Pressure ulcer risk assessment clinical nursing times gas unlimited houston

Risk assessment is not exclusive to the prevention of pressure ulcers; it is used in many aspects of life and healthcare. The Health and Safety Executive (2011) argues that it helps us to “focus on the risks that have the potential to cause harm”. These risks need to be identified and processes initiated to reduce the likelihood of harm occurring.

In the case of pressure ulcers, many risk factors have been identified within different risk assessment tools (Table 1). These tools usually give a numeric result associated with the level of risk; in most tools the higher the score the higher the risk.

There are many risks associated with pressure ulcer development but, essentially, people with no impairment to sensation and mobility are unlikely to develop a pressure ulcer. However, this could oversimplify the risk as it implies that the only risk factors are reduced mobility and loss of sensation, which is not the case.

Each identified risk factor needs to be considered. For instance, a patient with dementia may have both an intact sensory pathway and be able to move. What this person may lack is the cognitive ability to recognise the pain signal associated with the beginnings of pressure damage (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel, 2009). This would normally trigger movement, sometimes subconsciously.

In addition, patients in pain may stay still because moving increases discomfort; they may be taking analgesics, sometimes opiates. Pain is an early warning signal for pressure damage and the use of strong analgesics may diminish this, which delays a trigger to move. Risk factors

The most common method of assessing risk of pressure ulcers is by using a risk assessment tool (Table 1). Some tools are better suited to specialist clinical areas; using different tools for different areas may be more effective than using the same tool throughout an organisation.

The variety of risk factors used by many of the tools have been considered and compared elsewhere (Webster et al, 2011; Tannen et al, 2010; Mortenson et al, 2008; Bolton, 2007; Sharp and McClaws, 2006; Seongsook et al, 2004). This article discusses only the most frequently mentioned. Reduced mobility or immobility

The pressure at the point of the bone is higher than at the skin surface (Collier and Moore, 2006). Pain is a warning signal that pressure has been exerted for too long (EPUAP and NPUAP, 2009), and this usually triggers movement. If patients cannot move, they need to be advised to report the pain to someone who can help them to do so (EPUAP and NPUAP, 2009). Lack of sensation

In pale skin a visible circular pink/red blanching mark, known as blanching erythema (the area of redness blanches white when pressed lightly with a finger), over a bony prominence is an indication that pressure damage is starting (Bethell, 2003). If this is not noticed and continued pressure is sustained, the discolouration will become darker until it is purple/black (EPUAP and NPUAP, 2009).

Identifying skin colour changes can be difficult in patients with darker skin colours (EPUAP and NPUAP, 2009), as areas of redness are neither visible nor blanch white (Bethell, 2005). This means these patients may be at increased risk of pressure damage (Fogerty et al, 2008).

An already compromised vascular supply will be further hampered by pressure, resulting in a more rapid deterioration of skin. Patients with peripheral arterial disease may be at increased risk of damage to their heels. In one area, 88% of hospital-acquired grade 4 ulcers were on patients’ heels (Guy, 2011).

The surface on which patients sit, lie or lean can influence their risk of pressure ulcers (Norton et al, 2011). Bony prominences resting against a hard surface result in high pressures at the bone/tissue interface and pressure damage may occur relatively quickly.

Changing the mattress or cushion on which patients lie or sit can reduce the risk of pressure ulcer development. Areas such as operating theatres, accident and emergency and radiology may need to consider the surfaces on which patients will lie while in their department (Haugen et al, 2011). The additional use of gel, polymer or air products may help to protect patients. Risk assessment tools

A tool that achieves these aims is deemed to have reliability and validity (Table 2). Many studies have compared the validity and reliability of different risk assessment tools (Bolton, 2007; Thompson, 2005; Seongsook et al, 2004; Schoonhoven et al, 2002). Weaknesses

Risk assessment for pressure ulcer development is the first step in the process of prevention. Using a tool is usually part of that first step and must be combined with clinical judgement, skin assessment and considering the surface. An assessment then triggers care interventions that prevent pressure ulcers from developing (Fig 1). Challenges in prevention Patient refusal

On occasion, patients may not wish to change their position as often as needed to protect their skin, or they may refuse to use a pressure-relieving mattress. In such instances, nurses should first consider patients’ mental capacity (Mental Capacity Act 2005).

The skin is an organ and, like the heart, kidneys and other organs, may fail at some point in a person’s life (Sibbald et al, 2009). This is most likely to occur at the end of life and may result in unavoidable skin damage (Bedfordshire and Hertfordshire TVN Forum, 2010; NPUAP, 2010).

The SCALE consensus document provides further explanation on the care needed under these circumstances (Sibbald et al, 2009). One aspect of this care involves helping patients and family members to understand that skin breakdown is unavoidable and may be part of their terminal illness. This allows for sensitive management of the skin and the patient’s situation, as well as reducing the likelihood of a complaint. Conclusion

All members of the healthcare team, healthcare organisations, patient safety organisations, patients, relatives and carers need to accept that some pressure ulcers are unavoidable, while taking a zero-tolerance approach towards the development of avoidable ones. Keep up to date

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