Pressure Ulcer Prevention Toolkit

Module 3 Tools
3A: Pressure Ulcer Prevention Pathway for Acute Care

3B: Elements of a Comprehensive Skin Assessment

3C: Pressure Ulcer Identification Notepad
3D: The Braden Scale for Predicting Pressure Sore Risk
3E: Norton Scale
3F: Care Plan
3G: Patient and Family Education Booklet
Pressure Ulcer Risk Assessment Case Study

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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.

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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.

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 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.

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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.

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Braden Pressure Ulcer Risk Assessment

Patient’s Name ______________________ Evaluator’s Name _____________________ Date of Assessment

SENSORY 1. Completely Limited: 2. Very Limited: 3. Slightly Limited: 4. No Impairment:
PERCEPTION Unresponsive (does not moan, Responds only to painful stimuli. Responds to verbal commands, Responds to verbal commands,
ability to respond flinch, or grasp) to painful stimuli, Cannot communicate discomfort but cannot always communicate has no sensory deficit which would
meaningfully to due to diminished level of except by moaning or discomfort or need to be turned. limit ability to feel or voice pain or
pressure-related consciousness or sedation. restlessness. OR has some sensory impairment discomfort.
discomfort OR limited ability to feel pain over OR has a sensory impairment which limits ability to feel pain or
most of body surface. which limits the ability to feel pain discomfort in 1 or 2 extremities.
or discomfort over 1/2 of body.
MOISTURE 1. Constantly Moist: 2. Very Moist: 3. Occasionally Moist: 4. Rarely Moist:
degree to which Skin is kept moist almost constantly Skin is often, but not always, moist. Skin is occasionally moist, Skin is usually dry, linen only
skin is exposed to by perspiration, urine, etc. Linen must be changed at least requiring an extra linen change requires changing at routine
moisture Dampness is detected every time once a shift. approximately once a day. intervals.
patient is moved or turned.
ACTIVITY 1. Bedfast: 2. Chairfast: 3. Walks Occasionally: 4. Walks Frequently:
degree of Confined to bed. Ability to walk severely limited or Walks occasionally during day, but Walks outside the room at least
physical activity non-existent. Cannot bear weight for very short distances, with or twice a day and inside room at least
and/or must be assisted into chair without assistance. Spends once every 2 hours during waking
or wheelchair. majority of each shift in bed or hours.
chair.
MOBILITY 1. Completely Immobile: 2. Very Limited: 3. Slightly Limited: 4. No Limitations:
ability to change Does not make even slight changes Makes occasional slight changes Makes frequent though slight Makes major and frequent changes
and control body in body or extremity position without in body or extremity position but changes in body or extremity in position without assistance.
position assistance. unable to make frequent or position independently.
significant changes independently.
NUTRITION 1. Very Poor: 2. Probably Inadequate: 3. Adequate: 4. Excellent:
usual food intake Never eats a complete meal. Rarely Rarely eats a complete meal and Eats over half of most meals. Eats Eats most of every meal. Never
pattern eats more than 1/3 of any food generally eats only about 1/2 of a total of 4 servings of protein refuses a meal. Usually eats a total
offered. Eats 2 servings or less of any food offered. Protein intake (meat, dairy products) each day. of 4 or more servings of meat and
protein (meat or dairy products) per includes only 3 servings of meat or Occasionally will refuse a meal, but dairy products. Occasionally eats
day. Takes fluids poorly. Does not dairy products per day. will usually take a supplement if between meals. Does not require
take a liquid dietary supplement. Occasionally will take a dietary offered. supplementation.
OR is NPO and/or maintained on supplement. OR is on a tube feeding or TPN
clear liquids or IV's for more than 5 OR receives less than optimum regimen which probably meets
days. amount of liquid diet or tube most of nutritional needs.
feeding.
FRICTION 1. Problem: 2. Potential Problem: 3. No Apparent Problem:
AND SHEAR Requires moderate to maximum Moves feebly or requires minimum Moves in bed and in chair
assistance in moving. Complete assistance. During a move skin independently and has sufficient
lifting without sliding against sheets probably slides to some extent muscle strength to lift up
is impossible. Frequently slides against sheets, chair, restraints, or completely during move. Maintains
down in bed or chair, requiring other devices. Maintains relatively good position in bed or chair at all
frequent repositioning with good position in chair or bed most times.
maximum assistance. Spasticity, of the time but occasionally slides
contractures or agitation lead to down.
almost constant friction.

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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.

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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.

Physical Mental Activity Mobility Incontinent Total

condition condition Score

Good 4 Alert 4 Ambulant 4 Full 4 Not 4

Fair 3 Apathetic 3 Walk-help 3 Slightly limited 3 Occasional 3

Poor 2 Confused 2 Chair-bound 2 Very limited 2 Usually-Urine 2

Very bad 1 Stupor 1 Stupor 1 Immobile 1 Doubly 1

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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.

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Sample Care Plan

Braden
Category Braden Score: 1 Braden Score: 2 Braden Score: 3 Braden Score: 4
Sensory Completely limited Very limited Slightly limited No limitation
Perception  Skin assessment and inspection q shift.  Skin assessment and inspection q shift.  Skin assessment and inspection q  Encourage patient to
Pay attention to heels. Pay attention to heels. shift. Pay attention to heels. report pain over bony
 Elevate heels and use protectors.  Elevate heels and use protectors.  Elevate heels and use protectors . prominences.
 Consider specialty mattress or bed.  Consider specialty mattress or bed.  Check heels daily.
 Use pillows between knees and bony
prominences to avoid direct contact.
Moisture Constantly Moist Moist Occasionally Moist Rarely Moist
 Skin assessment and inspection q shift.  Use moisture barrier ointments  Use moisture barrier ointments  Encourage patient to
 Use moisture barrier ointments (protective barriers). (protective skin barriers). use lotion to prevent
(protective skin barriers).  Moisturize dry unbroken skin.  Moisturize dry unbroken skin. skin cracks.
 Moisturize dry unbroken skin.  Avoid hot water. Use mild soap and  Avoid hot water. Use mild soap and  Encourage patient to
 Avoid hot water. Use mild soap and soft soft cloths or packaged cleanser wipes. soft cloths or packaged cleanser report any moisture
cloths or packaged cleanser wipes.  Check incontinence pads frequently (q wipes. problem (such as
 Check incontinence pads frequently (q 2-3h).  Check incontinence pads frequently. under breasts).
2-3h) and change as needed.  Avoid use of diapers but if necessary,  Avoid use of diapers but if necessary,
 Apply condom catheter if appropriate. check frequently (q 2-3h)and change as check frequently (q 2-3h) and change
 If stool incontinence, consider bowel needed. as needed.
training and toileting after meals or  If stool incontinence, consider bowel  Encourage patient to report any other
rectal tubes if appropriate. training and toileting after meals. moisture problem (such as under
 Consider low air loss bed  Consider low air loss bed breasts).
 If stool incontinence, consider bowel
training and toileting after meals.
Activity Bedfast Chairfast Walks Occasionally Walks Frequently
 Skin assessment and inspection q shift.  Consider specialty chair pad.  Provide structured mobility plan.  Encourage
 Position prone if appropriate or elevate  Consider postural alignment, weight  Consider chair cushion. ambulating outside
head of bed no more than 30 degrees. distribution, balance, stability, and  Consider physical therapy consult.. the room at least bid.
 Position with pillows to elevate pressure pressure relief when positioning  Check skin daily.
points off of the bed. individuals in chair or wheelchair.  Monitor balance and
 Consider specialty bed.  Instruct patient to reposition q 15 endurance.
 Elevate heels off bed and/or use heel minutes when in chair.
protectors.  Stand every hour.
 Consider physical therapy consult for  Pad bony prominences with foam
conditioning and W/C assessment. wedges, rolled blankets, or towels.
 Turn/reposition q 1-2h.  Consider physical therapy consult for
 Post turning schedule. conditioning and W/C assessment.
 Teach or do frequent small shifts of
body weight.
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 Braden
Category Braden Score: 1 Braden Score: 2 Braden Score: 3 Braden Score: 4
Mobility Completely Immobile Very Limited Slightly Limited No Limitations
 Skin assessment and inspection q shift.  Skin assessment and inspection q shift.  Check skin daily.  Check skin daily.
 Turn/reposition q 1-2 hours.  Turn/reposition 1-2 hours.  Turn/reposition frequently.  Encourage
 Post turning schedule.  Post turning schedule.  Teach frequent small shifts of body ambulating outside
 Teach or do frequent small shifts of  Teach or do frequent small shifts of weigh. the room at least bid.
body weight. body weight.  PT consult for  No interventions
 Elevate heels.  Elevate heels. strengthening/conditioning. required.
 Consider specialty bed.  Consider specialty bed.  Gait belt for assistance.

Nutrition Very Poor Probably Inadequate Adequate Excellent

 Nutrition consult.  Nutrition consult.  Monitor nutritional intake.  Out of bed for all
 Skin assessment and inspection q shift.  Offer nutrition supplements and water.  If NPO for > 24 hours, discuss plan meals.
 Offer nutrition supplements and water.  Encourage family to bring favorite with MD.  Provide food choices.
 Encourage family to bring favorite foods.  Record dietary intake and I&O if  Offer nutrition
foods.  Monitor nutritional intake. appropriate. supplements. If NPO
 Monitor nutritional intake.  Small frequent meals. for > 24 hours,
 If NPO for > 24 hours, discuss plan with  If NPO for > 24 hours, discuss plan discuss plan with
MD. with MD. MD.
 Record dietary intake and I & O if  Record dietary intake and I & O if  Record dietary intake.
appropriate. appropriate.
Friction Problem Potential Problem No apparent problem
and Shear  Skin assessment and inspection q shift.  Keep bed linens clean, dry, and wrinkle  Keep bed linens clean, dry, and
 Minimum of 2 people + draw sheet to free. wrinkle free.
pull patient up in bed.  Avoid massaging pressure points.
 Keep bed linens clean, dry, and wrinkle  Apply transparent dressing or
free. elbow/heel protectors to intact skin
 Apply elbow/heel protectors to intact over elbows and heels.
skin over elbows and heels.
 Elevate head of bed 30 degrees or less.

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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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 PRESSURE ULCER RISK ASSESSMENT CASE STUDY
Mr. K, a 60 year old male, was admitted to the Hospital for ongoing complex
medical care and need for management of advanced Parkinson’s disease,
dysphagia, and failure to thrive. He developed difficulty swallowing after usual
Parkinson’s medication schedule was inadvertently altered at rehab one month ago.
He is now NPO and has trouble with secretions. Mr. K is alert and oriented.

Currently he is being fed Ensure Plus via a tube feeding. A nutrition consult is
ordered. He is usually unable to walk and has difficulty talking. He requires total
care for bathing, toileting, dressing, and feeding. At least two nurses or nurse
assistants are required to move him. He is occasionally incontinent.

A wound/ostomy nurse consult revealed he has a slightly pink coccyx area (base of
spinal column).

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