Vencor Hospital Minneapolis



Nursing Competency for Risk Assessment and Prevention of Pressure Ulcers

Instructions

Skin Safety Case Study (may complete in advance and bring to skills day)

1. Read Case study “Mr. P” (front page).

2. Complete Braden Scale (page 2).

3. Circle appropriate preventive interventions or skin safety precautions (page 3)

Case Study (Mr.P)

Admission assessment reveals a tall thin man, 68 years old with paraplegia and pneumonia. He has been wheelchair bound for 20 years. Mr. P has received extensive health care from an outpatient clinic but this is his first hospitalization in 15 years. In his handicapped accessible home, he requires transfer assistance of 1 person and is otherwise independent with ADLs. His wife tells you (in private) that her husband struggles with positioning in his hospital bed because everything is different than what he has set up at home. He is currently wearing ted stockings for anti-embolism because he is in bed all day. His wife keeps him sitting straight up in bed with his tray in front of him hoping he will eat between naps. He eventually eats over half his meal trays. P has intact skin but has started to have incontinent frequent loose stools. He has a suprapubic catheter.

|BRADEN SCALE FOR PRESSURE ULCER RISK-COMPLETE DAILY |

|SENSORY PERCEPTION |1. Completely limited |2. Very limited |3. Slightly limited |4. No impairment | |

|Ability to respond |Unresponsive (does not moan, |Responds only to painful |Responds to verbal commands but |Responds to verbal | |

|appropriately to |flinch, or grasp) to painful |stimuli. Cannot communicate |cannot always communicate |commands. Has no | |

|pressure related |stimuli, caused by diminished level|discomfort except by moaning |discomfort or need to be turned. |sensory deficit that | |

|discomfort |of consciousness or sedation. Or |or restlessness. Or has a |Or has some sensory impairment |would limit ability to | |

| |has limited ability to feel pain |sensory impairment that limits|that limits ability to feel pain |feel or voice pain or | |

| |over most of body surface. |the ability to feel pain or |or discomfort in 1 or 2 |discomfort. | |

| | |discomfort over half of body. |extremities. | | |

|MOISTURE |1. Constantly moist |2. Moist |3. Occasionally moist |4. Rarely moist | |

|Degree to which skin is|Skin is kept moist almost |Skin is usually but not always|Skin is occasionally moist, |Skin is usually dry; | |

|exposed to moisture |constantly by perspiration, urine, |moist. Linen must be changed |requiring an extra linen change |linen requires changing | |

| |and so on. Dampness is detected |at least once a shift. |approximately once a day. |only at routine | |

| |every time patient is moved or | | |intervals. | |

| |turned. | | | | |

|ACTIVITY |1. Bed bound |2. Chair bound |3. Walks occasionally |4. Walks frequently | |

|Degree of physical |Confined to bed. |Ability to walk severely |during day but for very short |Walks outside the room | |

|activity | |limited or nonexistent. |distances, with or without |at least twice a day and| |

| | |Cannot bear own weight or must|assistance. Spends most of each |inside room at least | |

| | |be assisted into the chair or |shift in bed or chair. |once every 2 hours | |

| | |wheel chair. | |during waking hours. | |

|MOBILITY |1. Completely immobile |2. Very limited |3. Slightly limited |4. No limitations | |

|Ability to change and |Does not make even slight changes |Makes occasional slight |Independently makes frequent |Makes major and frequent| |

|control body position |in body or extremity position |changes in body or extremity |though slight changes in body or |changes in position | |

| |without assistance. |position but unable to make |extremity position. |without assistance. | |

| | |frequent or significant | | | |

| | |changes independently. | | | |

|NUTRITION |1. Very poor |2. Probably inadequate |3. Adequate |4. Excellent | |

|Usual food intake |Never eats a complete meal. Rarely|Rarely eats a complete meal |Eats over half of most meals. |Eats most of every meal.| |

|pattern |eats more than one-third of any |and generally eats only about |Eats a total of 4 servings of |Never refuses a meal. | |

| |food offered. Eats 2 servings or |half of any food offered. |protein (meat, dairy products) |Usually eats a total of | |

| |less of protein (meat or dairy |Eats 3 servings of protein |each day. Occasionally will |4 or more servings of | |

| |products) per day. Takes fluids |(meat or dairy products) per |refuse a meal, but will usually |meat and airy products | |

| |poorly. Does not take a liquid |day. Occasionally will take a|take supplement if offered or is |daily. Occasionally | |

| |dietary supplement. Or is NPO or |dietary supplement. Or |on a tube feeding or TPN regimen.|eats between meals. | |

| |maintained on clear liquids or I.V.|receives less than optimum | |Does not require | |

| |fluids for more than 5 days. |amount of liquid diet or tube | |supplementation. | |

| | |feeding. | | | |

|FRICTION AND SHEAR |1. Problem |2. Potential problem |3. No apparent problem | | |

|The loss of epidermis |Requires moderate to maximum |Moves feebly or requires |Moves in bed and in chair | | |

|due to rubbing against |assistance in moving. Complete |minimum assistance. During a |independently and had sufficient | | |

|sheets, chair or other |lifting without sliding against |move, skin slides to some |muscle strength to lift up | | |

|devices. |sheets is impossible. Frequently |extent against sheets, chair, |completely during move. | | |

| |slides down in bed or chair, |restraints, or other devices. |maintains good position in bed or| | |

| |requiring repositioning with |Maintains relatively good |chair at all times. | | |

| |maximum assistance. Spasticity, |position in chair or bed most | | | |

| |contractures, or agitation leads to|of the time but occasionally | | | |

| |almost constant friction. |slides down. | | | |

Total score ____________

Copyright Barbara Braden and Nancy Bergstrom. 1988

PREVENTIVE INTERVENTIONS-SKIN SAFETY PRECAUTIONS

(Pressure Ulcer Prevention Decision Making Tool)

Circle interventions that must be initiated for Mr. P based on his individual risk factors.

|BRADEN SCALE RISK FACTOR |INTERVENTIONS (SKIN SAFETY PRECAUTIONS) |

|IMPAIRED: |Obtain a preventive support surface (or group 1 mattress) for patients with multiple intact turning surfaces and a Braden |

|SENSORY PERCEPTION |Score < 18 |

|MOBILITY |Obtain a therapeutic support surface (or group 2 mattress) for patients with: |

|ACTIVITY |a Stage III, IV, or necrotic pressure ulcer on the trunk |

| |wounds on multiple turning surfaces |

| |Reposition q 2 hours in bed regardless of bed/mattress type. |

| |Avoid positioning directly on the trochanter |

| |Collaborate with MD for pain control as needed to promote appropriate repositioning |

| |Use pillows to keep bony prominences from direct contact with surfaces.(including keeping the heels off the bed) |

| |Limit HOB elevation to 30 degrees or less |

| |Reposition q 1 hour in the chair |

| |Moisturize dry skin, Do not massage reddened bony prominences |

| |Remove devices (stockings, SCDs, etc) q shift for skin inspection. |

|MOISTURE |Address cause and offer bedpan/urinal/toileting every 2 hours if applicable. |

| |Notify MD if the patient has loose stools |

| |Use absorbent pads that wick moisture away from the body (avoid diapers/briefs when possible) |

| |Perineal cleansers and barriers BID and after each incontinent episode. |

| |Consider containment devices for frequent loose stools (i.e. rectal pouches and FDA approved rectal tubes) |

|NUTRITIONAL DEFICIT |Collaborate with MD to consult nutritional services |

| |Maintain adequate hydration |

|FRICTION & SHEAR  |Limit HOB elevation to 30 degrees or less (unless contraindicated) |

|  |Use trapeze when indicated |

| |Use lift sheet or hovermat to move patient |

| |Protect elbows & heels if being exposed to friction |

|Other |Perform and document a skin assessment daily |

| |Quality track all nosocomial pressure ulcers |

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