Ask Foster a calm and peaceful spirit standards interpretation question. The hospital was established Kn and worklpace outpatient te inpatient services for more than 5 Thee peoples living in its catchment area. AB - Implementation strategy of preventive and therapeutic interventions in the field of pressure ulcers must be comprehensive and timely and properly prepared. Optimally, the daily comprehensive skin assessment will be performed in a standardized manner by a single individual at a dedicated time.

Ulcer prevention in the workplace -

The following articles provide useful insights on how to do this: DeFloor T, Schoonhoven L, Fletcher J, et al. Statement of the European Pressure Ulcer Advisory Panel: pressure ulcer classification. J Wound Ostomy Continence Nurs ; Gray M, Bliss DZ, Doughty DB. Incontinence associated dermatitis a consensus.

J Wound Ostomy Continence Nurs ;34 1 Usual practice includes assessing the following five parameters: Temperature. Moisture level. Skin integrity skin intact or presence of open areas, rashes, etc. Tools Detailed instructions for assessing each of these areas are found in Tools and Resources Tool 3B, Elements of a Comprehensive Skin Assessment.

Practice Insights Take advantage of every patient encounter to evaluate part of the skin. Always remind staff performing comprehensive skin assessments of the following helpful hints: Don't forget to wash your hands before doing the skin assessment and after and to use gloves.

Make sure the patient is comfortable. Minimize exposure of body parts while you are doing the skin assessment. Ask for assistance if needed to turn the patient in order to examine the patient's backside, with a particular focus on the sacrum.

Look at the skin underneath any devices such as oxygen tubing, indwelling urinary catheter, etc. Make sure to remove compression stockings to check the skin underneath them. Action Steps Assess whether your staff know the frequency with which comprehensive skin assessment should be performed.

Action Steps Assess the following: Are results of the comprehensive skin assessment easily located for all patients? Are staff comfortable reporting any observed skin abnormalities to physicians and nurse managers?

Tools A sample sheet can be found in Tools and Resources Tool 5A, Unit Log. Practice Insights Have a standardized place to record in the medical record the results of the skin assessment. A checklist or standardized computer screens with drop-down prompts with key descriptors of the five components of a minimal skin assessment can help capture the essential information obtained through the patient examination.

Communication among licensed and unlicensed members of the health care team is important in identifying and caring for any skin abnormalities. Some places have found it effective to use a diagram of a body outline that an unlicensed heath care worker can mark with any skin changes they might see while bathing or performing care activities.

Be especially concerned about the following issues: Finding the time for an adequate skin assessment: As much as possible, integrate the comprehensive skin examination into the normal workflow.

But remember that this is a separate process that requires a specific focus by staff if it is to be done correctly. Determining the correct etiology of wounds: Many different types of lesions may occur on the skin and over bony prominences.

In particular, do not confuse moisture-associated skin changes with pressure ulceration. If unsure about the etiology of a lesion, ask someone else who may be more knowledgeable. Using documentation forms that are not consistent with components of skin assessments: Develop forms that will facilitate the recording of skin assessments.

Having staff who do not feel empowered to report abnormal skin findings: Communication among nursing assistants, nurses, and managers is critical to success. If communication problems exist, staff development activities targeting cross-level communication skills may be in order.

Nurses and managers may need to solicit and positively reinforce such reporting if nursing assistants do not have confidence in this area. Develop methods to facilitate communication. One example would be a sticky note pad that includes a body outline, patient name, and date.

Aides would mark down any suspicious lesions and give the note to nurses. Tools An example of a notepad to be used for communication among nursing assistants, nurses, and managers can be found in Tools and Resources Tool 3C, Pressure Ulcer Identification Notepad.

Encourage staff to: Ask a colleague to confirm their skin assessments. Having a colleague evaluate the skin assessment will provide feedback as to how they are doing and will help correct documentation errors.

Perform skin assessments with an expert. Consider having an expert or nurse from another unit round with unit staff quarterly to confirm findings from the comprehensive skin assessment.

Ask for clarification when they are unsure of a lesion. Take advantage of the local wound care team or other staff who may be more knowledgeable. Use available resources to practice their ability to differentiate the etiology of skin and wound problems.

Resources This slide show illustrates how to perform a skin assessment: www. Practice Insights A full-body skin inspection does not have to mean visualizing all aspects of the patient in the same time period. When applying oxygen, check the ears for pressure areas from the tubing.

If the patient is on bed rest, look at the back of the head during repositioning. When checking bowel sounds, look into skin folds. When positioning pillows under calves, check the heels and feet using a hand-held mirror makes this easier. When checking IV sites, check the arms and elbows.

Examine the skin under equipment with routine removal e. Each time you lift a patient or provide care, look at the exposed skin, especially on bony prominences.

Action Steps Ask yourself and your team: Do you have a policy about who is responsible for the risk assessment on admission and thereafter?

Does everyone know the process for performing risk assessment? Pressure ulcer risk assessment is essential for a number of reasons: It aids in clinical decisionmaking. Many clinicians are not skilled in identifying patients at risk for developing pressure ulcers.

Use of a standardized risk assessment helps to direct the process by which clinicians identify those at risk and quantify the level of this risk. It allows the selective targeting of preventive interventions. Pressure ulcer prevention is resource intensive.

Resources should be targeted toward those at greatest risk who would most-benefit. It facilitates care planning. Care plans focus on the specific dimensions that place the patient at greatest risk.

It facilitates communication between health care workers and care settings. Workers have a common language by which they describe risk.

Action Steps Ask yourself and your team: Do the unit staff understand why they are doing the risk assessment? Are unit staff communicating the risk assessment results to all clinicians who need to know?

Presence of a pressure ulcer: All patients with an existing pressure ulcer should be considered at-risk for an additional ulcer. Prior Stage III or IV pressure ulcers: When Stage III or IV ulcers close through a process of scar tissue formation and eventual epithelialization, the resulting skin is not normal as it lacks its former tensile strength and is very prone to break down again.

Hypoperfusion states: Patients who are not perfusing vital organs as a result of conditions such as sepsis, dehydration, or heart failure are also not adequately perfusing the skin. Minimal amounts of pressure may then cause ulceration. Peripheral vascular disease: Because of the limited blood supply to the legs, these patients are predisposed to pressure ulcers of the feet, particularly the heels.

Diabetes: Patients with diabetes have consistently been shown to be at increased risk of pressure ulcers. Smoking: Smoking interferes with oxygen delivery. Smoking is associated with recurrence of pressure ulcers postsurgery and likely increases risk of new pressure ulcers.

Restraint use: Patients with physical restraints have limited mobility in addition to having pressure applied at the site of the restraints.

Chemical restraints with resulting sedation may lead to rapid decline in mobility. Spinal cord injury: Immobility, incontinence, and impaired sensation may combine to place these patients at exceptionally high risk. The level and completeness of the spinal cord injury is critical in this determination.

Operating room OR and emergency room ER stays: Prolonged time on a hard surface or in one position increases the risk of skin breakdown.

This often happens in an OR or ER, with lengthy procedures, or while transporting a patient,. Always consider the length of time that the patient may need to stay in one position. Patients who undergo a procedure longer than 4 hours are at particularly high risk. Practice Insights Comprehensive risk assessment includes both the use of a standardized scale and an assessment of other factors that may increase risk of pressure ulcer development.

Action Steps Ask yourself and your team: Are we using a risk assessment tool in conjunction with the assessment of additional specific patient risk factors? When and what kind of training did the staff receive on how to use and interpret the scales?

Are risk assessment results being used as a basis for planning care? Tools Copies of the Braden and Norton scales are included in Tools and Resources Tool 3D, Braden Scale , and Tool 3E, Norton Scale.

Resources Consider the following resources for risk assessment in special populations: Palliative Care: Hunters Hill Marie Curie Centre Risk Assessment Tool. Chaplin J, McGill M. Pressure sore prevention. Palliative Care Today ;8 3 Home Care: Braden Scale for Predicting Pressure Sore Risk in Home Care.

Available at: www. Pediatrics: Braden Q 21 days to 8 years. Quigley SM, Curly MAQ. Skin integrity in the pediatric population: preventing and managing pressure ulcers.

J Spec Pediatr Nurs ;1 1 Glamorgan Scale birth to 18 years. Willock J, Harris C, Harrison J, et al. Identifying the characteristics of children with pressure ulcers. Nursing Times ; 11 Pediatric Waterlow neonate to 16 years. Waterlow J. Pressure sore risk assessment in children.

Pediatr Nurs ;9 6 Neonatal Skin Risk Assessment Scale NSARS 26 to 46 weeks. Huffines B, Logsdon MC. The neonatal skin risk assessment scale for predicting skin breakdown in neonates.

Issues Compr Pediatr Nurs ; Action Steps Considering the specific patient situation, ask yourself and your team: How often should the risk reassessment be done on your unit? How often is it actually being done?

Among the options to consider for complete documentation are: Having a dedicated form computerized or paper in the medical record. Incorporating results in the daily patient flowsheets. Including results as part of patient report or handover. Having a separate form for the pressure ulcer risk assessment tool that allows multiple date entries.

J Spinal Cord Med Spring;24 Suppl 1:S National Pressure Ulcer Advisory Panel NPUAP and European Pressure Ulcer Advisory Panel EPUAP. American Medical Directors Association: Pressure Ulcers in the Long-Term Care Setting. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel.

Prevention and treatment of pressure ulcers: clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; October Wound, Ostomy and Continence Nurses Society.

Pressure ulcer assessment: best practices for clinicians. Internet Citation: 3. What Are the Best Practices in Pressure Ulcer Prevention that We Want to Use? Content last reviewed October Agency for Healthcare Research and Quality, Rockville, MD.

Browse Topics. Topics A-Z. National Healthcare Quality and Disparities Report Latest available findings on quality of and access to health care.

Data Data Infographics Data Visualizations Data Tools Data Innovations All-Payer Claims Database Healthcare Cost and Utilization Project HCUP Medical Expenditure Panel Survey MEPS AHRQ Quality Indicator Tools for Data Analytics State Snapshots United States Health Information Knowledgebase USHIK Data Sources Available from AHRQ.

Notice of Funding Opportunities. Funding Priorities Special Emphasis Notices Staff Contacts. Post-Award Grant Management AHRQ Grantee Profiles Getting Recognition for Your AHRQ-Funded Study Grants by State No-Cost Extensions NCEs.

AHRQ Grants by State Searchable database of AHRQ Grants. PCOR AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund.

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Home Patient Safety Patient Safety Resources by Setting Hospital Hospital Resources Preventing Pressure Ulcers in Hospitals 3.

Preventing Pressure Ulcers in Hospitals 3. Previous Page. Next Page. Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1.

Are we ready for this change? How will we manage change? What are the best practices in pressure ulcer prevention that we want to use? How do we implement best practices in our organization? How do we measure our pressure ulcer rates and practices? How do we sustain the redesigned prevention practices?

Tools and Resources. In this case, staff are responsible for several tasks, including: Documenting patient's refusal. Trying to discover the basis for the patient's refusal. Presenting a rationale for why the intervention is important.

Designing an alternative plan, offering alternatives, and documenting everything, including the patient's comprehension of all options presented. This revised strategy needs to be described in the care plan and documented in the patient's medical record.

Update the care plan to reflect any changes in the patient's risk status. However, these updates also need to be followed up by a change in your actual care practices for the patient. Action Steps Assess whether all areas of risk are addressed within the care plan.

Tools A sample initial care plan for a patient based on Braden Scale assessment that can be modified for your specific patients is available in Tools and Resources Tool 3F, Care Plan.

Practice Insights Most patients do not fit into a "routine" care plan. Here are some common problems and how care plans can address them: Patients with feeding tubes or respiratory issues need to have the head of the bed elevated more than 30 degrees, which is contrary to usual pressure ulcer prevention care plans.

Care plans and documentation in the medical record will need to address this difference. Preventing heel pressure ulcers is a common problem that must be addressed in the care plans.

Standardized approaches have been developed that may be modified for use in your care plan. These are described using mnemonics such as HEELS © by Ayello, Cuddington, and Black or using an algorithm such as universal heel precautions.

Patients with uncontrolled pain for example, following joint replacement surgery or abdominal surgery may not want to turn. Care plans must address the pain and how you will encourage them to reposition.

Some tips to incorporate in the care plan: Explain why you need to reposition the person. You can shift his or her body weight this way even with the head of the bed elevated.

Sit the person in a chair. This maintains the more elevated position and allows for small shifts in weight every 15 minutes. Try having patients turn toward their stomach at a 30 degree angle.

They can be propped up or leaning on pillows. Ask the patient what his or her favorite position is. All of us have certain positions we prefer for sleep.

Pain and temperature changes often preceded skin color changes. Discoloration may appear differently in darkly pigmented skin. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss.

If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury unstageable, Stage 3 or Stage 4.

Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Medical Device-Related Pressure Injury — This describes the etiology.

Medical device-related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes.

The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

Mucosal Membrane Pressure Injury — Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, injuries cannot be staged. The prevention of pressure injuries is a great concern in health care today.

Many clinicians believe that pressure injury development is not solely the responsibility of nursing, but the entire health care system. Pressure injury prevention and treatment requires multi-disciplinary collaborations, good organizational culture and operational practices that promote safety. Per the International Guideline, risk assessment is a central component of clinical practice and a necessary first step aimed at identifying individuals who are susceptible to pressure injuries.

Risk Assessment should be considered as the starting point. The earlier a risk is identified, the more quickly it can be addressed. Skin Care. Hospitalized individuals are at great risk for undernutrition. Positioning and Mobilization. Immobility can be a big factor in causing pressure injuries.

Immobility can be due to several factors, such as age, general poor health condition, sedation, paralysis, and coma. Monitoring, Training and Leadership Support. In any type of process improvement or initiative, implementation will be difficult without the right training, monitoring and leadership support.

Reddy M, et al. Treatment of pressure ulcers: A systematic review. The Journal of the American Medical Association. Cooper KL. Evidence-based prevention of pressure ulcers in the intensive care unit.

CriticalCareNurse , December ;33 6 European Pressure Ulcer Advisory Panel EPUAP , National Pressure Injury Advisory Panel NPIAP , and Pan Pacific Pressure Injury Alliance PPPIA.

The International Guideline.

Implementation strategy Ulcer prevention in the workplace preventive and therapeutic interventions in Uocer field of pressure ulcers must rpevention comprehensive and timely and Ullcer prepared. It has to be based on identification workplac the Proper nutrition for weight class sports situation in preventioh workplace, Ulcer prevention in the workplace the planned implementation of new clinical recommendations will be implemented. The implementation strategy should lead to better care and should enhance professional caregiver's satisfaction. The most important part of the local assessment situation is the evaluation of the type of workplace, human resources and financial resources and costs. N2 - Implementation strategy of preventive and therapeutic interventions in the field of pressure ulcers must be comprehensive and timely and properly prepared. AB - Implementation strategy of preventive and therapeutic interventions in the field of pressure ulcers must be comprehensive and timely and properly prepared.

Ulcer prevention in the workplace -

Pressure ulcer prevention. Home Patients and families Patient safety Pressure ulcer prevention. Pressure ulcers: Advice for patients and carers We are committed to preventing pressure ulcers and helping local patients, families or carers to manage pressure ulcers more effectively.

What is a pressure ulcer? Pressure ulcer information:. Play video. Pressure ulcer information: The facts about pressure ulcers: Pressure ulcers can occur within a matter of hours for those at risk Regular top to toe skin inspections are needed to help prevent pressure ulcers occurring.

Look out for reddening that does not subside over bony areas. Good SSKIN can help prevent pressure ulcers click here. Michael McGrath's story How to prevent pressure ulcers film Play video.

Pressure ulcer blanch test film. Pressure ulcers: Signs to watch out for click here Look out for red areas over bony prominences and take pressure off area: A reddened area over sacrum Non-blanching area - demonstrating early stage pressure damage Please note: The darker the skin, the harder pressure ulcers will be to detect.

Useful links and resources:. Some of the factors that make pressure ulcer prevention so difficult include:. Given the complexity of pressure ulcer prevention, with many different items that need to be completed, thinking about how to implement best practices may be daunting.

One approach that has been successfully used is thinking about a care bundle. A care bundle incorporates those best practices that if done in combination are likely to lead to better outcomes. It is a way of taking best practices and tying them together in a systematic way.

These specific care practices are among the ones considered most important in achieving the desired outcomes. The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers:.

Because these aspects of care are so important, we describe them in more detail in the subsequent subsections along with helpful clinical hints. While these three components of a bundle are extremely important, your bundle may stress other aspects of care.

It should build on existing practices and may need to be tailored to your specific setting. Whatever bundle of recommended practices you select, you will need to take additional steps. We describe strategies to ensure their successful implementation as described in Chapter 4. The bundle concept was developed by the Institute for Healthcare Improvement IHI.

The following article describes successful efforts to improve pressure ulcer prevention that relied on the use of the components in the IHI bundle: Walsh NS, Blanck AW, Barrett KL. Pressure ulcer prevention in the acute care setting.

J Wound Ostomy Continence Nurs ;36 4 Each component of the bundle is critical and to ensure improved care, each must be consistently well performed. To successfully implement the bundle, it is important to understand how the different components are related.

A useful way to do this is by creating or following a clinical pathway. A clinical pathway is a structured multidisciplinary plan of care designed to support the implementation of clinical guidelines.

It provides a guide for each step in the management of a patient and it reduces the possibility that busy clinicians will forget or overlook some important component of evidence-based preventive care. Given the complexity of pressure ulcer preventive care, develop a clinical pathway that describes your bundle of best practices and how they are to be performed.

Return to Contents. The first step in our clinical pathway is the performance of a comprehensive skin assessment. Prevention should start with this seemingly easy task. However, as with most aspects of pressure ulcer prevention, the consistent correct performance of this task may prove quite difficult.

Comprehensive skin assessment is a process by which the entire skin of every individual is examined for any abnormalities. It requires looking and touching the skin from head to toe, with a particular emphasis over bony prominences.

As the first step in pressure ulcer prevention, comprehensive skin assessment has a number of important goals and functions. These include:. It is important to differentiate MASD from pressure ulcers. The following articles provide useful insights on how to do this:. A comprehensive skin assessment has a number of discrete elements.

Inspection and palpation , though, are key. To begin the process, the clinician needs to explain to the patient and family that they will be looking at their entire skin and to provide a private place to examine the patient's skin.

Make sure that the clinicians' hands have been washed, both before and after the examination. Use gloves to help prevent the spread of resistant organisms. Recognize that there is no consensus about the minimum for a comprehensive skin assessment. Usual practice includes assessing the following five parameters:.

Detailed instructions for assessing each of these areas are found in Tools and Resources Tool 3B, Elements of a Comprehensive Skin Assessment. Comprehensive skin assessment is not a one-time event limited to admission.

It needs to be repeated on a regular basis to determine whether any changes in skin condition have occurred. In most hospital settings, comprehensive skin assessment should be performed by a unit nurse on admission to the unit, daily, and on transfer or discharge.

In some settings, though, it may be done as frequently as every shift. The admission assessment is particularly important on arrival to the emergency room, operating room, and recovery room. It may be appropriate to have more frequent assessments on units where pressure ulcers may develop rapidly, such as in a critical care unit; or less frequently on units in which patients are more mobile, such as psychiatry.

Staff on each unit should know the frequency with which comprehensive skin assessments should be performed.

Optimally, the daily comprehensive skin assessment will be performed in a standardized manner by a single individual at a dedicated time. Alternatively, it may be possible to integrate comprehensive skin assessment into routine care. Nursing assistants can be taught to check the skin any time they are cleaning, bathing, or turning the patient.

Different people may be assigned different areas of the skin to inspect during routine care. Someone then needs to be responsible for collecting information from these different people about the skin assessment. The risk with this alternative approach is that a systematic exam may not be performed; everybody assumes someone else is doing the skin assessment.

Decide what approach works best on your units. Assess whether your staff know the frequency with which comprehensive skin assessment should be performed. In order to be most useful, the result of the comprehensive skin assessment must be documented in the patient's medical record and communicated among staff.

Everyone must know that if any changes from normal skin characteristics are found, they should be reported. Nursing assistants need to be empowered and feel comfortable reporting any suspicious areas on the skin. Positive reinforcement will help when nursing assistants do find and report new abnormalities.

In addition to the medical record, consider keeping a separate unit log that summarizes the results of all comprehensive skin assessments. This sheet would list all patients present on the unit, whether they have a pressure ulcer, the number of pressure ulcers present, and the highest stage of the deepest ulcer.

By regularly reviewing this sheet, you can easily determine whether each patient has had a comprehensive skin assessment. This log will also be critical in assessing your incidence and prevalence rates go to section 5. Nursing managers should regularly review the unit log.

A sample sheet can be found in Tools and Resources Tool 5A, Unit Log. There are many challenges to the performance of comprehensive skin assessments. Be especially concerned about the following issues:. An example of a notepad to be used for communication among nursing assistants, nurses, and managers can be found in Tools and Resources Tool 3C, Pressure Ulcer Identification Notepad.

Comprehensive skin assessment requires considerable skill and ongoing efforts are needed to enhance skin assessment skills. Take advantage of available resources to improve skills of all staff.

Encourage staff to:. This slide show illustrates how to perform a skin assessment: www. org for useful advice on evaluating erythema and the proper staging of pressure ulcers. A full-body skin inspection does not have to mean visualizing all aspects of the patient in the same time period.

As discussed above, one purpose of comprehensive skin assessment is to identify visible changes in the skin that indicate increased risk for pressure ulcer development. However, factors other than skin changes must be assessed to identify patients at risk for pressure ulcers.

This can best be accomplished through a standardized pressure ulcer risk assessment. After a comprehensive skin examination, pressure ulcer risk assessment is the next step in pressure ulcer prevention.

Pressure ulcer risk assessment is a standardized and ongoing process with the goal of identifying patients at risk for the development of a pressure ulcer so that plans for targeted preventive care to address the identified risk can be implemented.

This process is multifaceted and includes many components, one of which is a validated risk assessment tool or scale. Other risk factors not quantified in the assessment tools must be considered.

Risk assessment does not identify who will develop a pressure ulcer. Instead, it determines which patients are more likely to develop a pressure ulcer, particularly if no special preventive interventions are introduced. In addition, risk assessment may be used to identify different levels of risk.

More intensive interventions may be directed to patients at greater risk. Pressure ulcer risk assessment is a standardized process that uses previously developed risk assessment tools or scales, as well as the assessment of other risk factors that are not captured in these scales.

Risk assessment tools are instruments that have been developed and validated to identify people at risk for pressure ulcers. Typically, risk assessment tools evaluate several different dimensions of risk, including mobility, nutrition, and moisture, and assigns points depending on the extent of any impairment.

Clinicians often believe that completing the risk assessment tool is all they need to do. Help staff understand that risk assessment tools are only one small piece of the risk assessment process.

The risk assessment tools are not meant to replace clinical assessments and judgment but are to be used in conjunction with clinical assessments. Many other factors might be considered as part of clinical judgment.

However, many of these factors, such as having had a stroke, are captured by existing tools through the resulting immobility. Several additional specific factors should be considered as part of the risk assessment process. However, also remember that patients who are just "not doing well" always seem to be at high risk for pressure ulcers.

Comprehensive risk assessment includes both the use of a standardized scale and an assessment of other factors that may increase risk of pressure ulcer development. Remember that risk assessment scales are only one part of a pressure ulcer risk assessment.

These scales or tools serve as a standardized way to review some factors that may put a person at risk for developing a pressure ulcer.

Research has suggested that these tools are especially helpful in identifying people at mild to moderate risk as nurses can identify people at high risk or no risk. All risk assessment scales are meant to be used in conjunction with a review of a person's other risk factors and good clinical judgment.

While some institutions have created their own tools, two risk assessment scales are widely used in the general adult population: the Norton Scale and the Braden Scale.

Both the Norton and Braden scales have established reliability and validity. When used correctly, they provide valuable data to help plan care. The Norton Scale is made up of five subscales physical condition, mental condition, activity, mobility, incontinence scored from 1 for low level of functioning and 4 for highest level of functioning.

The subscales are added together for a total score that ranges from 5 to A lower Norton Scale score indicates higher levels of risk for pressure ulcer development. Scores of 14 or less generally indicate at-risk status.

Total scores range from 6 to A lower Braden Scale score indicates higher levels of risk for pressure ulcer development. Scores of 18 or less generally indicate at-risk status. This threshold may need to be adjusted for the specific patient population on your unit or according to your hospital guidelines.

Other scales may be used instead of the Norton or Braden scales. What is critical is not which scale is used but just that some validated scale is used in conjunction with a consideration of other risk factors not captured by the risk assessment tool.

By validated, we mean that they have been shown in research studies to identify patients at increased risk for pressure ulcer development.

Copies of the Braden and Norton scales are included in Tools and Resources Tool 3D, Braden Scale , and Tool 3E, Norton Scale. The risk assessment tools described above are appropriate for the general adult population.

However, these tools may not work as well in terms of differentiating the level of risk in special populations. These include pediatric patients, patients with spinal cord injury, palliative care patients, and patients in the OR.

Risk assessment tools exist for these special settings but they may not have been as extensively validated as the Norton and Braden scales.

Overall scale scores provide data on general pressure ulcer risk and help clinicians plan care according to the amount of risk high, moderate, low, etc. Subscale scores provide information on specific deficits such as moisture, activity, and mobility.

These deficits should be specifically addressed in care plans. Remember, even a score that indicates no risk does not guarantee that a person will not develop a pressure ulcer, especially as their condition changes. Consider performing a risk assessment in general acute care settings on admission and then daily or with a significant change in condition.

However, pressure ulcer risk may change rapidly, especially in acute care settings. Therefore, recommendations for frequency of risk assessment will vary.

In settings where patients' status may change quickly, such as in critical care, risk assessment should be performed more frequently, such as every shift. In the OR, recommendations exist to assess on admission, at discharge to the recovery room, and periodically for operations lasting longer than 4 hours.

Consider the time in the holding and recovery rooms when assessing the time. For patients with more stable conditions, such as acute rehabilitation, pressure ulcer risk assessment may be less frequent.

What is important is that the frequency of pressure ulcer risk assessment be individualized to the person's unique setting and circumstances. Documenting pressure ulcer risk is essential to ensure that all staff are aware of patients' pressure ulcer risk status.

While documenting in the medical record is necessary, documentation alone may not be sufficient to ensure that all staff know the level of risk. Among the options to consider for complete documentation are:.

Remember that in documenting pressure ulcer risk, you want to incorporate not only the score and subscale scores of the standardized risk assessment tool, but also other factors placing the individual at risk. This information is often included in narrative text. Risk status should be communicated orally at shift change or by review of the written material in the medical record or patient care worksheet.

Consider innovative approaches to conveying level of risk. For example, some facilities have color-coded the patient wristband, placed stickers on the patient chart or worksheet, or used picture magnets on the doors to indicate risk status.

The accuracy of a risk assessment scale depends on the person completing it. Experience has shown tremendous variability among staff even when evaluating the same patient.

Therefore, training in how to use the scale is needed to ensure consistency. Refer to Issue 5 under the General Assessment Series. Lindgren M, Unosson M, Krantz AM, et al. A risk assessment scale for the prediction of pressure sore development: reliability and validity.

J Adv Nurs ;38 2 Internet Citation: 3. What are the best practices in pressure ulcer prevention that we want to use?. Content last reviewed October Agency for Healthcare Research and Quality, Rockville, MD. Browse Topics. Topics A-Z. National Healthcare Quality and Disparities Report Latest available findings on quality of and access to health care.

Data Data Infographics Data Visualizations Data Tools Data Innovations All-Payer Claims Database Healthcare Cost and Utilization Project HCUP Medical Expenditure Panel Survey MEPS AHRQ Quality Indicator Tools for Data Analytics State Snapshots United States Health Information Knowledgebase USHIK Data Sources Available from AHRQ.

Notice of Funding Opportunities. Funding Priorities Special Emphasis Notices Staff Contacts. Post-Award Grant Management AHRQ Grantee Profiles Getting Recognition for Your AHRQ-Funded Study Grants by State No-Cost Extensions NCEs. AHRQ Grants by State Searchable database of AHRQ Grants.

PCOR AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. Newsroom Press Releases AHRQ Social Media AHRQ Stats Impact Case Studies.

Blog AHRQ Views. Newsletter AHRQ News Now. Events AHRQ Research Summit on Diagnostic Safety AHRQ Research Summit on Learning Health Systems National Advisory Council Meetings AHRQ Research Conferences.

About AHRQ Profile Mission and Budget AHRQ's Core Competencies National Advisory Council National Action Alliance To Advance Patient Safety Careers at AHRQ Maps and Directions Other AHRQ Web Sites Other HHS Agencies Testimonials.

Careers Contact Us Español FAQs. Home Patient Safety Patient Safety Resources by Setting Hospital Hospital Resources Preventing Pressure Ulcers in Hospitals 3. What are the best practices in pressure ulcer prevention that we want to use? Preventing Pressure Ulcers in Hospitals 3. Previous Page.

Next Page. Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? How will we manage change? How do we implement best practices in our organization? How do we measure our pressure ulcer rates and practices?

How do we sustain the redesigned prevention practices?

Once you Ulcee determined that you are ready for change, the Implementation Team Liver detoxification protocol Unit-Based Teams should demonstrate a Ulcer prevention in the workplace understanding of where they are headed in terms of implementing best practices. People involved in prevejtion Ulcer prevention in the workplace improvement prevenion need to agree on woroplace it is that they are trying to U,cer. Consensus should be reached on the following questions:. In addressing these questions, this section provides a concise review of the practice, emphasizes why it is important, discusses challenges in implementation, and provides helpful hints for improving practice. Further information regarding the organization of care needed to implement these best practices is provided in Chapter 4 and additional clinical details are in Tools and Resources. In describing best practices for pressure ulcer prevention, it is necessary to recognize at the outset that implementing these best practices at the bedside is an extremely complex task. Some of the factors that make pressure ulcer prevention so difficult include:.

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PRESSURE SORES EXPLAINED - CAUSES, STAGES, MANAGEMENT, TREATMENT - PRESSURE ULCERS AND BED SORES