Introduction

Pressure injuries are common among patients who experience extended exposure to pressure on a bony prominence or shear to areas of poor turgor, two factors that lead to constriction of a patient’s blood supply to the exposed area. A patient who is bedridden or has certain chronic conditions, such as diabetes,¹ is more likely to develop a pressure injury. When mechanical force is imposed on the skin, it can result in poor blood flow and damage to the bone-muscle interface, thus making tissue sensitive and painful. For patients with limited mobility, this can be especially frustrating because they may not be able to adjust positions or medical equipment. If pressure injuries are left untreated or unnoticed, they can also become infected and even enter muscle and bone. Risk assessment tools are available to assess pressure injury risk and can work in tandem with practice standardization, thereby leading to effective treatment plans for practitioners and patients.

Pressure Injury Risk Assessments in Inpatient Settings

Hospital-acquired pressure injuries can be common in sedentary patients, especially in the geriatric population. Risk factors,² such as muscle weakness, malnutrition, and poor circulation, contribute to an increase in wounds in inpatient settings. The Agency for Healthcare Research and Quality³ reported that approximately 2.5 million patients per year are affected by pressure injuries, leading to more than 17,000 lawsuits and 60,000 annual deaths.

This is not only costly for the health care system, but also a heavy burden on patients and families. Some patients may leave their inpatient stay with medical equipment that can lead to pressure injury. Education should be provided to the patient or caregiver before discharge. Although patients who are discharged from the hospital may find relief in an outpatient setting, those patients in long-term care settings have debilitating illnesses that will require more extensive treatment. Approximately one-half of patients in nursing homes are aged over 85,⁴ putting them at higher risk for infection.

The most common reasons that patients are placed in long-term care settings are deficits in three or more activities of daily living, such as bathing, walking, or dressing. In fact, about 90% of long-term care patients need assistance to walk. Additionally, many patients may have psychological conditions such as dementia, which may hinder or complicate the communication of pain. When a patient first arrives in a long-term care setting, an appropriate assessment should be completed, including the presence of any pressure injuries before admission.

Standardized Tools

There are currently three common pressure injury risk assessment tools. Although it is excellent in theory to have various options available for specific situations, this variation makes a standardized process difficult to achieve. The most commonly used pressure injury risk assessments include the Braden Scale, the Norton Scale, and the Waterlow tool. The difficulty that results from the existence of a variety of assessments is that trends may be difficult to examine, given the incongruity and differences in scaling.

Inconsistencies in Tools

Some assessment tools allow for clinicians’ interpretation of the questions rather than adherence to a set standard. This protocol can lead to inconsistencies and errors. For example, the Braden Scale⁵ assesses sensory perception, moisture, mobility, and nutrition. This assessment proves especially difficult for patients with cognitive impairments, spinal cord injuries, or other diagnoses that prevent the ability to feel pressure. Because there is currently no universal documentation method for health care systems, consistent documentation among providers should be a priority.

Beginning Steps Toward Standardization

Documentation and face-to-face contact should be prioritized, particularly regarding wound assessments, which can lay a clear foundation for the next clinician to monitor the injury appropriately. Streamlining the documentation method can make the relevant information easily identifiable. Nursing supervisors should monitor nursing staff to ensure that documentation is performed correctly and ascertain whether additional education is needed. Health care practitioners in varying environments should undergo comprehensive pressure injury assessment education, which can help organize assessment use and process, thus leading to solidified data. A holistic approach should be utilized, including any other ailments that may contribute to questions in the chosen assessment strategy.

To reduce the frequency of pressure injury risks, documentation should include the steps the clinician took, as well as a recommendation for continued treatment. Examples include how the wound appeared, what interventions were implemented during the shift or visit, and any education provided to the patient. Patients who lie in bed for long periods should be turned often, and wounds should be regularly cleaned to prevent infection. Assessments should be performed every 7 days to monitor healing progress or changes. Leadership can act by identifying which assessments they think are most applicable to their patients and train staff on how to document consistently and accordingly. Although pressure injuries can be extremely painful and difficult for patients, prevention and proper care can minimize pressure injury development and improve quality of life.

References

1. Pressure injuries (bedsores. Cleveland Clinic. Accessed February 28, 2022. https://my.clevelandclinic.org/health/diseases/17823-pressure-injuries-…
2. Pressure injuries. Cedars-Sinai. 2022. Accessed January 25, 2022. https://www.cedars-sinai.org/health-library/diseases-and-conditions/p/b…
3. Preventing pressure ulcers in hospitals . Agency for healthcare Research and Quality. 2014. Accessed January 25, 2022. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressure…
4. Nursing homes. HealthinAging.org. 2020. Accessed January 25, 2022. https://www.healthinaging.org/age-friendly-healthcare-you/care-settings…
5. Braden B, Bergstrom N. Braden scale for predicting pressure sore risk. In.Gov. 1998. Accessed January 25, 2022. https://www.in.gov/health/files/Braden_Scale.pdf