real limitations. It is important to keep in mind that residents who are chairfast or bedfast are almost always at risk for skin breakdown