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Pressure Ulcer Risk Assessment Tools
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Pressure Ulcers in Adults: Prediction and Prevention -- Clinical Practice Guideline Number 3      
           Risk Assessment Tools and Risk Factors
                                                             (less references) 

Goal

Identify at-risk individuals needing prevention and the specific factors placing them at risk.
 

Bed- and Chair-Bound Individuals

Bed- and chair-bound individuals or those with impaired ability to reposition should be assessed for additional factors that increase risk for developing pressure ulcers.

These factors include immobility, incontinence, nutritional factors such as inadequate dietary intake and impaired nutritional status, and altered level of consciousness.

Individuals should be assessed on admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities.

A systematic risk assessment can be accomplished by using a validated risk assessment tool such as the Braden Scale or Norton Scale. Pressure ulcer risk should be reassessed at periodic intervals. (Strength of Evidence = A.) All assessments of risk should be documented. (Strength of Evidence = C.)

Rationale.

To prevent pressure ulcers, individuals at risk must be identified so that risk factors can be reduced through intervention. The primary risk factors for pressure ulcers are immobility and limited activity levels.

Therefore, persons with impaired ability to reposition themselves or those whose activity is limited to bed or any chair should be assessed for their risk of developing a pressure ulcer. To determine the magnitude of risk, the degree to which mobility and activity levels are limited can be quantified. Both the Norton Scale and the Braden Scale assess these factors. Instructions on use of both scales are available.

Other risk factors for pressure ulcer development include incontinence, impaired nutritional status, and altered level of consciousness.

Incontinence is assessed by the Moisture subscale of the Braden Scale and the Incontinence component of the Norton Scale Nutritional factors are considered indirectly in the General Condition component of the Norton Scale and the Nutritional Status subscale of the Braden Scale. Altered level of consciousness is assessed by the Norton Scale's Mental Condition subscale and the Braden Scale's Sensory Perception subscale.

Numerous risk assessment tools exist; however, only the Braden Scale and the Norton Scale (original, and modified) have been tested extensively. The Braden Scale has been evaluated in diverse sites that include medical-surgical units, intensive care units, and nursing homes. The Norton Scale has been tested with elderly subjects in hospital settings.

The reported sensitivity and specificity of these risk assessment tools have varied greatly. This variability probably reflects differences in study settings, populations, and outcome measures. Some studies have included Stage I ulcers as an outcome with inconsistent definitions of these lesions. The degree to which preventive interventions have been implemented in response to the findings of the risk assessments in these studies may have also contributed to the variability in their reported performance. Good interrater reliability for the Braden Scale has been reported Reliability data are not available for the Norton Scale, and the original version did not include definitions for its subscales . Modifications of the Norton Scale have included such definitions.

Despite the limitations of the Norton and Braden scales, their use ensures systematic evaluation of individual risk factors. No information is currently available to suggest that adaptations of these risk assessment tools or the assessment of any single risk factor or a combination of risk factors predict risk as well as the overall scores obtained by the tools.

The condition of an individual admitted to a health care facility is not static; consequently, pressure ulcer risk requires routine re-examination. The frequency with which such re-evaluations need to be done is unknown. However, if an individual becomes bed- or chair-bound or develops difficulty with repositioning, pressure ulcer risk needs to be assessed. Accurate and complete documentation of all risk assessments ensures continuity of care and may be used as a foundation for the skin care plan.

Skin Care and Early Treatment


Goal:

Maintain and improve tissue tolerance to pressure in order to prevent injury.

Recommendations:

1. Skin Inspection

All individuals at risk should have a systematic skin inspection at least once a day, paying particular attention to the bony prominences. Results of skin inspection should be documented. (Strength of Evidence = C.)

Rationale.

It is customary practice to include procedures for inspecting skin in an overall skin care program that also includes interventions. As a result, the exact role that a systematic, comprehensive, and routine skin inspection plays in decreasing the incidence of pressure ulcers has not been identified. For this guideline, it was deemed sufficient that health care professionals advocate skin inspection as fundamental to any plan for preventing pressure ulcers. Skin inspection provides the information essential for designing interventions to reduce risk and for evaluating the outcomes of those interventions.

2. Skin Cleansing

Skin cleansing should occur at the time of soiling and at routine intervals. The frequency of skin cleansing should be individualized according to need and/or patient preference. Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness of the skin. During the cleansing process, care should be utilized to minimize the force and friction applied to the skin. (Strength of Evidence = C.)

Rationale.

Daily activities result in metabolic wastes and environmental contaminants accumulating on the skin. For maximum skin vitality, these potentially irritating substances should be removed frequently. If unexpected contamination occurs, such as fecal or urinary incontinence, the skin should be cleansed as soon as possible to limit chemical irritation.

As a person ages, the frequency of routine skin cleansing may decrease because there is less sebum and perspiration. This reduced frequency of cleansing lessens the magnitude of trauma experienced by the more sensitive skin.

Skin injury due to excess thermal energy or the accelerated metabolic activity induced by elevated temperature should be minimized by only using wash water that is comfortable (slightly warm) to the skin.

During the cleansing process, some of the skin's natural barrier is removed. The more the barrier is removed, the drier the skin becomes and the more susceptible it becomes to external irritants. Under most conditions, the individual's skin is minimally soiled and can be properly cleansed with a very mild cleansing agent that does not disrupt the natural barrier.

3. Dry Skin

Minimize environmental factors leading to skin drying, such as low humidity (less than 40 percent) and exposure to cold. Dry skin should be treated with moisturizers. (Strength of Evidence = C.)

Rationale.

Preliminary research evidence suggests that a weak association may exist between dry, flaky, or scaling skin and an increased incidence of pressure ulcer development .

It also appears that adequate hydration of the stratum corneum helps protect against mechanical insult. The level of stratum corneum hydration decreases with decreasing ambient air temperature, particularly when the relative humidity of the ambient air is low. Further, the development of clinically dry skin may result from a decreased level of relative humidity in the ambient air.

Decreased skin hydration results in reduced pliability, and severely dry skin is associated with fissuring and cracking of the stratum corneum. Also, a number of studies have shown that both the clinical picture of dry skin and measures of stratum corneum hydration generally improve with the application of various topical moisturizing agents.

Although efficacy of any specific moisturizing agent has not been established, it would appear prudent to treat clinical signs and symptoms of dry skin with a topical moisturizer.

Further, although there is no direct evidence to support efficacy in preventing pressure ulcers, maintenance of ambient environmental conditions (relative humidity, and temperature) appears to be prudent to facilitate stratum corneum hydration and minimize the incidence of dry skin.