Pressure Ulcer Prevention
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Modules - Pressure Ulcer Prevention
FREQUENTLY ASKED QUESTIONS
Do we have to assess all residents for pressure ulcer risk? (Back to top)
Yes, a risk assessment should be conducted for all residents upon admission to the facility. For those residents who are judged at risk, with Braden scores below 18, "follow along" assessments should be performed weekly for the next four weeks. Thereafter, residents should be re-assessed periodically, such as quarterly with their MDS re-assessment.
How do I document that scheduled repositioning is unnecessary for a resident who is judged at risk for pressure ulcers? (Back to top)
Conducting our turn-in-bed physical performance test is one way to document that a resident does not need to be repositioned. Once this assessment test is completed, document the results in the medical record as the rationale for not putting the resident on a scheduled repositioning program.
How do I monitor implementation of a pressure ulcer prevention program? (Back to top)
One of the easiest interventions to monitor is use of pressure reduction surfaces on beds and wheelchairs. Start with a list of the residents who are most at risk for pressure ulcers (PU) and consequently should be on pressure reduction surfaces. At least once a week, check each of these residents' beds and, most importantly, their wheelchairs for the presence of a pressure reducing surface. If any surfaces are missing, find out why and take corrective action.
Methods for evaluating and monitoring feeding assistance for nutritionally at-risk residents, many of them also at risk for PU, are presented in our weight loss prevention module. Click here to review these procedures.
Other PU prevention interventions are more difficult to monitor, especially repositioning. Several innovative methods have been tried. One involves placing color-coded pads underneath high risk residents who require two-hour repositioning. The different colors correspond to different time periods. Thus, for example, red may signify 8-10 a.m., yellow, 10 a.m. to noon, and so on. A supervisor can tour the facility and quickly spot residents who are sitting on the wrong color, presumably because they haven't been repositioned on schedule.
One administrator attached post-it notes on the right and left trochanters of residents who needed repositioning. The notes read, "Come find me when you find this note." As the nurse aides found the notes and reported to the supervisor, she was able to track the time intervals between notifications.
A movement monitoring device may soon be available to allow continuous movement monitoring of those residents at highest risk. Until that time, creative approaches and diligent attention are the keys to success.
We know that when we pay attention to specific work processes and provide feedback to staff, those work processes improve. This means that making rounds of the residents who need repositioning, noting their location (e.g., in bed or in a chair) and positioning (e.g., lying on left side, right side, etc.), and then providing immediate feedback to staff based on your observations may be enough of a stimulus to motivate staff to consistently implement repositioning interventions.
Shouldn't we consider all residents who trigger the pressure ulcer RAP to be at high risk for developing a pressure ulcer? (Back to top)
No. The seven items that trigger the pressure ulcer (PU) Resident Assessment Protocol (RAP) do not constitute a validated assessment of PU risk. Compared to validated risk assessment tools such as the Braden Scale, the PU RAP is a blunt instrument. About 60% of nursing home residents will trigger the PU RAP. In most facilities, a lower percentage will be deemed at risk for PU when a validated risk assessment tool is used.
Because of differences in what they assess, you should not assume that residents who trigger the PU RAP are at risk for PU development. At the same time, you should not assume that residents who do not trigger the PU RAP are not at risk of PU development.
The best way to evaluate a resident's risk for PU is to use a validated assessment tool such as the Braden Scale, the Gosnell Scale, or the Norton Scale.
A comparison of their assessment items highlights the differences between the RAP triggers and a validated assessment tool for PU risk. The PU RAP is initiated whenever a resident presents with one or more of seven conditions:
- Limited bed mobility
- Bed-fastness
- Bowel incontinence
- Peripheral vascular disease
- A stage 1-4 PU
- History of PU in the last 90 days
- Use of a trunk restraint daily
The items that appear on PU risk assessment instruments are quite different. While the Braden Scale, for example, assesses for mobility and bed-fastness, its other four items look nothing like the RAP triggers. It asks users to rate the following resident risk factors on a four-point scale:
- Mobility (assesses mobility in bed)
- Activity level (assesses for bed-fastness)
- Sensory perception
- Skin moisture
- Nutrition
- Friction and shear
Should we automatically schedule for repositioning any resident who triggers the pressure ulcer Resident Assessment Protocol (RAP)? (Back to top)
No. We've seen evidence that this is a common practice in some nursing homes, but it's not recommended.
Routine repositioning, a costly intervention because it is so labor intensive, is recommended in best practice guidelines for pressure-ulcer (PU) risk residents who are bedfast or who are unable or have limited ability to reposition themselves. Many of the estimated 60% of nursing home residents who trigger the PU RAP are capable of independently repositioning themselves, and thus do not need staff assistance with this task.
The best way to determine who needs repositioning is to conduct a performance assessment that evaluates a resident's ability to reposition him- or herself. Residents who are capable of independently repositioning themselves are at lower risk of developing PUs. Our performance assessment can be used to determine who needs routine repositioning. Click here to access the assessment.
The assessment takes about three minutes per resident to complete, but in the long run can save staff time. The reason is that, in the absence of an objective assessment, nursing home staff tend to overestimate the number of residents who are unable to reposition themselves, thus creating more work for themselves. In a recent study, for example, we found that, of 144 residents whom nursing home staff had identified as in need of repositioning, 46 residents-about 32%--could in fact independently reposition themselves (1).
REFERENCES (Back to top)
- Bates-Jensen BM, Simmons SF, Alessi C, and Schnelle JF. Evaluating the Accuracy of Minimum Data Set Activities of Daily Living Ratings Against Independent Performance Assessments: Systematic Error and Directions for Improvement. Journal of the American Geriatrics Society, submitted.
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