Module 3: Best Practices in Pressure Injury Prevention

Slide Presentation

Slide 1: Best Practices in Pressure Injury Prevention

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ADD Hospital Name

Module 3

Slide 2: Best Practices

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  • Best practices are those care processes—based on literature and expert opinion—that represent the best ways we currently know of preventing pressure injuries in the hospital.
  • AHRQ Patient Safety Network (PSNET)
    https://psnet.ahrq.gov/

Image: Puzzle pieces are labeled “assess readiness,” “manage change,” “implement practices,” “best practices,” “measure,” “sustain,” and “tools.” The piece labeled “best practices” is highlighted in blue.

Slide 3: Module 3 Goals

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  • Identify opportunities for improvement:
    • Which pressure injury prevention practices to use.
    • How to perform a comprehensive skin assessment.
    • How to conduct a standardized assessment of pressure injury risk factors.
    • How to incorporate risk factors into care planning.

Note: At various points during the module, we’ll discuss which best practices you want to include in your prevention program.

Slide 4: Bundle of Best Practices

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  • Pressure injury prevention practices checklist:
    • ___ Comprehensive skin assessment.
    • ___ Standardized pressure injury risk assessment.
    • ___ Care planning and implementation to address areas of risk.

Slide 5: Best Practice

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Comprehensive Skin Assessment

Slide 6: Comprehensive Skin Assessment

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  • Examine the entire skin (from head to toe) for abnormalities.

Images: Two overlapping screenshots show Elements of a Comprehensive Skin Assessment. An icon of a magnifying glass in front of open book identifies this as Tool 3B.

Slide 7: How To Do a Skin Assessment

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Video Clip of Skin Assessment

Image: Icon of a blank movie-projection screen.

Slide 8: Skin Assessment Frequency

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  • Not a one-time event.
  • Repeated on a regular basis.
  • Optimally done daily in a systematic manner by a single individual at a dedicated time.
  • May be integrated into routine care—any time the patient is cleaned or turned.

Image: Photograph shows a medical provider examining a patient's head.

Slide 9: Medical Device Skin Assessment

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Image: A screenshot shows a checklist card titled "Best practices for prevention of medical device-related pressure ulcers."

Slide 10: Reporting and Documenting

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  • Skin assessment results must be documented in the medical record. Then staff must be made aware of the assessment.

Image: Photograph shows medical providers consulting a tablet.

Slide 11: Barriers to Practice

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  • Finding time for skin assessments.
  • Determining correct etiology of wounds.
  • Using inadequate documentation forms.
  • Lacking ways to empower staff to report abnormal skin findings:
    • Consider using Tool 3C: Pressure Ulcer Identification Pocket Pad.

Slide 12: ID Pocket Pad

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Images: The Pressure Ulcer Identification Pocket Pad is shown. An icon of a magnifying glass in front of open book identifies this as Tool 3C.

Slide 13: Practice Insight

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Images: Icon of binoculars. A screenshot shows the annotated body image for admission documentation; on the screenshot are the following notes and instructIons: "Complete within first 24 hours of admission"; "Cosign required"; "If pressure injury is POA, make sure that document is sent to be cosigned by the medical provider"; "Annotated image needs to be completed on all admissions even if no skin disruption is found. Or note location if skin disruption noted".

Slide 14: Improving Assessment Practice

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  • Ask a colleague to confirm skin assessment.
  • Perform skin assessment with an expert.
  • Ask for clarification.
  • Use available resources.
  • See tips for making assessments part of the routine.

Image: An icon of a magnifying glass in front of open book refers to Page 42.

Slide 15: Best Practice

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Pressure Injury Risk Assessment

Slide 16: Pressure Injury Risk Assessment

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  • Next step in prevention.
  • Goal: to identify patients at risk.

Image: Photograph shows a medical provider at a patient’s bedside, examining the patient's legs.

Slide 17: Risk Assessment Scales

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  • Only one part of risk assessment.
  • Meant to be used in conjunction with a review of other risk factors and clinical judgment.
    • More factors to consider.
  • Especially helpful in identifying patients at mild to moderate risk.
  • Two widely used scales:
    • Braden Scale (Tool 3D).
    • Norton Scale (Tool 3E).

Image: An icon of a magnifying glass in front of open book refers to Page 44.

Slide 18: Braden Scale

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  • Six subscales, scored from 1-4 or 1-3:
    • Sensory perception.
    • Moisture.
    • Activity.
    • Mobility.
    • Nutrition.
    • Friction/shear.

Image: Photograph shows a medical provider with a patient in a wheelchair.

Slide 19: Risk Assessment Case Study—Mr. K

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Image: Photograph shows a patient lying in bed.

Slide 20: Braden Scale—Mr. K

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Image: A screenshot shows a sample Braden Pressure Ulcer Risk Assessment scale filled out for Mr. K's case.

Slide 21: How Often?

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  • Recommendations vary.
  • In general acute care settings, do risk assessment upon admission, then daily or with a significant change in condition.
  • In critical care settings, frequent assessments should be done, such as at every shift.
  • For risk assessment in pediatrics.

Image: An icon of a magnifying glass in front of open book refers to Page 46.

Slide 22: Documentation

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  • Have computerized (or paper) form in medical record.
  • Incorporate results in daily patient flowsheet.
  • Include results in patient report or handover.

Slide 23: Next Steps

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  • Knowing which patients are at risk is not enough; you must also do something about it.
  • Care planning guides what will be done to prevent pressure injuries.

Image: Photograph shows medical providers holding a meeting in a hospital corridor.

Slide 24: Best Practice

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Pressure Injury Care Planning

Slide 25: Care Planning

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  • A process to transfer the patient’s risk assessment information into an action plan to address his or her needs:
    • Implement care practices so that your patient does not develop a pressure injury.
    • Develop a care plan for any area of risk.
    • Tailor the plan to fit the patient’s needs.
    • Modify as needed to capture your patient’s response to interventions and any changes in condition.

Slide 26: Patient and Family Education

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Images: Two screenshots show a patient brochure titled "Help Us Protect Your Skin". An icon of a magnifying glass in front of open book identifies this brochure as Tool 3G.

Updated brochure available at: http://www.njha.com/media/43477/puconsumereng.pdf

Slide 27: Sample Care Plan

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Images: Two screenshots show a sample care plan. An icon of a magnifying glass in front of open book identifies this care plan as Tool 3F.

Slide 28: Practice Insight

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EHR Care Plans Triggered Based on Risk Assessment

Braden Scale for Predicting Pressure Sore Risk

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. Rarely Moist
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  
  Total Score

© Barbara Braden and Nancy Bergstrom, 1988. Used with permission.

Images: Icon of binoculars. A series of arrows pointing to the right in six rows depict the following process:

Sensory Perception → Less than 3 → Sensory Perception Care Plan Triggered

Moisture → Less than 4 → Moisture Care Plan Triggered

Activity →  Less than 3 → Activity Care Plan Triggered

Mobility → Less than 3 → Mobility Care Plan Triggered

Nutrition → Less than 3 → Nutrition Care Plan Triggered

Friction & Shear → Less than 3 → Friction & Shear Care Plan Triggered

Slide 29: Improve Care Planning

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  • Ensure that staff appreciate the value of care planning.
    • Let staff know their roles and responsibilities in reducing pressure injury incidence.
    • Empower staff to carry out their roles.

Image: Photograph shows medical providers looking at a wall-mounted computer monitor. 

Slide 30: Improve Care Planning

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  • Make care planning more streamlined—link to the assessment task.
    • Document using the computer to tie the assessment directly to the care plan (saves time).
    • Use prompts to update the plan as your patient’s condition changes (helps ensure his or her needs will continue to be met).

Image: Photograph shows medical providers looking at a tablet.

Slide 31: Improve Care Planning

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  • Examples of prompts linked to routine practice:
    • Generate a reminder to conduct pressure injury risk assessment when a patient is in the OR for more than 4 hours.
    • Order support surfaces and skin care products for patients you identify as at risk.
    • Include the care plan in shift reports and patient handoffs.

Remember: Let all levels of staff know what is required daily so they automatically carry out the task.

Slide 32: Identify Your Bundle of Best Practices

Identify Your Bundle of Best Practices

Slide 33: Identify Best Practices

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  • Comprehensive skin assessment.
  • Standardized risk assessment:
    • Norton? Braden? Waterlow?
    • Another validated scale?
  • Care planning.

Slide 34: Identify Best Practices

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  • Comprehensive skin assessment:
    • Would you recommend that each admitted patient receive a skin assessment?
    • When would you recommend it get done again, if needed?
    • How do you want the assessment to be conducted?

Slide 35: Identify Best Practices

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  • Risk assessment:
    • Which standardized risk assessment scale do you plan to use?
    • When do you plan to complete risk assessments?

Slide 36: Identify Best Practices

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  • Care plan:
    • Does your current pressure injury planning process suffice for your prevention program?
    • Or should it be revised? If so, who will revise it? Care plan:
    • Does your current pressure injury planning process suffice for your prevention program?
    • Or should it be revised? If so, who will revise it?

Slide 37: Best Practices

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  • Need to be customized:
    • Each patient has a different set of pressure injury risk factors, so care must address each patient’s unique needs.

Slide 38: Practice Insight

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Images: Icon of binoculars. A screenshot shows the Pressure Ulcer Prevention Program Action Plan: June 2015-January 2016. Key Intervention 2 is circled in red.

Slide 39: Action Plan

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  • Discuss action steps for Key Intervention 2.
  • Determine who is responsible for this task and when it will be completed.

Images: A sample Action Plan is shown with Key Intervention 2 circled in red. An icon of a magnifying glass in front of open book sits beside the text "Refer to your Action Plan Template."

Slide 40: Summary

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  • We reviewed:
    • Comprehensive skin assessment.
    • Braden and Norton risk assessment tools.
    • Care planning.
  • You identified best practices for your hospital.
  • You completed Key Intervention 2 of the Action Plan.
Page last reviewed October 2017
Page originally created September 2017
Internet Citation: Module 3: Best Practices in Pressure Injury Prevention. Content last reviewed October 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/professionals/systems/hospital/pressureinjurypxtraining/workshop/module3/mod3-slides.html
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