Ask the Treatment Expert about ... pressure injury assessments
Rosalyn Jordan, RN, BSN, MSc, CWOCN, WCC
Why are formalized pressure injury risk assessments so important?
Pressure injury risk assessments will assist with patient-centered care planning, improve care plans, provide information related to discharge planning, and, of course, address resident rights.
Facility staff should take into account the mobility status of each resident on admission and at specified intervals thereafter, according to the National Pressure Ulcer Advisory Panel. Residents who are admitted unable to walk or requiring assistance to transfer, such as bedfast or chairfast, should be considered at risk for pressure injury and will require a pressure injury prevention focus with care planning. Staff should be informed of residents' mobility status immediately after admission.
NPUAP also suggests that a formalized risk-assessment tool should be used for effective pressure injury prevention. The panel suggests that this tool be completed within the first eight hours after admission. The principal gauge used today is the Braden Risk Assessment tool. It uses a numeric scale that indicates a resident's risk by assessing sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
NPUAP also recommends including other risk factors such as frail skin, impairments in blood flow due to disease processes, existing pressure injuries, and pain noted in areas exposed to high pressure. In the long-term care setting, these can all lead to pressure injury.
Each issue noted should be documented and should be clear about specific risk. In the long-term care setting, it is suggested that risk assessments be completed and documented weekly for four weeks and then monthly or with a change in the resident's condition. These steps should reduce the number of pressure injuries developed in long-term care settings.