Ask the treatment expert ... about pressure ulcer documentation

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Rosalyn Jordan, RN, BSN, MSc, CWOCN, WCC
Rosalyn Jordan, RN, BSN, MSc, CWOCN, WCC

How much do we have to document risk and implemented interventions to prevent pressure ulcer development? 

These are two very important action areas for every clinician to consider when a resident is admitted to a nursing facility or if the resident has a change in condition after he or she has been treated in the facility. 

The late professor Tom Defloor once said at a National Pressure Ulcer Advisory Panel conference that while risk assessments are helpful in identifying patients at-risk for pressure ulcers, one could simply identify persons at risk based on their mobility status. 

If residents are partially immobile or fully immobile, they are at-risk for developing pressure ulcers. Besides mobility problems, there are other conditions that contribute to pressure ulcer development such as age, incontinence, nutrition, and co-morbid medical conditions.

NPUAP guidelines suggest that each person admitted to a healthcare institution be assessed for pressure ulcer risk on admission. It is helpful to utilize a structured documentation tool so risk can be identified and immediate therapy to prevent pressure ulcers initiated. 

The most widely used pressure ulcer risk scale is the Braden Scale. Numeric risk scores are based on patient status in six areas: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

A patient's condition can change at any time. When using a structured pressure ulcer risk assessment tool, it is important to remember to include both periodic reassessments and also, reassess if the individual has a change in status or condition.

Of course, if a person is identified as being “at-risk,” document the risk status and commence a planned prevention program immediately. Document all interventions provided and the outcome of the program strategies.