examples of pressure ulcer risk assessment tools braden scale norton scale
TRANSCRIPT
Examples of Pressure UlcerRisk 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
4 No impairment
Activity 1 Bedfast 2 Chairfast 3 Walks Occasionally
4 Walks frequently
Mobility 1 Completely immobile
2 Very limited
3 Slightly limited
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
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
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
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
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
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
Changes the interface pressure on the skin over time by periodically inflating and deflating air cells under the body
Alternating Pressure Air Support Surfaces
Made up of interconnected air cells that cyclically inflate and deflate to periodically remove pressure from soft tissue
Alternating cellsHeadsection
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