Section 7. Tools and Resources (continued)

Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care

3A: Pressure Ulcer Prevention Pathway for Acute Care

Background: This tool is an example of a clinical pathway, detailing the relationship among the different components of pressure ulcer prevention.

Reference: Developed by Zulkowski and Ayello (2009) in conjunction with the New Jersey Hospital Association Pressure Ulcer Collaborative.

Use: This tool can be used by the hospital unit team in designing a new system, as a training tool for frontline staff, and as an ongoing clinical reference tool on the units. This tool can be modified or a new one created to meet the needs of your particular setting. If you prepared a process map describing your current practices, you can compare that to desired practices outlined on the clinical pathway.

Pressure Ulcer Prevention Pathway

A flow chart depicts the steps to assess a newly admitted or readmitted patient for pressure ulcer risk, including a head-to-toe skin assessment and pressure ulcer risk assessment.

Top of Page

 

 

3B: Elements of a Comprehensive Skin Assessment

Background: This sheet summarizes the elements of a correct comprehensive skin assessment. You could, for example, integrate them into your documentation system or use this sheet for staff training.

Reference: Developed by Boston University Research Team.

Skin Temperature

  • Most clinicians use the back rather than the palm of their hand to assess the temperature of a patient's skin.
  • Remember that increased skin temperature can be a sign of fever or impending skin problems such as a Stage I pressure ulcer or a diabetic foot about to ulcerate.
  • Touch the skin to evaluate if it is warm or cool.
  • Compare symmetrical body parts for differences in skin temperature.
Skin Color
  • Ensure that there is adequate light.
  • Use an additional light source such as a penlight to illuminate hard to see skin areas such as the heels or sacrum.
  • Know the person's normal skin tone so that you can evaluate changes.
  • Look for differences in color between comparable body parts, such as left and right leg.
  • Depress any discolored areas to see if they are blanchable or nonblanchable.
  • Look for redness or darker skin tone, which indicate infection or increased pressure.
  • Look for paleness, flushing, or cyanosis.
  • Remember that changes in coloration may be particularly difficult to see in darkly pigmented skin.

Skin Moisture

  • Touch the skin to see if the skin is wet or dry, or has the right balance of moisture.
  • Remember that dry skin, or xerosis, may also appear scaly or lighter in color.
  • Check if the skin is oily.
  • Note that macerated skin from too much moisture may also appear lighter or feel soft or boggy.
  • Also look for water droplets on the skin. Is the skin clammy?
  • Determine whether these changes localized or generalized.

Skin Turgor

  • To assess skin turgor, take your fingers and "pinch" the skin near the clavicle or the forearm so that the skin lifts up from the underlying structure. Then let the skin go.
  • If the skin quickly returns to place, this is a normal skin turgor finding.
  • If the skin does not return to place, but stays up, this is called "tenting," and is an abnormal skin turgor finding.
  • Poor skin turgor is sometimes found in persons who are older, dehydrated, or edematous, or have connective tissue disease.
Skin Integrity
  • Look to see if the skin is intact without any cracks or openings.
  • Determine whether the skin is thick or thin.
  • Identify signs of pruritis, such as excoriations from scratching.
  • Determine whether any lesions are raised or flat.
  • Identify whether the skin is bruised.
  • Note any disruptions in the skin.
  • If a skin disruption is found, the type of skin injury will need to be identified. Since there are many different etiologies of skin wounds and ulcers, differential diagnosis of the skin problem will need to be determined. For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? 

Top of Page

 

3C: Pressure Ulcer Identification Notepad

Background: Reporting of abnormal skin findings among nursing staff is critical for pressure ulcer prevention. This notepad can be used by nursing aides to report any areas of skin concern to nurses.

Reference: This material originated from Status Health and was adapted for use by Mountain-Pacific Quality Health, the Medicare quality improvement organization for Montana, Wyoming, Hawaii, and Alaska, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents presented do not necessarily reflect CMS policy. The work was performed under the 9th Statement of Work, MPQHF-AS-PS-09-16.

Instructions: Place an X on any suspicious lesion and give the note to a nurse for followup on the issue.

Image shows chart of human body, front and back; instructions indicate to place an X on the area of the body where you see a skin concern and give this form to the nurse to check the patient/resident. Lines allow the person filling out the chart (the 'reporter') to place the patient's/resident's name, their own name, ad the date and time of the examination.

 

Top of Page

 

3D: The Braden Scale for Predicting Pressure Sore Risk

Background: This tool can be used to identify patients at-risk for pressure ulcers. The Braden Scale was developed by Barbara Braden and Nancy Bergstrom in 1988 and has since been used widely in the general adult patient population. The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development. Generally, a score of 18 or less indicates at-risk status.

Reference: http://www.bradenscale.com/images/bradenscale.pdf. Reprinted with permission.

Instructions: Complete the form by scoring each item from 1-4 (1 for low level of functioning and 4 for highest level of functioning) for the first five risk factors and 1-3 for the last risk factor.

Use: Use this tool in conjunction with clinical assessment to determine if a patient is at risk for developing pressure ulcers and plan the care accordingly. In addition to the overall score, abnormal scores on any of the subscales should be addressed in the care plan.

Braden Pressure Ulcer Risk Assessment

Patient's Name ______________________ Evaluator's Name _____________________ Date of Assessment

Sensory Perception
ability to respond meaningfully to pressure-related discomfort
1. Completely Limited:
Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation.
OR limited ability to feel pain over most of body surface.
2. Very Limited:
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.
OR has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body.
3. Slightly Limited:
Responds to verbal commands, but cannot always communicate discomfort or need to be turned.
OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
4. No Impairment:
Responds to verbal commands, has no sensory deficit which would limit ability to feel or voice pain or discomfort.
    
Moisture
degree to which skin is exposed to moisture
1. Constantly Moist:
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
2. Very Moist:
Skin is often, but not always, moist. Linen must be changed at least once a shift.
3. Occasionally Moist:
Skin is occasionally moist, requiring an extra linen change approximately once a day.
4. Rarely Moist:
Skin is usually dry, linen only requires changing at routine intervals.
    
Activity
degree of physical activity
1. Bedfast:
Confined to bed.
2. Chairfast:
Ability to walk severely limited or non-existent. Cannot bear weight and/or must be assisted into chair or wheelchair.
3. Walks Occasionally:
Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.
4. Walks Frequently:
Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.
    
Mobility
ability to change and control body position
1. Completely Immobile:
Does not make even slight changes in body or extremity position without assistance.
2. Very Limited:
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
3. Slightly Limited:
Makes frequent though slight changes in body or extremity position independently.
4. No Limitations:
Makes major and frequent changes in position without assistance.
    
Nutrition
usual food intake pattern
1. Very Poor:
Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement.
OR is NPO and/or maintained on clear liquids or IV's for more than 5 days.
2. Probably Inadequate:
Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.
OR receives less than optimum amount of liquid diet or tube feeding.
3. Adequate:
Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered.
OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.
4. Excellent:
Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
    
Friction and Shear1. Problem:
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction.
2. Potential Problem:
Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.
3. No Apparent Problem:
Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.
      

Top of Page

 

3E: Norton Scale

Background: This tool can be used to identify patients at-risk for pressure ulcers. The Norton Scale was developed in the 1960s and is widely used to assess the risk for pressure ulcer in adult patients. The five subscale scores of the Norton Scale are added together for a total score that ranges from 5-20. A lower Norton score indicates higher levels of risk for pressure ulcer development. Generally, a score of 14 or less indicates at-risk status.

Reference: Norton D, McLaren R, Exton-Smith AN. An investigation of geriatric nursing problems in the hospital. London, UK: National Corporation for the Care of Old People (now the Centre for Policy on Ageing); 1962. Reprinted with permission.

Instructions: Complete the form by scoring each item from 1-4. Put 1 for low level of functioning and 4 for highest level functioning.

Use: Use this tool in conjunction with clinical assessment to determine if a patient is at risk for developing pressure ulcers.

Physical condition Mental condition Activity Mobility Incontinent Total Score
Good4Alert4Ambulant4Full4Not4 
Fair3Apathetic3Walk-help3Slightly limited3Occasional3 
Poor2Confused2Chair-bound2Very limited2Usually-Urine2 
Very bad1Stupor1Stupor1Immobile1Doubly1  

Top of Page

 

3F: Care Plan

Background: Developing a care plan specific to the needs of each individual patient is critical. This tool is a sample care plan that gives specific examples of actions that should be performed to address a patient's needs. This example is based on the pressure ulcer risk assessment captured with the Braden Scale.

Reference: Developed by Zulkowski, Ayello, and Berlowitz (2010). Used with permission.

Instructions: This tool includes examples of interventions that may be considered for specific scores on each Braden subscale, along with the nurse and Certified Nursing Assistant (CNA) responsibilities for care provision. These should be tailored to meet the needs of your patient and used as examples of how all levels of unit staff have responsibilities for pressure ulcer prevention.

Use: Individualize the care plan to address the needs of at-risk patients.

Sample Care Plan

Braden CategoryBraden Score: 1Braden Score: 2Braden Score: 3Braden Score: 4
Sensory PerceptionCompletely limited
  • Skin assessment and inspection q shift. Pay attention to heels.
  • Elevate heels and use protectors.
  • Consider specialty mattress or bed.
  • Use pillows between knees and bony prominences to avoid direct contact.
Very limited
  • Skin assessment and inspection q shift. Pay attention to heels.
  • Elevate heels and use protectors.
  • Consider specialty mattress or bed.
Slightly limited
  • Skin assessment and inspection q shift. Pay attention to heels.
  • Elevate heels and use protectors.
No limitation
  • Encourage patient to report pain over bony prominences.
  • Check heels daily.
MoistureConstantly Moist
  • Skin assessment and inspection q shift.
  • Use moisture barrier ointments (protective skin barriers).
  • Moisturize dry unbroken skin.
  • Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes.
  • Check incontinence pads frequently (q 2-3h) and change as needed.
  • Apply condom catheter if appropriate.
  • If stool incontinence, consider bowel training and toileting after meals or rectal tubes if appropriate.
  • Consider low air loss bed
Moist
  • Use moisture barrier ointments (protective barriers).
  • Moisturize dry unbroken skin.
  • Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes.
  • Check incontinence pads frequently (q 2-3h).
  • Avoid use of diapers but if necessary, check frequently (q 2-3h)and change as needed.
  • If stool incontinence, consider bowel training and toileting after meals.
  • Consider low air loss bed
Occasionally Moist
  • Use moisture barrier ointments (protective skin barriers).
  • Moisturize dry unbroken skin.
  • Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes.
  • Check incontinence pads frequently.
  • Avoid use of diapers but if necessary, check frequently (q 2-3h) and change as needed.
  • Encourage patient to report any other moisture problem (such as under breasts).
  • If stool incontinence, consider bowel training and toileting after meals.
Rarely Moist
  • Encourage patient to use lotion to prevent skin cracks.
  • Encourage patient to report any moisture problem (such as under breasts).
ActivityBedfast
  • Skin assessment and inspection q shift.
  • Position prone if appropriate or elevate head of bed no more than 30 degrees.
  • Position with pillows to elevate pressure points off of the bed.
  • Consider specialty bed.
  • Elevate heels off bed and/or use heel protectors.
  • Consider physical therapy consult for conditioning and W/C assessment.
  • Turn/reposition q 1-2h.
  • Post turning schedule.
  • Teach or do frequent small shifts of body weight.
Chairfast
  • Consider specialty chair pad.
  • Consider postural alignment, weight distribution, balance, stability, and pressure relief when positioning individuals in chair or wheelchair.
  • Instruct patient to reposition q 15 minutes when in chair.
  • Stand every hour.
  • Pad bony prominences with foam wedges, rolled blankets, or towels.
  • Consider physical therapy consult for conditioning and W/C assessment.
Walks Occasionally
  • Provide structured mobility plan.
  • Consider chair cushion.
  • Consider physical therapy consult.
Walks Frequently
  • Encourage ambulating outside the room at least bid.
  • Check skin daily.
  • Monitor balance and endurance.
MobilityCompletely Immobile
  • Skin assessment and inspection q shift.
  • Turn/reposition q 1-2 hours.
  • Post turning schedule.
  • Teach or do frequent small shifts of body weight.
  • Elevate heels.
  • Consider specialty bed.
Very Limited
  • Skin assessment and inspection q shift.
  • Turn/reposition 1-2 hours.
  • Post turning schedule.
  • Teach or do frequent small shifts of body weight.
  • Elevate heels.
  • Consider specialty bed.
Slightly Limited
  • Check skin daily.
  • Turn/reposition frequently.
  • Teach frequent small shifts of body weigh.
  • PT consult for strengthening/conditioning.
  • Gait belt for assistance.
No Limitations
  • Check skin daily.
  • Encourage ambulating outside the room at least bid.
  • No interventions required.
NutritionVery Poor
  • Nutrition consult.
  • Skin assessment and inspection q shift.
  • Offer nutrition supplements and water.
  • Encourage family to bring favorite foods.
  • Monitor nutritional intake.
  • If NPO for > 24 hours, discuss plan with MD.
  • Record dietary intake and I & O if appropriate.
Probably Inadequate
  • Nutrition consult.
  • Offer nutrition supplements and water.
  • Encourage family to bring favorite foods.
  • Monitor nutritional intake.
  • Small frequent meals.
  • If NPO for > 24 hours, discuss plan with MD.
  • Record dietary intake and I & O if appropriate.
Adequate
  • Monitor nutritional intake.
  • If NPO for > 24 hours, discuss plan with MD.
  • Record dietary intake and I&O if appropriate.
Excellent
  • Out of bed for all meals.
  • Provide food choices.
  • Offer nutrition supplements. If NPO for > 24 hours, discuss plan with MD.
  • Record dietary intake.
Friction and ShearProblem
  • Skin assessment and inspection q shift.
  • Minimum of 2 people + draw sheet to pull patient up in bed.
  • Keep bed linens clean, dry, and wrinkle free.
  • Apply elbow/heel protectors to intact skin over elbows and heels.
  • Elevate head of bed 30 degrees or less.
Potential Problem
  • Keep bed linens clean, dry, and wrinkle free.
  • Avoid massaging pressure points.
  • Apply transparent dressing or elbow/heel protectors to intact skin over elbows and heels.
No apparent problem
  • Keep bed linens clean, dry, and wrinkle free.
  

Top of Page

 

3G: Patient and Family Education Booklet

Background: This is an example of an education booklet that can be handed out to patients at-risk for pressure ulcers and their families. The booklet was developed by the New Jersey Collaborative to Reduce the Incidence of Pressure Ulcers.

Reference: Available at: http://www.njha.com/qualityinstitute/pdf/pubrochure.pdf.

Image shows a copy of the booklet titled 'Help Us Protect Your Skin.'

 

Top of Page

 

4A: Assigning Responsibilities for Using Best Practice Bundle

Background: This tool can be used to determine who will be responsible for each of the tasks identified in your bundle of best practices for preventing pressure ulcers. One way to generate interest and buy-in from the staff is to ask them to self-assign their responsibilities from a prioritized list of tasks that need to be accomplished.

Reference: Developed by Boston University Research Team.

Instructions: Complete the table by entering the different best practices and the specific individuals who will be responsible for completing each task.

Use: Use this tool to assign and clarify the roles and responsibilities of each staff member.

What practices will we use?Who will be responsible?
Example:
Perform comprehensive skin assessment on admission, daily or if condition deteriorates.
Example:
RN
  
  
  
  
  
  
  
  
  
  
  
   

Top of Page

 

4B: Staff Roles

Background: This table gives an example of how responsibilities may be assigned among different staff members.

Reference: Developed by Boston University Research Team.

Wound care team*
Wound Care Physician
  • Directs patient care, orders tests and treatments, and reviews results
  • Collaborates on treatment with wound nurse
  • Helps facilitate communication between medical staff, wound team, and unit staff for pressure ulcer practice
Certified Wound Care Nurse
  • Assesses wounds, does complex treatments, collaborates with physician for care orders
  • Works with staff on pressure ulcer education and daily treatments
  • Works with all members to educate patient/family about care
  • Coordinates prevalence and incidence audits
Unit based team
RN
  • Conducts or supervises accurate assessment and documentation of head-to-toe skin assessment and pressure ulcer risk (Braden Scale or Braden Risk Assessment) on admission, daily, and if condition deteriorates (or according to facility policy)
  • Documents care plan tied to identified risk
    • Sensory perception
    • Moisture
    • Activity
    • Mobility
    • Nutrition
    • Friction/Shear
  • Performs or supervises performance of care plan procedures or treatments
  • Collaborates with other staff to ensure timely and accurate reporting of any skin issues
  • Notifies wound nurse of any skin conditions or high-risk patients
  • Notifies physician of any skin problems
  • Educates patient/family about risk factors
LPN
  • Conducts accurate assessment and documentation of head-to-toe skin assessment and pressure ulcer risk (Braden Scale) on admission, daily, and if condition deteriorates (or according to facility policy)
  • Documents care plan tied to identified risk
    • Sensory perception
    • Moisture
    • Activity
    • Mobility
    • Nutrition
    • Friction/Shear
  • Performs care for risk as needed
  • Informs RN of any skin issues
CNA
  • Checks skin each time person is turned or cleaned or bed is changed
  • Reports any skin issues to nurse
  • Turns/repositions patient as ordered
  • Offers liquids each time in room
  • Keeps skin clean and reapplies protective skin barrier
  • Applies products (lotion, cream, skin sealant, etc.) as needed
Hospitalist
  • Reviews needs for specific types of rehabilitation therapy
  • Writes orders for specific interventions
Other staff, such as dietitian, physical therapist, pharmacist, assigned to specific unit
  • Act as resource for unit staff
  • Educate family if problem is identified
  • Modify treatment as needed
  • Provide specialized care for patients

* May be large or small group that includes nurses and/or physicians in an outpatient or inpatient setting. 

Top of Page

 

4C: Assessing Staff Education and Training

Background: The purpose of this tool is to assess current staff education practices and to facilitate the integration of new knowledge on pressure ulcer prevention into existing or new practices.

Reference: Adapted from Facility Assessment Checklist developed by Quality Partners of Rhode Island. Available in the Nursing Home section of the MedQIC Web site: https://www.qualitynet.org/dcs/ContentServer?cid=1098482996140&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools.

Instructions: Complete the form by checking the response that best describes your facility.

Use: Identify areas for improvement and develop educational programs where they are missing.

Facility Assessment

Date:

A. Does your facility have initial and ongoing education on pressure ulcer prevention and management for both nursing and nonnursing staff?
__   No. If no, this is an area for improvement.
__   This is an area we are working on.
__   Yes.

B. Does your facility's education program for pressure ulcer prevention and management include the following components?

C. What areas of knowledge does the assessment of staff suggest need more attention in education?

 YesNoPerson Responsible:Comments:
1. Are new staff assessed for their need for education on pressure ulcer prevention and management?    
2. Are current staff provided with ongoing education on the principles of pressure ulcer prevention and management?    
3. Does education of staff provide discipline-specific education for pressure ulcer prevention and management?    
4. Is there a designated clinical expert available at the facility to answer questions from all staff about pressure ulcer prevention and management?    
5. Is the education provided at the appropriate level for the learner (e.g., CNA vs. RN?)    
6. Does the education provided address risk assessment tools and procedures?    
7. Does the education include staff training on documentation methods related to pressure ulcers (e.g., location, stage, size, depth, appearance, exudates, current treatment, effect on activities of daily living, pressure redistributing devices used, nutritional support)?    
Current as of April 2011
Internet Citation: Section 7. Tools and Resources (continued): Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. April 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool7b.html