Every Nurse Needs to Understand Pressure Ulcer Assessment

March 8th, 2012

By Jennifer Olin, BSN, RN

Decubitus ulcers or pressure ulcers, or as they are more commonly known, bedsores, are nursing practice priorities across all healthcare settings. From the nursing home to the operating room and everywhere in between, maintenance of skin integrity is a major aspect of nursing care. Consistent, planned skin care assessment and interventions are critical to ensuring high quality care.

A pressure ulcer is a localized area of tissue necrosis (death) that develops when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time.

Nurses cannot expect to make significant progress in preventing pressure ulcers if pressure ulcer risk assessment, prevention planning, prevention intervention, and outcomes evaluation function as distinct and unrelated activities. The mandate to proceed systematically to assess, diagnose, plan, implement, and evaluate is as relevant for managing pressure ulcer risk as it is for managing any other clinical condition.

Pressure Ulcer Staging

Pressure ulcers are defined in stages, how far tissue breakdown or necrosis has advanced.

1. Stage I ulcers are defined as intact skin with nonblanchable redness of localized areas, usually over bony prominences. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
2. Stage II ulcers have partial thickness loss of dermis presenting as a shallow ulcer with a pink-red wound bed without slough (dead tissue that separates from living tissue, often a yellow color). They may also present as an intact or open/ruptured serum-filled blister.
3. Stage III ulcers are defined as full thickness tissue loss. Subcutaneous tissue may be visible but muscle, bone or tendon are not. Slough may be present but does not obscure the depth of tissue loss. The ulcer may have undermining and tunneling.
4. Stage IV ulcers have full-thickness tissue loss with exposed bone, tendon and muscle. Slough or eschar (black tissue, often forms a hard shell over an ulcer) may be present on some parts of the wound bed. The ulcer may often have undermining and tunneling.
5. Unstageable wounds have full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Implications of Pressure Ulcers

Studies have revealed that pressure ulcers produce endless pain, restrict activities, and require a significant amount of coping on the part of the patient. The persistent pain is simply caused by the need to move (leading patients to lay still), the pain associated with dressing changes, and debridements. Pressure ulcers cause depression, anxiety, feelings of being burdensome, powerless, and inadequate. Wound odor affects both the patient and the people around them.

Pressure ulcers can take months to heal and involve elaborate surgical procedures, which are also painful. Pressure ulcers can impose severe financial and social burdens on families. The cost to treat pressure ulcers is over one billion dollars annually and there is an additional 2.2 million Medicare hospital days added to the healthcare system. The cost of treating ulcers is at least 2.5 times the cost of preventing them at $2000-$40,000 per pressure ulcer, depending on the stage of development.

Another issue, besides patient health and safety, which is of course the primary concern, are the recent changes in compensation for hospital acquired pressure ulcers. If they become rated at Stage III or Stage IV and could have reasonably been prevented it is very likely the healthcare facility will not get paid for the pressure ulcer treatment.

The Braden Scale for Predicting Pressure Sore Risk was developed during a Robert Wood Johnson Teaching Nursing Home project and while writing an NIH proposal to study pressure ulcer risk factors. This tool is in use on all continents and has been translated into many languages. Of the many risk assessment tools available the Braden Scale has demonstrated the best reliability and validity. It has been tested in the largest number of studies, has demonstrated the best reliability and validity indicators in a variety of settings, and has proven to be a better predictor of pressure ulcers than nursing judgment.

Braden Scale Criteria

The Braden scale assesses a patient's risk of developing a pressure ulcer by examining six criteria:

• Sensory Perception – This a measure of the patient’s ability to detect and respond to discomfort or pain related to pressure on different parts of their body. The ability to sense pain itself plays into this category, as does the patient’s level of consciousness and their ability to cognitively react to pressure-related discomfort.
• Moisture – Excessive and continuous skin moisture can pose a risk which will compromise the integrity of the skin. The constant state of dampness can cause skin tissue to become macerated and therefore be at risk for epidermal erosion.
• Activity – This category looks at a client’s level of physical activity since limited or no activity can encourage muscle atrophy and tissue breakdown.
• Mobility – This is a measure of the capability of the patient to adjust their body position independently. It addresses their physical competency and their willingness to move.
• Nutrition – Assessing the client’s nutritional status through their daily eating patterns. If the patient eats only a portion of their meal and/or have an imbalanced diet they are at a higher risk for skin breakdown.
• Friction and Shear – This is a measure of the amount assistance a patient needs to move and the degree of sliding on beds or chairs they experience. The issue at hand here is that the sliding motion can have skin and bones moving in opposite directions, causing the breakdown of cell walls and capillaries.

Braden Scale Scoring

Each of the six categories is rated on a scale of one to four, excluding the 'friction and shear' category which is rated on a one to three scale. This combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice-versa. A score of 23 means there is no risk for developing a pressure ulcer while the lowest possible score of six points represents the severest risk for pressure sore development. An adult with a score below 18 is considered to at high risk.

Using the Braden Scale not only identifies people at risk for getting a pressure ulcer but also provides information to help plan prevention interventions. Nurses should keep a copy of the Braden Scale at their fingertips (currently there is no Braden Scale app for the iPhone).

It was once thought that nurses needed no additional training to determine how to use the Braden Scale correctly. More recent research suggests that training on how to correctly use the Braden Scale is needed to improve the reliability of Braden Scale risk assessments made by RNs working in acute care hospitals. Even if a nurse has used the Braden Scale for a long time that does not mean that all of his or her pressure ulcer risk assessments are reliable. Research has shown that considerable room for improvement exists in the reliability of Braden Scale assessments made by nurses who regularly use the assessment tool. Brushing up on the Braden Scale risk assessment technique through annual competency training is recommended for all health care practitioners.