Pressure Ulcer Risk Assessment - HumanGood



|Pressure Ulcer Risk Assessment H5MAPR0219 |Level III |

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|Purpose |The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk |

| |of developing pressure ulcers. |

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|Preparation |Review the resident’s care plan to assess for any special needs of the resident. |

| |Assemble the equipment and supplies as needed. |

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|General Guidelines |Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time |

| |causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. |

| |The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of |

| |the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. |

| |Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. |

| |If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident,|

| |and often times become infected. |

| |Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the |

| |resident’s skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and |

| |hydration status, acute illness and/or decline in the resident’s physical and/or mental condition. |

| |Once a pressure ulcer develops, it can be extremely difficult to heal. |

| |Encourage the resident to participate in active and passive range of motion exercises to improve circulation. |

| |Ensure that the resident drinks plenty of fluids and eats a well-balanced diet. |

| |Pressure ulcers are a serious skin condition for the resident. |

| |Routinely assess and document the condition of the resident’s skin per facility wound and skin care program for |

| |any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to |

| |the supervisor. |

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|Assessment |Risk Assessment. A pressure ulcer risk assessment will be completed upon admission, with each additional |

| |assessment; quarterly, annually and with significant changes. |

| |Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more |

| |frequently if indicated. |

| |Monitoring: |

| |Staff will maintain a “skin alert,” performing routine skin inspections daily or every other day as needed. |

| |Nurses are to be notified to inspect the skin if skin changes are identified. |

| |Nurses will conduct skin assessments at least weekly to identify changes. |

| |Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk |

| |resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers.|

| |The admission evaluation helps define those initial care approaches. |

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|Assessment (continued) |In addition, the admission evaluation may identify pre-existing signs (such as a purple or very dark area that is |

| |surrounded by profound redness, edema, or induration) suggesting that deep tissue damage has already occurred and |

| |additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of an unavoidable |

| |Stage III or IV pressure ulcer or progression of a Stage I pressure ulcer to an ulcer with eschar or exudate |

| |within days after admission. (Some situations that may have contributed to this tissue damage include pressure |

| |resulting from immobility during hospitalization or surgical procedures, during prolonged ambulance transport, or |

| |while waiting to be discovered or assisted after a debilitating event, such as a fall or a cerebral vascular |

| |accident.) |

| |Because it may be harder to identify erythema in an older adult with darkly pigmented skin, older adults with |

| |darkly pigmented skin may be more at risk for developing pressure ulcers. It may be necessary in a darker skinned |

| |individual to focus more on other evidence of pressure ulcer development, such as bogginess, induration, coolness,|

| |or increased warmth as well as signs of skin discoloration. |

| |Multiple factors, including pressure intensity, pressure duration, and tissue tolerance, significantly affect the |

| |potential for the development and healing of pressure ulcers. An individual may also have various intrinsic risks |

| |due to aging, for example: decreased subcutaneous tissue and lean muscle mass, decreased skin elasticity, and |

| |impaired circulation or innervation. |

| |The comprehensive assessment, which includes the Resident Assessment Instrument (RAI)/ Minimum Data Set (MDS), |

| |evaluates the resident’s intrinsic risks, the resident’s skin condition, other factors (including causal factors) |

| |which place the resident at risk for developing pressure ulcers and/or experiencing delayed healing, and the |

| |nature of the pressure to which the resident may be subjected. The assessment should identify which risk factors |

| |can be removed or modified. |

| |The assessment also helps identify the resident who has multi-system organ failure or an end-of-life condition or |

| |who is refusing care and treatment. If the resident is refusing care, an evaluation of the basis for the refusal, |

| |and the identification and evaluation of potential alternatives is indicated. |

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| |Identifying Residents at Risk |

| |Extrinsic risk factors for pressure ulcers include: |

| |Pressure – the resident is not capable of moving without assistance, is confined to bed, and/or requires a regular|

| |schedule of turning. |

| |Friction and shear – the resident slides down in the bed or is moved by sliding rather than lifting. |

| |Maceration – the resident is persistently wet (especially from fecal incontinence, wound drainage or |

| |perspiration). |

| |Intrinsic risk factors for pressure ulcers include: |

| |Immobility |

| |Altered mental status |

| |Incontinence |

| |Poor nutrition |

| |Medications that increase risk of pressure ulcers include: |

| |Antipsychotics |

| |Antianxiety agents |

| |Antidepressants |

| |Hypnotics |

| |Steroids |

| |Narcotics |

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|Assessment (continued) | |

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| |Diagnoses and Conditions that increase risk for pressure ulcers: |

| |Severe pulmonary disease |

| |Urinary incontinence |

| |Paraplegia/quadriplegia |

| |Sepsis |

| |Terminal cancer |

| |Chronic or end stage renal, liver, or heart disease |

| |Diabetes |

| |Alzheimer’s disease or other dementia |

| |Multiple sclerosis |

| |Edema |

| |Depression |

| |Hemiplegia/hemiparesis |

| |Cerebrovascular accident |

| |Comatose |

| |Steroid therapy |

| |Radiation therapy |

| |Chemotherapy |

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|Equipment and Supplies |The following equipment and supplies will be necessary when providing a pressure ulcer risk assessment: |

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| |Resident’s medical record, including admission data; |

| |Minimum Data Set (MDS) assessment form; |

| |Assessment tools such as the Braden Scale or Norton Plus Pressure Ulcer Scale; and |

| |Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). |

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|Steps in the Procedure |Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the |

| |resident’s condition and willingness to participate. |

| |If necessary, allow the resident to take rest periods during the assessment. |

| |When conducting a physical assessment of skin condition, provide for the resident’s privacy. |

| |Once risk factors have been identified, proceed to the Care Area Assessment, care planning and interventions |

| |individualized for the resident and their particular risk factors. |

| |Document the procedure. |

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|Documentation |The following information should be recorded in the resident’s medical record: |

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| |The type of assessment conducted. |

| |The date and time and type of skin care provided, if appropriate. |

| |The position in which the resident was placed upon completion of the assessment. |

| |The name and title of the individual conducted the assessment. |

| |Any change in the resident’s condition. |

| |The condition of the resident’s skin (i.e., the size and location of any red or tender areas). |

| |How the resident tolerated the procedure or his/her ability to participate in the procedure. |

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|Documentation (continued) |continues on next page |

| |Any problems or complaints made by the resident related to the procedure. |

| |If the resident refused the assessment and the reason(s) why. |

| |Observations of anything unusual exhibited by the resident. |

| |The signature and title of the person recording the data. |

| |Documentation of advance directives. |

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|Reporting |Notify the supervisor if the resident refuses the procedure. |

| |Report other information in accordance with facility policy and professional standards of practice. |

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|References |

|MDS (CAAs) |Section M; (CAA 16) |

|Survey Tag Numbers |F309; F314 |

|Related Documents |Norton Plus Pressure Ulcer Scale (See CD-ROM) |

| |Skin Care Alert (See CD-ROM) |

|Risk of Exposure |Blood–Body Fluids–Infectious Diseases–Air Contaminants–Hazardous Chemicals |

|Procedure |Date:________________ By:__________________ |

|Revised |Date:________________ By:__________________ |

| |Date:________________ By:__________________ |

| |Date:________________ By:__________________ |

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