Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality

Section 7. Tools and Resources (continued)

2E: Assessing Screening for Pressure Ulcer Risk

Background: The purpose of this tool is to determine if your facility has a process to screen patients for pressure ulcer risk. The tool is one of a series of Facility Assessment Checklists developed to identify areas that need improvement.

Reference: Quality Partners of Rhode Island. Pressure Ulcers: Facility Assessment Checklists. Available at: https://www.qualitynet.org/dcs/ContentServer?cid=1098482996140&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools.

Instructions: Complete the checklist. For certain questions, you may want to consult with appropriate staff in your organization.

Use: Use the results of this assessment to identify issues that you need to deal with, and formulate goals for your pressure ulcer prevention initiative.

Assessment of Screening for Pressure Ulcer Risk

Does your facility have a process for screening that addresses all the areas listed below?

 YesNoPerson ResponsibleComments
1. Do you screen all patients for pressure ulcer risk at the following times:
  • Upon admission
  • Upon readmission
  • When condition changes
    
2. If the patient is not currently deemed at risk, is there a plan to rescreen at regular intervals?    

3. Do you use either the Norton or Braden pressure ulcer risk assessment tool?

If Yes, STOP. If No, please continue to #4.

    
4. If you are not currently using the Norton or Braden risk assessment, does your screening address the following areas:
  • Impaired mobility:
    • Bed
    • Chair
  • Incontinence:
    • Urine
    • Stool
  • Nutritional deficits:
    • Malnutrition
    • Feeding difficulties
  • Diagnosis of:
    • Diabetes Mellitus
    • Peripheral Vascular Disease
  • Contractures
  • Hx of pressure ulcers
    

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2F: Assessing Pressure Ulcer Care Planning

Background: This tool can be used to determine if your facility has a process for developing and implementing a pressure ulcer care plan for patients who have been found to be at risk or who have a pressure ulcer. The tool is one of a series of Facility Assessment Checklists developed to identify areas that need improvement.

Reference: Quality Partners of Rhode Island. Pressure Ulcers: Facility Assessment Checklists. Available at: https://www.qualitynet.org/dcs/ContentServer?cid=1098482996140&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools.

Instructions: Complete the checklist. For certain questions, you may want to consult with appropriate staff in your organization.

Use: Use the results of this assessment to identify issues that you need to deal with, and formulate goals for your pressure ulcer prevention initiative.

Assessment of Pressure Ulcer Care Plan

Does the care plan for pressure ulcers address all the areas below (as they apply)?

 YesNoPerson ResponsibleComments
Impaired Mobility
  • Assist with turning, rising, position
  • Encourage ambulation
  • Limit static sitting to 2 hours at any time
    
Pressure Relief
  • Support surfaces: Bed
  • Support surfaces: Chair
  • Pressure-relieving devices
  • Repositioning
  • Bottoming out in bed and chair*
    
Nutritional Improvement
  • Supplements
  • Feeding assistance
  • Adequate fluid intake
  • Dietitian consult as needed
    
Urinary Incontinence
  • Toileting plan
  • Wet checks
  • Treat causes
  • Assist with hygiene
  • Use of skin barriers and protectants
    
Fecal Incontinence
  • Toileting plan
  • Soiled checks
    
Skin Condition Check
  • Intactness
  • Color
  • Sensation
  • Temperature
    
Treatment
  • Physician-prescribed regimen
  • Appropriateness to wound staging
  • Treatment reassessment timeframe
    
Pain
  • Screen for pain related to ulcer
  • Choose appropriate pain med
  • Provide regular pain med administration
  • Reassess effectiveness of med
  • Assess/treat side effects
  • Change or cease pain med as needed
    

* To determine if a patient has bottomed out, the caregiver should place his or her outstretched hand (palm up) under the mattress overlay below the existing pressure ulcer or that part of the body at risk for pressure formation. If the caregiver can feel that the support material is less than an inch thick at this site, the patient has bottomed out.

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2G: Pieper Pressure Ulcer Knowledge Test

Background: This tool can be used to assess staff knowledge on pressure ulcer prevention. The 47-item test was developed by Pieper and Mott in 1995 to examine the knowledge of nurses on pressure ulcer prevention, staging, and wound description. Questions 1, 3, 15, 29, 33, and 40 have been modified from the original to make it more specific to hospital care.

Reference: Pieper B, Mott M. Nurses' knowledge of pressure ulcer prevention, staging, and description. Adv Wound Care 1995;8:34-48.

Instructions:

  1. Administer the test to nursing and other clinical staff members.
  2. It is generally recommended that responses be anonymous, but some staff might appreciate the opportunity to receive individual feedback. Find out what people on your unit want to do.
  3. Use the answer key to evaluate the responses. Note that some questions may need to be modified for your hospital.

Use: Mean scores on this test are usually analyzed. Analyze the test results. If you find gaps of knowledge, work with your education department to develop and tailor educational programs that address these items.

Pieper Pressure Ulcer Knowledge Test

For each question, mark the box for True, False, or Don't Know.

QuestionTrueFalseDon't Know
1. Stage I pressure ulcers are defined as intact skin with nonblanchable erythema in lightly pigmented persons.   
2. Risk factors for development of pressure ulcers are immobility, incontinence, impaired nutrition, and altered level of consciousness.   
3. All hospitalized individuals at risk for pressure ulcers should have a systematic skin inspection at least daily and those in long-term care at least once a week.   
4. Hot water and soap may dry the skin and increase the risk for pressure ulcers.   
5. It is important to massage bony prominences.   
6. A Stage III pressure ulcer is a partial thickness skin loss involving the epidermis and/or dermis.   
7. All individuals should be assessed on admission to a hospital for risk of pressure ulcer development.   
8. Cornstarch, creams, transparent dressings (e.g., Tegaderm, Opsite), and hydrocolloid dressings (e.g., DuoDerm, Restore) do not protect against the effects of friction.   
9. A Stage IV pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure.   
10. An adequate dietary intake of protein and calories should be maintained during illness.   
11. Persons confined to bed should be repositioned every 3 hours.   
12. A turning schedule should be written and placed at the bedside.   
13. Heel protectors relieve pressure on the heels.   
14. Donut devices/ring cushions help to prevent pressure ulcers.   
15. In a side lying position, a person should be at a 30 degree angle with the bed unless inconsistent with the patient's condition and other care needs that take priority.   
16. The head of the bed should be maintained at the lowest degree of elevation (hopefully, no higher than a 30 degree angle) consistent with medical conditions.   
17. A person who cannot move him or herself should be repositioned every 2 hours while sitting in a chair.   
18. Persons who can be taught should shift their weight every 30 minutes while sitting in a chair.   
19. Chair-bound persons should be fitted for a chair cushion.   
20. Stage II pressure ulcers are a full thickness skin loss.   
21. The epidermis should remain clean and dry.   
22. The incidence of pressure ulcers is so high that the government has appointed a panel to study risk, prevention, and treatment.   
23. A low-humidity environment may predispose a person to pressure ulcers.   
24. To minimize the skin's exposure to moisture on incontinence, underpads should be used to absorb moisture.   
25. Rehabilitation should be instituted if consistent with the patient's overall goals of therapy.   
26. Slough is yellow or creamy necrotic tissue on a wound bed.   
27. Eschar is good for wound healing.   
28. Bony prominences should not have direct contact with one another.   
29. Every person assessed to be at risk for developing pressure ulcers should be placed on a pressure-redistribution bed surface.   
30. Undermining is the destruction that occurs under the skin.   
31. Eschar is healthy tissue.   
32. Blanching refers to whiteness when pressure is applied to a reddened area.   
33. A pressure redistribution surface reduces tissue interface pressure below capillary closing pressure.   
34. Skin macerated from moisture tears more easily.   
35. Pressure ulcers are sterile wounds.   
36. A pressure ulcer scar will break down faster than unwounded skin.   
37. A blister on the heel is nothing to worry about.   
38. A good way to decrease pressure on the heels is to elevate them off the bed.   
39. All care given to prevent or treat pressure ulcers must be documented.   
40. Devices that suspend the heels protect the heels from pressure.   
41. Shear is the force that occurs when the skin sticks to a surface and the body slides.   
42. Friction may occur when moving a person up in bed.   
43. A low Braden score is associated with increased pressure ulcer risk.   
44. The skin is the largest organ of the body.   
45. Stage II pressure ulcers may be extremely painful due to exposure of nerve endings.   
46. For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals.   
47. Educational programs may reduce the incidence of pressure ulcers.   
Pieper Pressure Ulcer Knowledge Test: Answer Key
QuestionAnswer
1. Stage I pressure ulcers are defined as intact skin with nonblanchable erythema in lightly pigmented persons.True 
2. Risk factors for development of pressure ulcers are immobility, incontinence, impaired nutrition, and altered level of consciousness.True 
3. All hospitalized individuals at risk for pressure ulcers should have a systematic skin inspection at least daily and those in long-term care at least once a week.True 
4. Hot water and soap may dry the skin and increase the risk for pressure ulcers.True 
5. It is important to massage bony prominences. False
6. A Stage III pressure ulcer is a partial thickness skin loss involving the epidermis and/or dermis. False
7. All individuals should be assessed on admission to a hospital for risk of pressure ulcer development.True 
8. Cornstarch, creams, transparent dressings (e.g., Tegaderm, Opsite), and hydrocolloid dressings (e.g., DuoDerm, Restore) do not protect against the effects of friction. False
9. A Stage IV pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure.True 
10. An adequate dietary intake of protein and calories should be maintained during illness.True 
11. Persons confined to bed should be repositioned every 3 hours. False
12. A turning schedule should be written and placed at the bedside.True 
13. Heel protectors relieve pressure on the heels. False
14. Donut devices/ring cushions help to prevent pressure ulcers. False
15. In a side lying position, a person should be at a 30 degree angle with the bed unless inconsistent with the patient's condition and other care needs that take priority.True 
16. The head of the bed should be maintained at the lowest degree of elevation (hopefully, no higher than a 30 degree angle) consistent with medical conditions.True 
17. A person who cannot move him or herself should be repositioned every 2 hours while sitting in a chair. False
18. Persons who can be taught should shift their weight every 30 minutes while sitting in a chair. False
19. Chair-bound persons should be fitted for a chair cushion.True 
20. Stage II pressure ulcers are a full thickness skin loss. False
21. The epidermis should remain clean and dry.True 
22. The incidence of pressure ulcers is so high that the government has appointed a panel to study risk, prevention, and treatment.True 
23. A low-humidity environment may predispose a person to pressure ulcers.True 
24. To minimize the skin's exposure to moisture on incontinence, underpads should be used to absorb moisture.True 
25. Rehabilitation should be instituted if consistent with the patient's overall goals of therapy.True 
26. Slough is yellow or creamy necrotic tissue on a wound bed.True 
27. Eschar is good for wound healing. False
28. Bony prominences should not have direct contact with one another.True 
29. Every person assessed to be at risk for developing pressure ulcers should be placed on a pressure-redistribution bed surface.True 
30. Undermining is the destruction that occurs under the skin.True 
31. Eschar is healthy tissue. False
32. Blanching refers to whiteness when pressure is applied to a reddened area.True 
33. A pressure redistribution surface reduces tissue interface pressure below capillary closing pressure.True 
34. Skin macerated from moisture tears more easily.True 
35. Pressure ulcers are sterile wounds. False
36. A pressure ulcer scar will break down faster than unwounded skin.True 
37. A blister on the heel is nothing to worry about. False
38. A good way to decrease pressure on the heels is to elevate them off the bed.True 
39. All care given to prevent or treat pressure ulcers must be documented.True 
40. Devices that suspend the heels protect the heels from pressure.True 
41. Shear is the force that occurs when the skin sticks to a surface and the body slides.True 
42. Friction may occur when moving a person up in bed.True 
43. A low Braden score is associated with increased pressure ulcer risk.True 
44. The skin is the largest organ of the body.True 
45. Stage II pressure ulcers may be extremely painful due to exposure of nerve endings.True 
46. For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals.True 
47. Educational programs may reduce the incidence of pressure ulcers.True 

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2H: Pressure Ulcer Baseline Assessment

Background: The purpose of this tool is to assess general staff knowledge on pressure ulcer prevention. It is shorter than the Pieper but has not been as widely used. The tool is available on the Web site of the Institute for Healthcare Improvement.

Reference: Adapted from: Iowa Health Des Moines. Pressure Ulcer Baseline Assessment. Available at: http://www.ihi.org/NR/rdonlyres/F2EF9AB3-BB0F-4D3D-A99A-83AC7E0FB0D3/6224/IowaHealthDesMoinesPUBaselineAssesment.pdf.

Instructions: Administer the questionnaire to registered nurses and nursing assistants. The survey may need to be modified if certain questions are not consistent with your policies and procedures.

Use: Use the findings to assess gaps in knowledge. Work with your education department to tailor specific education programs to the needs of your staff.

Pressure Ulcer Baseline Assessment for Registered Nurse

For which factors in the Braden Scale are you evaluating the patient's ability to respond to verbal command?

A. Activity
B. Mobility
C. Sensory/Perception
D. Friction/Shear

Minimally, a patient in the acute care setting should be assessed for pressure ulcer risk at least every:

A. 48 hours
B. 24 hours
C. 8 hours
D. 4 hours

How often should you, the RN, assess and document skin condition?

A. Daily
B. Once a shift
C. Upon admission and discharge, every shift, and as patient condition warrants
D. Upon admission and discharge

What can you, the RN, do when one of your patients has discoloration of the skin (red, purple, blue) indicating pressure?

A. See what happens over the next 24 hours.
B. Let the next nurses know about it. Start a skin care plan.
C. Place the patient on a pressure-reducing surface and explain to the patient and family that the patient needs to limit pressure to the area.
D. B&C from above

Who is the primary person accountable for patient skin assessment, pressure ulcer prevention, and documentation?

A. WOC Nurse (ET nurse)
B. RN
C. Nursing assistant
D. All of the above

Pressure Ulcer Baseline Assessment for Nursing Assistant

What is the most common reason a patient gets a pressure ulcer?

A. Patient is a smoker.
B. Patient is very thin.
C. Patient is incontinent.
D. Patient does not move.

How often should you look at every patient's skin to look for signs of redness or discoloration?

A. Daily, when patient bathes.
B. Every time the patients asks me to look.
C. Every 8 hours.
D. The RN should do that.

The correct procedure for checking an air mattress every shift is

A. Push down and if it feels soft it is OK.
B. Ask the patients if it feels like there is enough air underneath them.
C. Do a hand check by placing palm up and feeling for a cushion of air under the heaviest areas of the body.
D. The air mattress should be OK once it is blown up and does not need to be checked.

What should you report to your patient's RN every shift?

A. Skin tears
B. Discoloration of skin, such as red, blue, or purple
C. Open sores
D. All of the above

Pressure Ulcer Baseline Assessment: Answer Key

Registered Nurse

For which factors in the Braden Scale are you evaluating the patient's ability to respond to verbal command?

A. Activity
B. Mobility
C. Sensory/Perception
D. Friction/Shear

Minimally, a patient in the acute care setting should be assessed for pressure ulcer risk at least every:

A. 48 hours
B. 24 hours
C. 8 hours
D. 4 hours

How often should you, the RN, assess and document skin condition?

A. Daily
B. Once a shift
C. Upon admission and discharge, every shift, and as patient condition warrants
D. Upon admission and discharge

What can you, the RN, do when one of your patients has discoloration of the skin (red, purple, blue) indicating pressure?

A. See what happens over the next 24 hours.
B. Let the next nurses know about it. Start a skin care plan.
C. Place the patient on a pressure-reducing surface and explain to the patient and family that the patient needs to limit pressure to the area.
D. B&C

Who is the primary person accountable for patient skin assessment, pressure ulcer prevention, and documentation?

A. WOC Nurse (ET nurse)
B. RN
C. Nursing assistant
D. All of the above

Nursing Assistant

What is the most common reason a patient gets a pressure ulcer?

A. Patient is a smoker.
B. Patient is very thin.
C. Patient is incontinent.
D. Patient does not move.

How often should you look at every patient's skin to look for signs of redness or discoloration?

A. Daily, when patient bathes.
B. Every time the patients asks me to look.
C. Every 8 hours.
D. The RN should do that.

The correct procedure for checking an air mattress every shift is

A. Push down and if it feels soft it is OK.
B. Ask the patients if it feels like they have enough air underneath them.
C. Do a hand check by placing palm up and feeling for a cushion of air under the heaviest areas of the body.
D. The air mattress should be OK once it is blown up and does not need to be checked.

What should you report to your patient's RN every shift?

A. Skin tears
B. Discoloration of skin, such as red, blue, or purple
C. Open sores
D. All of the above

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2I: Action Plan

Background: The purpose of this tool is to provide a framework for outlining steps that will be needed to design and implement the pressure ulcer prevention initiative.

Reference: Adapted from material produced by MassPro, a participant in the Centers for Medicare & Medicaid Services Quality Improvement Organization Program.

Instructions:

  1. Note the date and the objective. A sample objective is provided.
  2. The form lists six key tasks. For each, list in the second column the steps that will be taken to address the task, including tools to be used.
  3. In developing the plan, it is not expected that you will provide results, only that you will lay out what needs to be done.
  4. In the last two columns, determine who will have lead responsibility for completing each task, and estimate an appropriate timeframe for completing the activities.
  5. Use the plan as a working document that can be revised. As you begin to carry out the plan, you may need to make adjustments and add details to the later tasks.

Use: Use the completed sheet to plan, manage, and carry out the identified tasks. The plan should guide the implementation process and can be continually amended and updated.

A sample completed form is shown below, followed by a blank form.

Pressure Ulcer Prevention Action Plan

Date: February 16, 2011

Improvement Objective: Implement standard pressure ulcer prevention practices within 6 months.

Key Interventions/TaskSteps To Complete Task and Tools To UseTeam Members Responsible for Task CompletionTarget Date for Task Completion
 ExamplesExamplesExamples
1. Analyze current state of pressure ulcer prevention practices in this organization.Identify strengths and weaknesses using process mapping and gap analysis. Tool 2C and Tools 2E-2G.Team leader, RNs, and WOCNsWithin 6 weeks from initiative start
Assess the current state of staff knowledge about pressure ulcer prevention. Tool 2H.Education departmentWithin 6 weeks from initiative start
Set target goals for improvement.QI departmentWithin 8 weeks from initiative start
2. Identify the bundle of prevention practices to be used in redesigned system.Determine how comprehensive skin assessment should be performedWound care teamWithin 12 weeks from initiative start
Decide which scale will be used for performing risk assessment.Wound care teamWithin 12 weeks from initiative start
Decide what items of pressure ulcer prevention should be in your bundleClinical staff membersWithin 12 weeks from initiative start
3. Assign roles and responsibilities for implementing the redesigned pressure ulcer prevention practices.ExamplesExamplesExamples
Determine who will complete the daily skin and risk assessments. Tool 4A.Implementation teamWithin 16weeks from initiative start
Identify unit champions.Team leaderWithin 16 weeks from initiative start
Determine how prevention work will be organized at the unit level, such as paths of communication and lines of oversight.QI teamWithin 16 weeks from initiative start
4. Put the redesigned bundle into practice.Engage staff and get them excited about the changes needed.Team leader, unit staffWithin 12 weeks from initiative start
Pilot test the new practices.QI departmentWithin 20 weeks from initiative start
5. Monitor pressure ulcer rates and practices.Determine how incidence and prevalence data will be collected. Tool 5A.QI departmentWithin 6 weeks from initiative start
Organize quarterly prevalence studies.QI departmentWithin 6 weeks from initiative start, ongoing
6. Sustain the redesigned prevention practices.Ensure continued leadership support.Team leaderWithin 4 weeks from initiative start and ongoing
Ensure ongoing support from other units such as facilities management and IT.IT, facilities management, PT, dietitiansWithin 40 weeks from initiative start
Designate responsibility and accountability for pressure ulcer prevention oversight and continuous quality improvement.Team leader and implementation teamWithin 40 weeks from initiative start

 

Pressure Ulcer Prevention Action Plan       Date: ________________________

Improvement Objective:

Key Interventions/TasksSteps To Complete Task and Tools To UseTeam Members Responsible for Task CompletionTarget Date for Task Completion
1. Analyze current state of pressure ulcer prevention practices in this organization.   
   
   
2. Identify the bundle of prevention practices to be used in redesigned system.   
   
   
3. Assign roles and responsibilities for implementing the redesigned pressure ulcer prevention practices.   
   
   
   
4. Put the redesigned bundle into practice.   
   
   
5. Monitor pressure ulcer rates and practices.   
   
   
6. Sustain the redesigned prevention practices.   
   
   
Current as of April 2011
Internet Citation: Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality: Section 7. Tools and Resources (continued). April 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool7a.html