Which of the following is not a subscale on the braden scale for predicting pressure ulcer risk?

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

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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? 

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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.

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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

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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.

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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

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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.

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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.

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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.

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

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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?