By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN

Prevention of pressure ulcers and skin breakdown begins with a comprehensive risk assessment. Most providers use a skin risk assessment tool, such as the Braden or Norton scale. While these tools have been validated to predict pressure ulcer development, their use alone isn’t considered a comprehensive assessment, and frequently the individual risk factors they identify aren’t carried through to the plan of care.

A comprehensive assessment

A comprehensive assessment for risk of skin breakdown should include a validated tool such as the Braden scale, but clinicians should also look for risk factors not included on the tool. For example, if your staff uses the Braden scale, you would also want them to consider other risk factors, including diagnoses, medications such as steroids, history of skin breakdown, cognition, the patient’s choice to follow the interventions, and the use of medical devices. (See Prevention points.)

In addition, staff should evaluate the validated tool’s scale subscores to help identify what is putting the patient at risk (for example, a person scored poorly under mobility and nutrition, so these areas should be addressed in the plan of care).

After completing the comprehensive risk assessment, the next step is creating the plan of care. All individual risk factors must be reviewed as the interdisciplinary team develops individualized interventions to help modify, stabilize, or remove the factors that are putting the patient at risk for skin breakdown.

A valuable tool

Managers should audit the current system to ensure it prompts staff to conduct a comprehensive risk assessment, not just complete the validated tool. Audit patient health records to ensure that everything that was identified on the comprehensive risk assessment has correlating interventions. The goal is to move away from paper compliance of filling out a risk assessment to truly developing a plan of care that will prevent skin breakdown.

Jeri Lundgren is vice president of clinical consulting at Joerns in Charlotte, North Carolina. She has been specializing in wound prevention and management since 1990.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.