Insert your name and credentials on the title slide Hello…my name is_____________. I am a _________nurse, PT etc…and a certified wound specialist. Thank you for this opportunity to present Pressure Ulcer Risk Assessment to you. How many of you are involved in the process of Pressure Ulcer Risk Assessment for the residents at your facility?
Disclaimer The information presented herein is provided for educational and informational purposes only and to promote the safe-and-effective use of the wound care products provided. It is for the attendees’ general knowledge and is not a substitute for legal or medical advice. Although every effort has been made to provide accurate information herein, laws change frequently and vary from state to state. The material provided herein is not comprehensive for all legal and medical developments and may contain errors or omissions. If you need advice regarding a specific medical or legal situation, please consult a medical or legal professional. Gordian Medical, Inc. dba American Medical Technologies shall not be liable for any errors or omissions in this information.
Upon completion of this program you will be able to describe the importance of Risk Assessment and be able to recognize Extrinsic and Intrinsic factors that contribute to the risk of the development of Pressure Ulcers.
consistent use of a risk assessment tool can reduce the incidence of pressure ulcers by 60%!!!!
Presenter
Presentation Notes
JUST LIKE AN SHELL OF AN EGG, RESIDENTS IN THE LTC SETTING ARE OFTEN VERY FRAGILE! The risk assessment for pressure ulcers is a critical component of prevention. Please remember prevention is the priority and treatment is the alternative. You will want to do your head to toe skin assessment in addition to your pressure ulcer risk assessment. These are two different assessments as we will discuss in the next slide. The National Pressure Ulcer Advisory Panel (NPUAP) NPUAP recommends each facility have a risk assessment policy. Does your facility have a risk assessment policy and procedure that is written and has been reviewed and approved by your DON and Medical Director? Reference: NPUAP/EPUAP Pressure Ulcer Prevention & Treatment Clinical Practice Guideline, 2009. NPUAP.org In a prospective study of LTC residents, investigators followed new admissions for 3 months. The study determined that 80% of those residents who developed a pressure ulcer did so within 2 weeks of admission and 96% of residents developed a pressure ulcer within 3 weeks of admission* Reference Barbara Braden, 1989, “Clinical Utility of the Braden Scale for Predicting Pressure Sore Risk”. Recommend performing a risk assessment any time there is a change in patient’s status and/or discharge and return from hospital. This will also help to prevent finger pointing between LTC, hospital and ambulance because it is provided an objective baseline.
Difference Between Skin Assessment and Pressure Ulcer Risk Assessment
There is a distinct difference between the Skin Assessment and the PrU Risk Assessment The Skin Assessment Goals are to: Gather info to describe the current health of the skin Detect variations from normal (erythema, rashes, lesions, dryness, etc) Identify age-related or disease-related changes (thinning, decreased elasticity, trophic changes, etc) The PrU Risk Assessment Goals are to: Gather info about specific factors, such as immobility, poor nutrition, and other issues that place a resident at risk for developing a PrU From: The nursing process and pressure ulcer prevention: making the connection. Adv Skin Wound Care 2009;22:83-92.
Risk Assessment Steps Identify: ALL risk factors Pre-existing skin issues
Assess level of pain Include the Resident Assessment
Instrument (RAI) Identify the automatic high risk resident Assess additional factors impacting
development, treatment and healing of pressure ulcers
When you do your Pressure Ulcer risk assessment you want to Identify and document ALL risk factors within 8 hours of admission if possible but for sure no longer than 24 hours. Include identify of all pre-existing skin issues such as skin trauma, DTI or a previous pressure ulcer. Assess and document the residents level of pain. Include the Resident Assessment Instrument (RAI) Identify the resident with automatic high risk such as multi-system organ failure, end-of-life condition, refusal of care and treatment. Be sure to also address factors that have been identified as having an impact on the development, treatment and/or healing of pressure ulcers.
CMS considers a pressure ulcer to be a sentinel event in a resident of a LTC facility who had been assessed as being at low risk for pressure ulcer development
According to CMS: • Residents at high risk: • impaired transfer or bed
mobility • Comatose • malnourished, • end-stage disease • any other patient is at low risk
Presenter
Presentation Notes
CMS considers a pressure ulcer to be a sentinel event in a resident of a long-term-care facility who had been assessed as being at low risk for pressure ulcer development. According to CMS: The only residents who are at high risk are those who have impaired transfer or bed mobility, are comatose, malnourished, or have end-stage disease. All other residents are considered to be at low risk. This is why it is imperative to do frequent risk reassessments to identify changes that can impact a residents risk for Pressure Ulcer development.
Risk for Pressure Ulcers altered cognition malnutrition incontinence immunosuppression corticosteroid history fractures diminished pain awareness poor circulation • drugs that impair wound
healing diabetes
dehydration bed rest/chronic immobility intrinsic/extrinsic/ iatrogenic
NOTE to presenter: it is not necessary to mention each and every one of these conditions. The ones in Yellow have descriptions below and you may choose to discuss others if you like. All of these conditions put the resident at higher risk for pressure ulcer development. Let’s discuss a few of these. Consider fractures as an example.. If your resident has a history of fractures, there may be hardware implanted which may contribute to your residents risk factors. Diabetes is another example…unstable blood glucose levels as well as poor circulation in the lower extremity may contribute to pressure ulcer development. Previous pressure ulcer history can decrease the skins tensile strength by 20% or more. These residents are always at higher risk for pressure ulcers and more susceptible for further breakdown. Low blood pressure is another risk factor which we will discuss further later in the program
areas exposed to tubes, lines and/or external devices (casts, splints, etc)
• medial/lateral malleoli • knee (all aspects)
•olecranon process
• occiput • ears
Presenter
Presentation Notes
Although these bony prominences are the most common sites for pressure ulcer formation. Pressure Ulcers can occur any where there is pressure. For example, a catheter line, nasal cannula or needle cap can produce a pressure ulcer if they resident is lying on the object. Anatomical sites at risk calcaneous greater trochanter ischial tuberosities sacrum medial/lateral malleoli knee (all aspects) olecranon process scapulae occiput ears toes (tight sheets) thoracic vertabrae areas exposed to tubes, lines and/or external devices (casts, splints, etc)
Extrinsic and Intrinsic factors both contribute to risk factors and the development of pressure ulcer formation. Some brief definitions are listed here to help you understand the difference between extrinsic factors and intrinsic factors. Extrinsic being outside or originating from outside where intrinsic is belonging to a thing or originating from within. The next slide will give you some additional examples.
Listed here are some extrinsic & intrinsic factors affecting the fragile shell of our egg example. Can you think of some comparisons to our fragile residents in the long term care facility? Note to presenter: At this point hopefully you can get some audience participation and have them discuss various examples of extrinsic and intrinsic factors which effect the residents they are caring for. Please utilize this as a time to get them to understand the difference in extrinsic and intrinsic.
Intrinsic Risk Factors Which Can Be Eliminated/Modified?
• Previous Hx of PrU • Malnutrition • Dehydration • Excessive perspiration • Urinary/fecal incontinence • sensory perception • Impaired circulation • Altered mental status • mobility • Age >70 years
• Altered blood pressure • Increased temperature
– either internal to the patient or at the patient/surface
(Note to presenter, you do not have to read every single factor listed) The University of Iowa Pressure Ulcer Prevention and Treatment Algorithm identifies some intrinsic factors can be modified and others cannot. For example you cannot you modify the fact that the resident has had a previous pressure ulcer or the residents age. However, you can modify malnutrition by increase proteins and attempting to resolve the state of malnutrition. You can attempt to modify the decrease in mobility by using physical and occupational therapy to initiate a mobility and transfer program that is followed up by restorative services, and you can often improve the altered blood pressure by medications.
Low Blood Pressure as a Risk Factor • Systolic BP <100 mmHg • Diastolic BP <60mmHg • Hypotension may shunt blood
flow away from the skin to more vital organs
• Decreases skin tolerance for pressure by allowing capillaries to close at lower interface pressures
Low blood pressure is an independent risk factor for pressure ulcer risk. Systolic BP below 100 mmHg and diastolic below 60mmHg has been associated with pressure ulcer development. When interface pressures are near diastolic pressure, little if any functional pressure redistribution is realized. Hypotension may shunt blood flow away from the skin to more vital organs, thus decreasing the skin tolerance for pressure by allowing capillaries to close at lower levels of interface pressure.
Extrinsic Factors • Treatment protocols • Failure to recognize risk • Patient handling techniques • Use of restraints • Hygiene • Medications • Emotional stress • Smoking
It is very important to pay close attention to your treatment protocols. Surveyors are recognizing that inappropriate treatment interventions can further impair the wound’s ability to heal. A good example of this would be wet to dry dressings on granulating wounds. We must provide care that is acceptable standard practice and provide justification for all we do. Failure to recognize risk can place the resident at further risk of pressure ulcer development. Patient handling techniques such as transfers must be done properly. Sliding the resident up in the bed with the heels dragging on the sheets creates friction and weakens the skin mantel. The use of restraints is listed; however, as we all know these are no longer or rarely used in the LTC setting. Hygiene can be a very important factor. Is your resident being bathed on a regular basis? Medications can also effect your resident. Is your resident on steroids for example? Stress can also be a factor. Is your resident experiencing some form of emotional stress? As we all are aware of smoking can place the resident at increased risk for many different reasons. Can anyone name some of the risks associated with smoking?
Risk Assessment Tools • Norton Scale:
• oldest, developed in 1961 • Gosnell’s Scale:
• based on further refinement of Norton • Braden Scale:
• published 1987. • Most common risk assessment tool used in
The Braden scale is the most widely used risk assessment tool. The Norton scale is the oldest scale and the Gosnell’s scale was developed based on refining the Norton scale; however, the Braden scale seems to be the most widely used in the LTC setting today. Has anyone seen the Norton or Gosnell scale being used recently? The Braden scale is the most common and it is based off of the residents assigned risk score ranging from 6 to 23 Please remember the LOWER THE NUMBER, THE HIGHER THE RISK.
Pressure Ulcer Risk Assessment • Determine if person at risk for pressure ulcers
– On admission – Repeat as regularly & frequently as required by patient
acuity – Or when a change in status – Ref. National Pressure Ulcer Advisory Panel=NPUAP.org
• Consider clinical setting – Acute care: on admission: at least every 48 hours – LTC: On admission\readmission, weekly for 1st 4 weeks,
then quarterly Any time a change in patient’s status and/or
discharge/return from hospital. – Home Health: On admission reassess every visit
Pressure Ulcer Risk Assessment Screening is done to determine if person at risk for developing pressure ulcers. The National Pressure Ulcer Advisory Panel (NPUAP) recommends a structured risk assessment be performed on admission and repeated as regularly and as frequently as required by the patient's acuity. And that a reassessment should be done if there is any change in the patient’s condition. Each care setting has developed their recommended frequencies for performing pressure ulcer risk assessments. For example: Acute care: on admission: at least every 48 hours LTC: On admission, weekly for 1st 4 weeks, then quarterly, and any time these is a change in the patient’s status and discharge to or return from the hospital. Home Health: On admission reassess every visit Your agency or facility should set a policy on which tool will be used, the frequency of use, and the interventions based on the findings from the screen. It is critical that you follow your own policy without exception. If there is a negative outcome and you did not follow your own policy there could be serious consequences for you or your organization.
Recommendations for Risk Assessments and Reassessments
• WOCN, AMDA • Initial risk assessment at admission or
readmission • Reassess weekly for the first 4 weeks • At least weekly during routine care (i.e. at bath) • Then quarterly • Or whenever the resident’s condition changes or
In addition to the NPUAP’s pressure ulcer risk assessment recommendations on frequency…both the Wound Ostomy Continence Nurses Society, the American Medical Directors Association have written guidelines on how often to do the initial risk assessment and follow up risk assessments for residents in LTC. These recommendations include performing an initial risk assessment for PrUs on admission and readmission; reassess weekly for the first 4 weeks; ongoing at least weekly during routine care (i.e. at bath time); then quarterly or whenever a resident’s condition changes or deteriorates.
How often are you doing pressure ulcer assessments in your setting?
Since the Braden scale is the most common risk assessment tool in use today let’s look at it a little more closely. The Braden parameters provide a numerical score for residents risk of pressure ulcer development. There are 6 parameters on the Braden Risk Assessment scale that are evaluated to determine a resident’s risk for acquiring PrUs…these are Sensory Perception, Moisture, Activity, Mobility, Nutrition and Friction and Shear. Friction and shear are two different types of mechanical stress on the skin.
Braden Scale Scores • Mild Risk = 15 - 18 • Moderate Risk = 13 - 14 • High Risk = 10 – 12 • Very High Risk = 9 or below
**If other major risk factors are present (e.g., age,
fever, poor dietary intake of protein, diastolic pressure <60, and/or hemodynamic instability), advance to next level of risk.
Presenter
Presentation Notes
Mild risk is 15 to 18. Moderate risk is 13 to 14. High Risk is 10 to 12 and Very high Risk is 9 or below. Regarding the Braden Scale Scores, please remember, The LOWER the NUMBER, the HIGHER the RISK. (NOTE to presenter, most do not realize that if other risk factors are present, you advance to the next level of the Braden Scale.) If other major risk factors are present (e.g., age, fever, poor dietary intake of protein, diastolic pressure <60, and/or hemodynamic instability), advance to next level of risk.
You want to be aware of and remember that the Risk Assessment is not a only a number. There must be interventions associated with EACH risk and they must be care planned and completed. The surveyor expects risk assessments to identify specific risk factors and to be implemented. Document in the residents plan of care the interventions put in place for each identified risk factor. Again, risk assessment is not just a number you must utilize it.
• Identify • Remove • Modify • Stabilize risk factors • To the BEST of your ability • DOCUMENT, DOCUMENT, DOCUMENT
Presenter
Presentation Notes
Identify the risk factors, remove those that can be removed, modify and/or stabilize risk factors that cannot be removed, and then DOCUMENT, DOCUMENT, DOCUMENT. Take credit for your hard work and write it down. Realize not all risk factors are modifiable, however they need to be managed and addressed to the best of your ability. Documentation is critical.
Risk Assessment • Prevention and early
intervention of at-risk patients is essential
• Thorough systems review • Observation and palpation of
Most pressure ulcers are preventable however, a thorough systems review will uncover conditions that may make residents prone and at greater risk for the development of pressure ulcers. Always treat the underlying pathology and etiology. Research suggests that skin which is the largest organ of the body, begins to fail with the other organ systems, making prevention of pressure ulcers not always possible. It is imperative that a comprehensive head to toe assessment of the skin is conducted on all residents (low and high risk individuals alike.) Skin assessment involves all the senses (look, listen, feel, smell This is particularly important in residents with darker pigmentation. Again, think of your resident’s skin to be as fragile as the shell of an egg.
Risk Assessment and POC • Risk assessment
• Address each in the resident’s plan of care • Risk assessment directs interventions
• Offloading/positioning/heel elevation • Pressure redistribution and support surfaces (bed
/wheelchair) • Nutrition & hydration • Dietary consult or re-consult • Consider resident food preferences, social & cultural
After performing the risk assessment for PrUs you must documented and addressed each one individually in the plan of care. F314 of the States Operation Manual has recommendations for prevention and treatment of pressure ulcers and addresses the minimum requirements for documentation for a resident with a pressure ulcer. F314 states that “The residents plan of care will direct treatments and interventions such as offloading, positioning, heel elevation, pressure redistribution and support surfaces (bed and wheelchair), as well as nutrition & hydration and dietary consult or re-consult. It should also reflect social and cultural differences, medication review (topical and systemic), functional mobility (rehab services), interventions for incontinence as well as specialist consults (vascular, endocrine, surgeon, psych, etc.).”
CMS: Avoidable Pressure Ulcers Resident developed a pressure ulcer and the facility
DID NOT DO one or more of the following: Evaluate the resident’s clinical
condition and pressure ulcer risk factors Define and implement interventions
that are consistent with resident needs, goals, and recognized standards of practice Monitor and evaluate the impact of the
CMS defines what they consider an unavoidable pressure ulcer…so…What is unavoidable? This is where a resident developed a pressure ulcer and the facility DID NOT DO one or more of the following: Evaluate the resident’s clinical condition and pressure ulcer risk factors. Define and implement interventions that are consistent with resident needs, goals, and recognized standards of practice. Monitor and evaluate the impact of the interventions. Revise the interventions if appropriate. The surveyor WILL be looking at your pressure ulcer risk assessments, the plans of care that should have been generated from the assessments, whether the plan of care was appropriate for that resident, and whether the plan of care was modified according to the resident’s response to the interventions for pressure ulcer prevention. Be specific and individualized with your plans of care for your residents. Surveyors recognized “cookie cutter” plans of care that do not match the needs of that particular resident.
CMS: Unavoidable Pressure Ulcers Resident developed a pressure ulcer even though the
facility: Evaluated the resident’s clinical
condition and risk factors Defined and implemented interventions
that are consistent with resident needs, goals, and recognized standards of practice Monitored and evaluated the impact of the
interventions Revised interventions as appropriate
What is unavoidable? This is where the resident developed a pressure ulcer even though the facility did do the following: Evaluated the resident’s clinical condition and risk factors. Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice. Monitored and evaluated the impact of the interventions. Revised interventions as appropriate.
REMEMBER: RESIDENTS AT RISK OR RESIDENTS WHO HAVE A PRESSURE ULCER ARE FRAGIL, JUST LIKE FRAGIL EGGS. According to CMS…and written in F314 Guide to Surveyors, the surveyor will be looking for daily monitoring when a pressure ulcer is present. This daily monitoring is mandated. The minimum components for daily monitoring of a wound are; evaluation of ulcer if no dressing is present, evaluation of the status of the dressing, if present. Is the dressing intact? Is there drainage? Is it leaking? You must also monitor and document the status of the peri-ulcer area…the area around the ulcer…that can be observed without removing the dressing. Presence of possible complications should be noted and include increased redness, swelling and drainage. If the resident is experiencing pain you must also monitor to insure the pain is being adequately assessed, documented, and controlled.
• Use a clinically validated tool • Obtain training • Use the full version of a risk assessment tool • Carefully match the resident’s clinical
presentation to the risk assessment tool’s descriptors
• Remember that PrU risk assessment & skin assessment are different tools with different goals
• Make independent assessments (do not copy other people’s work)
Presenter
Presentation Notes
In summary remember to always use a clinically validated tool to guide risk assessment. As recommended by the NPUAP, obtain training on how to use the tool correctly and most importantly use the full version of a risk assessment tool, not an abridged version. Always remember to carefully match the resident’s clinical presentation to the risk assessment tool’s descriptors to ensure reliability. Remember that pressure ulcer risk assessments and skin assessments are distinctly different activities and each has a very different goal. And always make independent assessments (do not copy other people’s work.) If you follow this guidelines, you won’t crack the egg. Thank you for your time and attention.
Review Questions 1. A skin assessment is all that is needed to assess your
patient’s risk for pressure ulcer development. True or False 2. The Braden Scale includes the following parameters: A. Mobility, skin health, age B. Moisture, nutrition, hypotension C. Mobility, moisture, activity D. Activity, skin health, hypotension 3. An unavoidable pressure ulcer occurs when risk factors are evaluated, interventions implemented, the patient monitored and interventions evaluated. True or False
References Continued • Slide 18 Guideline for Prevention and Management of Pressure Ulcers; WOCN Clinical Practice Guideline Series 2003 Pressure Ulcers in the Long-Term Care Setting; Clinical Practice Guideline; AMDA 2008 • Slide 24 The nursing process and pressure ulcer prevention: making the
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