Scales of Pressure

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June 2003

By Maureen A. Preston, MSN, RN, CANP, CRRN, CWOCN

Maureen A. Preston, MSN, RN, CANP, CRRN, CWOCN

Pressure ulcer prevention is one of the most challenging aspects of care of the individual with a spinal cord injury (SCI). From initial injury, through discharge from the rehabilitation hospital, to return home within the community, the person with an SCI is at risk for pressure ulcer development. Pressure ulcers delay the achievement of rehabilitation goals, often resulting in loss of independence, and potentially impacting overall quality of life.

As health care providers working with SCI clients, you are already aware of the importance of prevention. With the multitude of pressure ulcer risk factors that have been identified in research, how can busy clinicians begin to implement prevention strategies? One way is to identify pressure ulcer risk factors and specific interventions that can be pragmatically applied to clinical and home settings. What are pressure ulcers, and where do they occur? Let us begin with defining the terminology. Pressure ulcers are defined as areas of local tissue trauma usually developing where soft tissues are compressed between bony prominences and any external surface for prolonged time periods. A pressure ulcer is a sign of local tissue necrosis and death. Pressure ulcers are most commonly found over bony prominences subject to external pressure, and may cause significant muscle and subcutaneous fat tissue destruction underneath intact skin.¹

The key to preventing pressure ulcers is to accurately identify at-risk individuals so that preventive measures may be implemented. Therefore, risk assessment and preventive measures must begin with the initial onset of SCI and continue throughout the entire lifetime of the individual.

CALCULATING THE RISK

Systematic risk assessment should be incorporated into the overall comprehensive assessment of all individuals with SCI. The predictive value of existing risk assessment tools is imprecise for the SCI population because these were designed for the general medical population. An ideal risk assessment tool should have high predictive value for determining risk.² The Braden Scale is an example of one risk assessment tool that seems to be appropriate for use with the SCI population. Future research is required to establish the predictive merit for SCI risk assessment variables not included in the Braden Scale. Limitations exist to all formal assessment tools and, therefore, clinical judgment must be used in conjunction with the tool.

The Braden Scale was developed in 1987 and comprises six subscales that reflect degrees of sensory perception, moisture, activity, mobility, nutrition, friction, and shear. Each subscale is rated on a scale according to risk and the scores are then totaled. Higher scores indicate higher risk for pressure ulcer development. The Braden Scale has been tested extensively in acute and long-term settings. It is, therefore, one risk assessment tool that can be utilized with confidence. (See Table 1.)¹

Table 1. Abbreviated Braden Scale for predicting pressure sore risk.

In addition to the Braden Scale, other risk assessment indicators have been recommended. The Consortium for Spinal Cord Medicine (2000) produced Clinical Practice Guidelines with the purpose of describing effective strategies for identifying risk and reducing the incidence, prevalence, and recurrence of pressure ulcers in individuals with SCI. This guideline recommends that risk assessment be performed on admission and reassessment done on a routine basis, as determined by the health care setting, institutional guidelines, and changes in the individual’s health status. Demographic, medical, and psychosocial factors associated with pressure ulcer prevention should be assessed as well.² Once risk assessment is determined, appropriate preventive strategies should be initiated. Care should be modified according to the individual risk factors.

PREVENTION STRATEGIES

The objectives of pressure ulcer prevention should be resolving predisposing risk factors, reducing and controlling pressure placed on high-risk or impaired areas, preventing the development or recurrence of a pressure ulcer, and supporting the healing of an existing wound.³

Using the Braden Scale as a risk assessment tool, the following pressure ulcer prevention strategies are recommended. Additionally, SCI individuals require self-care education, which enables them to independently reduce their risk factors for pressure ulcer development, depending on their neurological impairment and functional abilities.

Sensory Perception Loss/Immobility/Inactivity: Mobility plans for each patient should be individualized with the goal of attaining the highest level of mobility and activity possible. Repositioning techniques, pillow bridging, and use of pressure-reduction or pressure-relief surfaces for bed and wheelchair are essential preventive interventions.

Moisture/Incontinence: General skin care involves routine skin assessment with particular attention to bony prominences. In terms of moisture, fecal and urinary incontinence should be assessed and managed. Use of moisture barrier creams and/or absorptive products may be helpful.

Friction/Shear: Measures to reduce friction and shear relate to passive or active movement of the patient. To reduce shear, appropriate techniques for transferring or moving the patient must be used. To reduce friction-induced skin breakdown, skin should not be dragged across linens. Topical dressings such as transparent films or thin hydrocolloids may offer added skin protection. Shear injuries are caused by sliding down in bed or in the wheelchair. Proper positioning can help in preventing sliding. Malnutrition: Nutrition is an important element in maintaining healthy skin and tissues. There is a strong relationship between nutrition and pressure ulcer development. The severity of pressure ulcerations is also correlated with severity of nutritional deficits, especially low protein intake or low serum albumin levels. A nutritional assessment is key in determining appropriate interventions for each patient. Nutritional deficiencies need to be corrected in order to promote healthy skin and prevent skin breakdown.1

The Consortium for Spinal Cord Medicine’s Clinical Practice Guidelines recommend the following preventive strategies:

Implement risk assessment and pressure reduction strategies as part of the management of acute SCI.
Conduct daily skin checks, with particular attention to bony prominences.
Turn or reposition every 2 hours in the acute and rehabilitation phases, being careful to eliminate shear.
Evaluate support surfaces for appropriateness.
Provide an individually prescribed wheelchair and pressure-reducing wheelchair cushion.
Implement a routine exercise program to promote health maintenance and cardiovascular fitness.
Provide educational information related to pressure ulcer prevention strategies to SCI individuals, families, and health care providers.²

Conclusion

Pressure ulcer prevention in SCI individuals requires an interdisciplinary approach. Health care providers in all disciplines must remain acutely aware of risk assessment, prevention, and management of this common complication in caring for individuals with SCI.

Maureen A. Preston, MSN, RN, CANP, CRRN, CWOCN, is a nurse practitioner in the Outpatient Clinic at Craig Hospital in Englewood, Colo. References

Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Model for Physical Therapists and Nurses. Gaithersburg, Md: Aspen Publishers Inc; 1998:235, 249-256.
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practical Guideline for Health-Care Professionals. Washington, DC; Paralyzed Veterans of America; 2000:1,17, 22-28.
McCourt A. The Specialty Practice of Rehabilitation Nursing: A Core Curriculum. 3rd ed. Skokie, Ill: Rehabilitation Nursing Foundation; 1993:83.

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June 2003