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Which client assessment would the nurse determine represents the highest risk for development of pressure ulcers?

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Nursing InterventionsRationale
Assess the specific risk factors for pressure ulcer: Even clients with an existing pressure ulcer continue to be at risk for further injury, Nurses should consider all potential risk factors for pressure ulcers development.
  • Determine the client’s age and general condition of the skin.
Elderly clients have less elastic skin, less moisture, less padding and have thinning of the epidermis, making it more prone to skin impairment.
  • Assess the client’s nutritional status, including weight, weight loss, and serum albumin levels, if indicated.
A severe protein depletion has an albumin level of less than 2.5 g/dL. Clients with pressure ulcer lose big amounts of protein in wound exudates and may require 4000 kcal/day or more to remain anabolic.
  • Assess for a history of preexisting chronic diseases (e.g., diabetes mellitus, acquired immune deficiency syndrome, guillain-barré syndrome, peripheral and/or cardiovascular disease).
Clients with chronic diseases typically exhibit multiple risk factors that predispose them to pressure ulceration. These include poor nutrition, poor hydration, incontinence, and immobility.
  • Assess the skin on admission and daily for an increasing number of risk factors.
The incidence of skin breakdown is directly related to the number of risk factor present.
  • Assess for a history of radiation therapy.
Irradiated skin becomes thin and brittle, may have less blood supply, and is at a higher risk for skin breakdown.
  • Assess the client’s awareness of the sensation of pressure.
 Usually, people shift their weight off pressure areas every few minutes; this occurs more or less automatically, even during sleep. Clients with decreased sensation are unaware of unpleasant stimuli and do not shift weight, thereby exposing the skin to excessive pressure.
  • Assess for fecal and urinary incontinence.
 The urea in urine turns into ammonia within minutes and is erosive to the skin. While the stool may contain enzymes that cause skin breakdown. Diapers and incontinence pads with plastic liners trap moisture and speed up breakdown.
  • Assess client’s ability to move (shift weight while sitting, turn over in bed, move from the bed to a chair).
 Immobility is a huge risk factor for pressure ulcer development among adult hospitalized clients.
  • Assess for environmental moisture (excessive perspiration, high humidity, wound drainage).
 Moisture may contribute to skin maceration.
  • Assess the amount of shear (pressure exerted laterally) and friction (rubbing) on the client’s skin.
 Shearing forces are most commonly noted on the sacrum, scapulae, heels, and elbows from skin-sheet friction, from semi-Fowler’s position and repositioning, and from lift sheets.
  • Assess the surface that the clients spend a majority of time on (mattress for bedridden clients, cushion for clients in wheelchairs).
 Clients who spend the majority of time on one surface need a pressure reduction or pressure relief device to reduce the risk of skin breakdown.
  • Assess the skin over bony prominences (sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back of the head).
These areas at highest risk for breakdown resulting from tissue ischemia from compression against a hard surface.
Use an objective tool for pressure ulcer risk assessment:
  • Braden scale.
  • Norton scale.
The Braden scale is the most widely used risk assessment. It consists of six subscales namely: activity, mobility, moisture, nutrition, sensory perception, and friction.

Acute care: Assessment should be carried out on all patients on admission and every 24 to 48 hours or sooner if the patient’s condition changes.

Long-term care: Assess on admission, weekly for 4 weeks, then quarterly and whenever the resident’s condition changes.

Assess the client’s level of pain, especially related to dressing change and procedures. Prophylactic pain medication may be indicated.
Assess and stage the pressure ulcers. Staging is essential because it determines the treatment plan. Staging should be assessed at each dressing stage. It reflects whether the epidermis, dermis, fat, muscle, bone, or joint is exposed. If the ulcer is covered with necrotic tissue (eschar), it cannot be accurately staged. Stage I ulcers are difficult to detect in darkly pigmented skin. The use of mirrors or a penlight may be helpful.
Determine the condition of the wound or wound bed. 
  • Presence of necrotic tissue.
Necrotic tissue is tissue that is dead and eventually must be removed before healing can take place. Necrotic tissue exhibits a wide range of appearance: black, brown, leathery, hard, shiny, thin, tough, white.
  • Color.
The color of tissue is an indication of tissue viability and oxygenation. White, gray, or yellow eschar may be present in stage II and III ulcers. Eschar may be black in stage IV ulcers.
  • Odor.
Odor may arise from infection present in the wound; it may also arise from the necrotic tissue. Some local wound care products may create or intensify the odors and should be distinguished from wound or exudate odors.
  • Viability of bone, joints, or muscle.
In stage IV pressure ulcers, these may be apparent at the base of the ulcer. Wounds may demonstrate multiple stages or characteristics in a single wound.
Measure the size of the ulcer, and note the presence of undermining. The ulcer dimensions include length, width, and depth. An ulcer begins in the deepest tissue layers before the skin breaks down. Hence the opening of the skin’s surface may not represent the true size of the ulcer.
Assess the condition of wound edges and surrounding tissue. Surronding tissue may be healthy or may have various degrees of impairment. Healthy tissue is necessary for the use of local wound care products requiring adhesion to the skin. The presence of healthy tissue demarcates the boundaries of the pressure ulcer.
Assess the wound exudate. Exudate is a normal part of wound physiology and must be differentiated from pus which is an indication of infection. Exudate may contain serum, blood, and white blood cells, and may appear clear, cloudy, or blood-tinged. The amount may vary from a few cubic centimeters, which are easily managed with dressings, to copious amounts not easily managed. Drainage is considered excessive when dressing changes are needed more often than every 6 hours.
Assess ulcer healing, using a pressure ulcer scale for healing (PUSH) tool. This tool provides standardization in the measurement of wound healing. It quantifies surface area, exudate, and the type of wound tissue.
Provide local wound care:
Stage I: 
  • Apply a topical vasodilator (e.g., Proderm)
It increases skin circulation.
  • Apply a flexible hydrocolloid dressing (e.g., Duoderm) or a vapor-permeable membrane dressing (Tegaderm).
It prevents shear and friction.
  • Apply a vitamin-enriched emollient to the skin every shift.
It moisturizes the skin.
Stage II:
  • Apply a Alginates (Sorbsan, Kalginate, Kaltostat).
Alginate dressings are a type that is highly absorbent and so can absorb the fluid (exudate) that is produced by some ulcers. These are often used for ulcers with moderate-to-heavy exudate.
  • Apply hydrocolloids or a vapor-permeable membrane dressing.
Hydrocolloids are used to promote healing and wound debridement. They are not advised to use for heavy-exudate-producing wounds.
  • Apply gauze with sodium chloride solution.
This maintains a moist environment but requires multiple dressing changes. Dressings must be removed while still wet. Dressings absorb small amounts of drainage.
  • Apply Hydrogels (Carrasyn V, Aqua Skin).
Hydrogels provide moisture to dry, sloughy or necrotic wounds and assists autolytic debridement. Can be used on wounds with low exudate. Usually use for shallow ulcers without exudates.
Stage III and IV: 
  • Foams.
Different foams have different levels of absorbency. They are best used on granulating wounds. Foams lessen odor and repel bacteria and water.
  • Gauze with sodium chloride solution.
This maintains a moist environment but requires multiple dressing changes as describe for stage II.
  • Wound fillers.
Wound fillers are used as a primary dressing and to pack wounds, maintain a moist environment.
  • Autolytic debridement.
Using a hydrocolloid or hydrogel, these create a moist wound interface that enhances the activity of endogenous proteolytic enzymes within the wound, liquefying and separating necrotic tissue from healthy tissue.
  • Sharp or surgical debridement.
This procedure removes the necrotic tissue and senescent cells that slow down the tissue repair process, converting a chronic wound into an acute one in the process.
  • Mechanical debridement.
Involves allowing a traditional gauze-type dressing to dry out and adhere to the surface of the wound before manually removing the dressing, debriding any tissue attached to it.
  • Electrical stimulation.
Stimulation of many cellular processes improves healing.
  • Biosurgery.
Therapeutic use of live blow fly larvae (maggots) for a quick debridement.
  • Topical growth factors.
Nerve-growth factors, colony-stimulating factors, and fibroblast growth factors are found to be effective in treating diabetic and venous ulcers.
  • Negative pressure wound therapy.
A wound dressing systems that continuously or intermittently apply a subatmospheric pressure to the surface of a wound to assist healing.
  • Enzymatic debridement (chlorophyll, collagenase, papain).
Enzymatic debridement uses proteolytic enzymes to remove necrotic tissue. These agents work by selectively digesting the collagen portion of the necrotic tissue. Care should be taken to prevent damage to surrounding healthy tissues.

What is the highest risk factor for the development of pressure ulcers?

Your risk of developing bedsores is higher if you have difficulty moving and can't change position easily while seated or in bed. Risk factors include: Immobility. This might be due to poor health, spinal cord injury and other causes.

What is the most widely used assessment tool for identifying pressure ulcer risk?

A number of tools have been developed for the formal assessment of risk for pressure ulcers. The three most widely used scales are the Braden Scale, the Norton Scale, and the Waterlow Scale.

What is pressure ulcer risk assessment?

Pressure ulcer risk assessment is part of the process used to identify individuals at risk of developing a pressure ulcer. Use of a risk assessment tool is recommended by many international guidelines on pressure ulcer prevention. Different tools are used for pressure ulcer risk assessment.

What are the nursing assessments for pressure ulcer?

How to assess pressure ulcers.
ulcer history, including etiology, duration, and previous treatment..
anatomic location..
stage..
size (length, width, and depth in centimeters).
sinus tracts, undermining, and tunneling..
drainage..
necrotic tissue (slough and eschar).
granulation tissue (newly formed tissue within a healing wound).

client assessment nurse determine represents highest risk development pressure ulcers

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