Examples of Pressure Ulcer Risk Assessment Tools Braden Scale Norton Scale

Braden Subscales Sensory perception Moisture Activity Mobility Nutrition Friction and shear

Braden Risk Assessment Scale (abridged version) Sensory Perception 1 Completely limited 2 Very limited 3 Slightly limited 4 No impairment Moisture 1 Constantly moist 2 Very moist 3 Occasionally moist Activity 1 Bedfast 2 Chairfast 3 Walks Occasionally 4 Walks frequently Mobility 1 Completely immobile 4 No limitation Nutrition 1 Very poor 2 Probably inadequate 3 Adequate 4 Excellent Friction & Shear 1 Problem 2 Potential problem 3 No apparent problem Bedfast: bed-bound Abridged: brief Copyright Barbara Braden and Nancy Bergstrom, 1988, reprinted with permission

Examine Braden scale Highest possible score is 23 Lowest possible score is 6 Mild risk = 15-18 Moderate risk = 13-14 High risk = 10-12 Very high = <9

Norton Scale Physical condition Mental condition Activity Mobility Continence

Norton Subscales Scale Physical condition Good 4 Fair 3 Poor 2 Very bad 1 Mental condition Alert 4 Apathetic 3 Confused 2 Stupor 1 Activity Ambulant 4 Walk/help 3 Chair-bound 2 Bed 1 Mobility Full 4 Slightly limited 3 Very limited 2 Immobile 1 Continence Not incontinent 4 Occasional 3 Usually Urine 2 Urine & Feces 1 Apathetic: showing no interest, careless

Examine Norton scale Highest possible score is 20 Lowest possible score is 5 Onset of risk = 16 or below High risk = 12 or below

Pressure ulcer risk management Develop a care plan based on subscale scores and other conditions Immobile = reposition q 2 hrs in bed Inactive = reposition q 1hr in w/c Incontinent = protect skin from exposure Malnourished = supplement oral intake Shearing = keep HOB as low as possible Limited awareness= assess skin daily

Reduce Shear Shear diminishes blood supply to skin Use positioning, transferring & turning techniques to minimize friction / shear injury

Repositioning Reposition bed-bound individuals at least every 2 hours Reposition chair-bound individuals every hour and encourage weight shifts every 15 minutes Reposition while on special beds/ overlays Person must be turned 40 degrees to remove pressure from sacrum

Positioning Devices Teach individual to reposition using the trapeze Use lifting devices to move individuals who cannot assist Place pillows or wedges between knees and ankles Trapeze: a horizontal bar hanging by two ropes

Head of Bed Elevation Limit amount of time head of bed is elevated to reduce friction and shear Maintain the lowest possible elevation Avoid more than 30° head-of-bed elevation unless medically needed

Side lying position Avoid positioning directly on the trochanters Use the 30° lateral inclined position

Elevate Heels There must be space between bed and heels (float heels) Use pillows to elevate heels off the bed surface Avoid hyper-extension of the knees Check for injury from splints when used for heel elevation

X No Donuts Do NOT use plastic rings or donuts for pressure relief Can cause larger area of tissue injury because of intense pressure along the donut X

Change Support Surfaces General information Most pressure reducing devices are more effective than standard hospital mattress

CONTROLLING IMMOBILITY Tilt Recline Cushion selection Seat pan or sling Sacral sitting Armrests Trunk supports Footrests Covers on cushions

Standing Circulation Tone Spasticity Pressure sores Bladder management Community environments Psycho-social indications Contraindications: Contractures Poor standing tolerance BMD loss Fractures Postural hypotension (dizziness)

Offloading Removes pressure from high risk areas or areas with ulcers Can be done with pillows, devices and/or beds

Elevate Heels There must be space between the heel and bed Use pillows to elevate heels off the bed surface Avoid hyper-extension of the knees Check for injury from splints when used for heel elevation

Repositioning Reposition bed-bound individuals (time should depend on patient (1 ½-3 hours) Reposition chair-bound individuals every hour Reposition even while on special beds

Positioning Devices Teach individual to reposition using the trapeze Use lifting devices to move individuals who cannot assist Place pillows or wedges between knees and ankles

Head of Bed Elevation Limit amount of time head of bed is elevated to reduce friction and shear Maintain the lowest possible elevation Avoid more than 30° head-of-bed elevation unless medically needed -Elevate head of bed for patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), reflux, and actively infusing enteral fluids. -Reflux: Gastroesophageal reflux disease (GERD), gastro-oesophageal reflux disease (GORD), gastric reflux disease, or acid reflux disease is a chronic symptom of mucosal damage caused by stomach acid coming up from the stomach into the esophagus

Side lying position Avoid positioning directly on the trochanters Use the 30° lateral inclined position

No Donuts Do NOT use plastic rings or donuts for pressure relief Can cause larger area of tissue injury because of intense pressure along the donut

Support Surfaces Most pressure reducing devices are more effective than standard hospital mattress Types Overlays Mattress replacements Beds

Constant Low Pressure Support Surface Devices

Constant Low Pressure Support Surface Devices

Constant Low Pressure Support Surfaces Maximize skin contact area to reduce peak interface pressures Foam Gel Fiber Low Air Loss Air Fluidized

Constant Low Pressure Support Surfaces The redistribution of skin interface pressure over as large an area as possible.

Constant Low Pressure Support Surfaces Interface Pressure Measurement

Alternating Pressure Air Support Surface Devices Removes pressure from a localized skin area Changes the interface pressure on the skin over time by periodically inflating and deflating air cells under the body Redistributes the pressure on soft tissue and encourages reperfusion of the previously supported areas Promote movement and re-establish blood flow Changes the interface pressure on the skin over time by periodically inflating and deflating air cells under the body

Alternating Pressure Air Support Surfaces Head section Alternating cells Made up of interconnected air cells that cyclically inflate and deflate to periodically remove pressure from soft tissue

Support Surfaces in Chair For individuals who spend majority of time in wheelchair: Use pressure reducing cushion Instruct to also relieve pressure with hand lifts if possible Consider changing chair to tilt/recline for more pressure distribution