(Content courtesy of Wound Care Education Institute)
When it comes to pressure ulcer prevention and treatment, traditional risk assessment tools don’t always tell the whole story. As nurses, we know how pressure ulcers can negatively affect patients’ lives. This serious skin condition can not only lead to further complications and higher costs, but also can inhibit a patient’s ability to participate in rehabilitation and ultimately lead an active role in his community.
It’s important to note that the more nurses can do to properly assess pressure ulcers from the very beginning, the better they can do to help promote healing, reduce hospital stays and accelerate recovery time. Obviously, this involves the use of valuable tools, such as the Braden Scale. But we should also implement a good dose of clinical judgment once pressure ulcer risk is determined. Here’s how:
The 2014 International Guidelines on the Prevention and Treatment of Pressure Ulcers stress the importance of looking at other factors and not just the risk score when establishing risk levels and interventions for your patients. As mentioned earlier, to accurately determine your patient’s risk, the use of traditional tools alone (like the Braden Scale) is no longer considered to be enough.
Since the current condition of the skin is a key factor to consider when determining risk levels and interventions, the guidelines recommend both risk and skin assessments be completed within eight hours of admission. Anytime a risk assessment is completed, a skin assessment must be done and it should be documented right along with it. This applies throughout the patient’s stay within your care setting.
When examining your patient’s chances for developing a pressure ulcer, taking note of the current skin condition is crucial. Are there reddened areas that barely blanch, and are they frequently recurring over the same bony prominence? Answering questions like these is important.
We always must look at the bigger picture of risk and then factor in additional information such as psychosocial status, patient size, care setting, support surface, lab data and other sources. Refer to the National Pressure Ulcer Advisory Panel’s Prevention and Treatment of Pressure Ulcers: Quick Reference Guide for risk factor assessment recommendations. In addition, our infographic includes specific recommendations when conducting skin and tissue assessments.
Using your clinical judgment, along with traditional assessment tools and the tools from the guidelines, is a must when it comes to skin and risk assessment for pressure ulcers.