1. Examples of Pressure Ulcer Risk Assessment Tools
Braden Scale
Norton Scale

2. Braden Subscales Sensory perception Moisture Activity Mobility
Nutrition
Friction and shear

3. 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

4. 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

5. Norton Scale Physical condition Mental condition Activity Mobility
Continence

6. 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

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

8. 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

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

10. 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

11. 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

12. 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

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

14. 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

15. 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

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

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

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

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

20. 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

21. 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

22. 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

23. 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

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

25. 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

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

27. Constant Low Pressure Support Surface Devices

28. Constant Low Pressure Support Surface Devices

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

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

31. Constant Low Pressure Support Surfaces
Interface Pressure Measurement

32. 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

33. 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

34. 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