The Braden Scale and Critical Thinking

Pressure Injury Prevention
by David Wheeler

Transcript

1. The Braden Scale and Critical Thinking Pressure Injury Prevention By David Wheeler Before you begin click here to take the Pre-Survey
2. How Do You Prevent Pressure Injury (PI)? qComplete the Braden Scale? qRely on personal nursing experience? qTrust that charting in the electronic health record (EHR) is enough? qUtilize critical thinking with the Braden?
3. Background Pressure injuries are a serious concern for the hospital and the patient.
4. From the Patient’s Perspective “Research shows that pressure ulcers and their treatment negatively affect every dimension of a patient’s life: emotional, mental, physical, and social. Patients in one study reported experiencing “endless pain,” and those in another said that nursing staff didn’t acknowledge or treat their discomfort and pain (although they received many pressure ulcer–related interventions). Even usual nursing care, such as turning, has been found to be painful for patients with pressure ulcers.” Stotts, N. A., & Gunningberg, L. (2007). How to try this: predicting pressure ulcer risk. Using the Braden scale with hospitalized older adults: the evidence supports it. The American Journal of Nursing, 107(11), 40–48; quiz 48–49.
5. Facts on Pressure Injury Ø Affects 14% to 25% of patients Ø 1.2% of health care expenditures in the U.S. Ø Cost to heal a single pressure ulcer: $3,500 to $60,000 Ø More than 17,000 lawsuits filed annually, $250,000 per judgement Baumgarten M, et al. Pressure ulcers among elderly patients early in the hospital stay. J Gerontol A Biol Sci Med Sci 2006;61(7):749-54
6. Hospitalizations Related to Pressure Ulcers among Adults 18 Years and Older, 2006 C. Allison Russo, M.P.H., Claudia Steiner, M.D., M.P.H., and William Spector, Ph.D.
7. Hospitalizations Related to Pressure Ulcers among Adults 18 Years and Older, 2006 C. Allison Russo, M.P.H., Claudia Steiner, M.D., M.P.H., and William Spector, Ph.D.
8. Objectives The Braden Scale and Critical Thinking ü Scoring and Interpreting the Braden Scale ü Subscales are Important Determinants for PI ü Risk Factors not Captured by the Braden ü Medical Device Related PI
9. Rethinking Assessment o Do you think it is just a task? o Have you lost the critical thinking piece while charting in the EHR? o How often do you find yourself “copying forward” the last assessment? o Have you modified the care plan produced by the EHR? A global perspective on clinical and policy standards in pressure ulcer reduction September 10, 2012 Elizabeth A. Ayello
10. Defining a Pressure Injury § Localized damage to the skin or soft tissue usually occurring over over a bony prominence § May be related to a medical device § Intact skin or an open ulcer and may be painful § Occurs as a result of intense or prolonged pressure § Other factors include: microclimate or moisture, nutrition, perfusion, co-morbidities affecting the soft tissue EPUAP, NPUAP, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. 2014
11. Some Myths About PI Patients should be repositioned no more than every 2 hours while in bed. Turning schedules should be individualized depending on the patient’s needs. ü Turning every 2 hours in bed ü Repositioning every hour in chair ü OR more frequently as needed Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice Guideline, No.15. AHCPR Publication No. 95-0652. Rockville MD: Agency for Health Care Policy and Research; December1994
12. Some Myths About PI A reddened area is not a pressure ulcer. Reddened area may be an indication of a Stage I pressure ulcer ü Intact skin ü Non-blanchable redness usually on bony prominences ü Blanchable red areas are NOT Stage I PI, but are a sign the patient is at high risk! National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention Points. Washington DC: NPUAP; 2007
13. Some Myths About PI Patients who can shift their own weight and reposition themselves don’t need to know about pressure ulcer prevention. ü Education all patients including those who can shift their own weight and reposition themselves ü Educate families and caregivers on repositioning and include them in the care plan ü Encourage patients to change positions frequently and monitor repositioning Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice Guideline, No.15. AHCPR Publication No. 95-0652. Rockville MD: Agency for Health Care Policy and Research; December1994
14. The Braden Scale u Developed in the 1980s by nurses Barbara Braden and Nancy Bergstrom, who developed the critical determinants of Pressure Ulcer Development u What is the intensity and duration of pressure? u What is the Ability of the skin and supporting tissues to tolerate the pressure?
15. Is the Braden Scale Accurate? u Highly effective in predicting risk factors u Reliability: 0.83 to 0.99 u Sensitivity or patients at risk u 83% u Specificity or patients not at risk u 64%
16. Braden Scale Risk Factors 1. Sensory and Perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and Shear
17. Scoring the Braden Risk factors are scored 1-4, with friction/shear scored 1-3. Total scores will range from 6 to 23, and a score of 18 or less indicates a patient is at risk. qNote: a low score in one Braden subscale places the patient at a higher risk for PI regardless of the total score!
19. If the Braden Scale is so Reliable how can a Patient with a Score of 19 Develop a PI? Ø No tool has perfect predictability Ø Patients at low risk may need interventions for a subscale that is low Ø Example: the total Braden score is 19, but the nutrition subscale is 1 Ø Include medical co-morbidities and factors not captured by the Braden Scale Ø Let tools supplement your critical thinking
20. Case Study ü Ms. P is a 78 year old female admitted to the intermediate care unit. She presented to the ED after being seen in the clinic. ü T: 101.4 ü BP 98/44 ü complaints of headache, lower back pain, nausea, along with diarrhea for the last two days and one episode of vomiting
21. Past Medical History (PMH) Kidney transplant 4 months ago, and co-morbidities including CHF with frequent hospitalizations, COPD, morbid obesity with a BMI of 41.3, chronic back pain with a diagnosis of spinal stenosis, occasional urinary incontinence due to urgency, DMII, on SSI insulin along with prandial insulin before each meal and long acting at bedtime.
22. PMH Her blood sugars have been between 225 to 250 over the last month. She reports having chronic anemia, and peripheral artery disease affecting her right leg with a bypass performed a year ago to improve blood flow. Other pertinent history includes paroxysmal afib, currently controlled and on Coumadin. She is currently on 5 mg of prednisone and blood pressure and immunosuppressive medications.
23. Admission Her primary care team, kidney transplant, asks for the patient to be evaluated in the ED for her low Bp and a WBC count of 22, and then admitted to the intermediate care unit, diagnosis of possible sepsis.
24. Admitted to the Unit Ms. P arrives on the unit and is settled in her room. A skin check with two nurses finds that she has red heels that are blanching, the skin on her sacrum is red but blanching, the backs of the elbows, ears, and sacrum are intact. Mrs. P reports that she has not felt well for the last 2 weeks, has resorted to using a walker at home and has not ventured out of the house except for clinic appointments.
25. Assessment She spends most days at home between bed and couch. She walks from the wheel chair to the bed, but states she was too weak to walk earlier and the staff transported her to the ED in a wheelchair. She reports her eating is unaffected for the most part. Her typical diet is toast in the morning, she is not hungry for lunch, and eats about half of her dinner. Ms. P is found to be alert and oriented to time, person, and place and reports back pain of an “8”
26. Ms. P’s Braden Assessment Sensory and Perception This subscale measures the “ability to respond meaningfully to pressure-related discomfort” by assessing the patient’s perception of pain and level of consciousness. Ms. P is alert and oriented, she scores her back pain an 8, and reports her right lower right leg has been feeling “strange”, a little numb, and reports she doesn’t feel the discomfort in that leg the same as she does in her left leg.
28. Ms. P’s Score Sensory and Perception A patient who is alert and oriented and can feel pain should score a 4, but because Ms. P reports a lessened ability to feel discomfort in her right leg, the nurse scores this subscale a 3. ü She has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
29. Ms. P’s Score Moisture Rate the degree to which the skin appears to be moist. Mrs. P appears exhausted after the events of the morning and during the initial skin inspection the nurse notes she is diaphoretic. She is wearing a brief which Is dry. She reports wearing one daily for incontinence. Because she is diaphoretic and may require a change of sheets at least once a day the nurse rates her a 3. ü Skin is occasionally moist, requiring an extra linen change approximately one a day.
31. Ms. P’s Braden Assessment Activity Ms. P is walking but It may be difficult to choose between chairfast and walks occasionally. ü Chairfast: Ability to walk severely limited or non- existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. ü Walks Occasionally: Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. How would you rate her ability to walk?
33. Ms. P’s Score Activity Ø Ms. P is rated a 3, Walks Occasionally Ø She was able to walk assisted from wheelchair to bed Ø Too weak to walk earlier today Ø Reports not walking much the last two weeks except from bed to couch
34. Ms. P’s Braden Assessment Mobility § The nurse asks Ms. P to roll onto her left side so that a protective Mepilex may be applied to her sacrum. § She has difficulty turning more than 20 degrees without assistance. § She reports difficulty getting out of bed in the morning. § We do not have a baseline on how well or often she is able to move in bed. § The nurse debates whether she should receive a score of 2 or 3.
36. Ms. P’s Score Mobility The nurse consider two choices: Ø Score 2: Very Limited Ø Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Ø Score 3: Slightly Limited Ø Makes frequent though slight changes in body or extremity position independently.
37. Ms. P’s Score Mobility Ø The nurse decides on a score of 2 Ø Ms. P can make slight changes independently as demonstrated by her ability to move less than 30 degrees to her side Ø She is unable to move more than that; unable to make significant changes to her body position without assistance
38. Ms. P’s Braden Assessment Nutrition ü It can be challenging to perform an accurate nutrition evaluation ü Assessment of oral intake requires knowledge of the patient’s eating patterns over several days ü Assessment should take into account NPO status and tube feedings If tube feeding is not at goal assign a 2: “less than optimum amount of liquid diet or tube feeding.”
40. Ms. P’s Score Nutrition Ø Ms. P reports to the nurse that she feels her nutrition is good and she wishes she could loose weight Ø The nurse notes previous statements regarding appetite and decides that her nutritional intake is insufficient Ø toast for breakfast Ø often skips lunch Ø typically eats half of dinner Ø She is rated a 2 for inadequate
41. Ms. P’s Braden Assessment § Friction: two surfaces in contact move in opposite directions § May result in superficial scuffing or abrasion of the skin § Shear: created when skin stays stationary while fascia and muscle move in the opposite direction § Occurs when a patient slides down in bed § May cause blood vessels to be pinched shut resulting in ischemia and tissue necrosis.
43. What Happens When a Patient is Upright in Bed
44. Ms. P’s Score Friction and Shear Ø CT scan is ordered and radiology and requests the patient be on a green lift sheet ü The nurse notices that over the last hour she has slid down in the bed twice and had to be repositioned with the overhead lift ü The nurse scores friction and shear a 1 since Ms. P is frequently sliding down in the bed
46. Ms. P’s Braden Assessment Score A total Braden score of 14 indicates that Ms. P is at moderate risk for a PI. ü Lower scores suggest higher risk and require more aggressive preventive efforts. ü Of foremost concern are the subscale scores in mobility, nutrition, and friction/shear subscales.
47. Coming Up With a Care Plan Ø Review areas of risk identified by the Braden Scale and risk factors related to PMH and identified in the physical assessment. Ø Select interventions to address low subscale scores regardless of the total score. Ø Share the plan with family members and encourage their involvement. Ø Modify the individualized plan of care produced by the EHR. All patients at risk should have heels and sacrum, the most commons sites for PI protected.
48. A Care Plan for Ms. P u The nurse places Mepilex protection to Ms. P’s heels and to her sacrum since she may be spending much of her time in bed or chair
49. Floating Heels Ø Best practice is to place a pillow vertically underneath each calf rather that one pillow horizontally
50. Care Plan for Ms. P Ø The nurse decides that Ms. P should be tuned every two hours since she was unable to turn more than 20 degrees without assistance. Ø The nurse writes a turning schedule on the White Board as a reminder Ø She asks the patient and family members present to speak up if a turn is overdue.
51. Care Plan for Ms. P Ø A nutrition consult is ordered because of Ms. P’s low score in the nutritional subscale Ø Ms. P is also had a low score in the Friction/Shear subscale and is at greater risk. Ø The head of the bed will be at 30 degrees except when Ms. P is upright for meals
52. Care Plan for Ms. P Ø Mrs. P scored low in Sensory Perception because she reports an inability to feel discomfort in her right leg Ø The nurse will elevate this leg with a pillow Ø When Ms. P is out of bed a waffle cushion is placed in the chair and she is reminded/assisted to reposition every hour
53. Care Plan for Ms. P Ø Patients with lower Braden scores, subscales scores, or an abnormal BMI may benefit from a specialty bed Ø The nurse decides to consult with the wound care nurse on whether the patient may benefit from a specialty bed
54. What are the Challenges with Nutrition Subscale? “It can be challenging to complete an accurate evaluation for the nutrition subscale. This subscale scores “usual” intake and is applicable to eating as well as to feeding methods such as IVs, total parenteral nutrition, or tube feeding. Assessment of oral intake requires knowledge of the patient’s eating patterns, so data must be gathered over several days. If a patient is nonresponsive upon admission and family or friends cannot report on intake, nutritional status can be evaluated using BMI and serum albumin level; the assessment will also take into account current plans for the patient’s nutrition (for example, if the patient has an injury that will prohibit intake or she or he is to take nothing by mouth for several days for tests or treatments). Clinical judgment is used to assign a score. The rule of thumb is to “do no harm,” so if the data are borderline, assign a lower risk score.” “Similarly, because it often takes several days for tube feeding target goals to be reached, the patient may be underfed. In this case, a score of 2 should be assigned because the patient is receiving “less than [the] optimum amount of liquid diet or tube feeding.” Stotts, N. A., & Gunningberg, L. (2007). How to try this: predicting pressure ulcer risk. Using the Braden scale with hospitalized older adults: the evidence supports it. The American Journal of Nursing, 107(11), 40–48; quiz 48–49.
55. Risk Factors Outside the Braden Ø Obesity Ø Affects mobility Ø Results in compromised tissue perfusion Ø Medical Co-morbidities Ø DM Ø Edema Ø CHF Ø Medications Ø Transplant patients on steroids which can aggravate DM and weaken skin integrity Rapp MP, Bergstrom N, Padhye NC. Contribution of skin temperature regularity to the risk of developing pressure ulcers in nursing facility residents. Adv Skin Wound Care 2009;22(11):506-13
56. Risk Factors in Critical Care Patients Assess Co-morbidities and Medications • Perfusion and oxygenation • Nutritional deficits • Higher rates of Steroids in • transplant patients • CHF • COPD – PVD • DM • Obesity • Hypotensive episodes and • hemodynamic instability • Medical Devices • Perioperative Patients
58. What Can Possibly Go Wrong? Ø A short case study describes a patient with a Braden score placing him at no risk for PI Ø Patient developed a PI within the first week Ø Could attention to subscales have prevented this?
59. Case Study Mr. D • 65 year old male who is well nourished and ambulatory and presents to the ED with c/o coughing yellow and blood tinged sputum, chills, and left-sided chest pain. • PMH: pneumonia, COPD, emphysema, use of nasal intermittent positive pressure ventilation (NIPPV) at night along with home oxygen. HTN, DMII, gastrointestinal bleeding, diverticulitis, and pancreatitis. 50 year pack h/o smoking, ceasing in 1990. Reports being independent with ADLs at home. Gadd, M. M. (2014). Braden scale cumulative score versus subscale scores: Are we missing opportunities for pressure ulcer prevention? Journal of Wound, Ostomy and Continence Nursing, 41(1), 86–89.
60. Admission • Vitals: 36.9, 139/59, HR 81, RR 18, 86% on RA and 92% on 3L NC. • A&O x4, no skin breakdown, elevated WBC, CXR with left lung infiltrate. • DX: Pneumonia, COPD exacerbation, exercise intolerance, DMII
61. Hospital Course • Mr. D stayed in the hospital for 16 days • Developed the first PI on day 7 • Developed the second PI on day 16 • He was discharged on day 16 with both PIs
62. Days 1 to 6 A. Total Braden score was 18 on 1 day, and 20 to 22 on the other 5 days a. Braden subscales were suboptimal during this same time B. On day 2 the total Braden placed the patient at NO risk, but he scored low in: a. sensory perception b. Activity c. mobility subscales.
63. Day 7: Deep Pressure Injury Ø On day 7 Mr. D’s total Braden score was 23. Ø A deep pressure injury (DPI) to the coccyx was found Ø Gadd suggests that the DPI is consistent with the lower subscale scores Ø Sensory perception Ø Activity Ø mobility Gadd, M. M. (2014). Braden scale cumulative score versus subscale scores: Are we missing opportunities for pressure Uucer prevention? Journal of Wound, Ostomy and Continence Nursing, 41(1), 86–89.
64. The Next 8 Days • During this time the total Braden score indicated NO risk. • He had a total of 5 suboptimal subscales during 4 of 5 days • He had a nutrition consult placed at admission and this subscale was not scored
65. Day 16: 2nd PI Found u Stage 3 to the coccyx u Located in a different area than the first
66. Why the 2nd PI? • Lower activity subscales due to activity intolerance associated with pneumonia, tissue hypoxia, nighttime immobility with use of NIPPV, DMII • Sensory Perception suboptimal 22% of the time • Activity suboptimal 56% of the time • Mobility suboptimal 56% of the time • Friction/Shear Suboptimal 17% or the time Gadd, M. M. (2014). Braden scale cumulative score versus subscale scores: Are we missing opportunities for pressure Uucer prevention? Journal of Wound, Ostomy and Continence Nursing, 41(1), 86–89.
68. Discussion q Failure to implement PI prevention when the patient’s cumulative score was high but individual sub scores were suboptimal? q When total scores are greater than 18 are subscales ignored? q Should interventions be based on subscales and not the total Braden score? Gadd, M. M. (2014). Braden scale cumulative score versus subscale scores: Are we missing opportunities for pressure ulcer prevention? Journal of Wound, Ostomy and Continence Nursing, 41(1), 86–89.
69. Day Two for Ms. P Ø On the 2nd day of her admission Ms. P is unable to maintain her oxygen saturation and is placed on oxygen via a nasal cannula and BIPAP at night Ø Foley catheter is placed since is had fluid overload and will receive Lasix Ø Bilateral weeping edema to lower extremities Ø Ms. P at risk for a medical device related PI
70. Devices May Cause Injury 1. Not captured by the Braden assessment 2. What are the patient’s risk factors? q Foley tubing laying under her edematous legs may impede circulation q The patient has SCDs over her lower legs q A BIPAP may compromise facial tissue
72. Recommendations • Consider all patients with a medical device to be at risk • Inspect the skin around and under medical device at least twice a day looking for signs of pressure-related injury and perform ongoing skin assessment throughout the shift • Inspect the skin more than twice a day if the patient is at risk for fluid shifts or shows signs of localized or generalized edema • Remove potential device-related sources of pressure as soon as possible
73. In Closing Thank you for participating in this education and don’t forget to utilize critical thinking skills! Click here for the Post-Survey
74. References Institute for Healthcare Improvement. Five million lives cam- paign. Prevent pressure ulcers: getting started kit. 2006. http:// www.ihi.org/IHI/Programs/Campaign/PressureUlcers.htm. Wound, Ostomy, and Continence Nurses Society. Guideline for the prevention and management of pressure ulcers. Mount Laurel, NJ; 2002. Report 000-2002. American Medical Directors Association. Pressure ulcers [Clinical Practice Guideline]. Columbia, MD; 1996. CPG2. Virani T. Risk assessment and prevention of pressure ulcers. Toronto, ON: Registered Nurses’ Association of Ontario, Nursing Best Practice Guidelines Program; 2005. http://www.guideline. gov/summary/summary.aspx?doc_id=7006&nbr=004215& string=pressure+AND+ulcers. Folkedahl BA, Frantz R. Prevention of pressure ulcers. Iowa City, IA: University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core; 2002 May. http://www.guideline.gov/summary/summary.aspx?doc_id= 3458&nbr=2684. John A. Hartford Institute for Geriatric Nursing. Assessment Tools- Try This. http://www.hartfordign.org/practice/try_this/ Lyder CH, Wang Y, Metersky M, et al. Hospital-acquired pressure ulcers: results from the National Medicare Patient Safety Monitoring System Study. J Am Geriatr Soc 2012;60(9):1603-8.
75. References National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: clinical practice guideline. Perth, Australia: Cambridge Media; 2014. Niederhauser A, VanDeusen Lukas C, Parker V, et al. Comprehensive programs for preventing pressure ulcers: a review of the literature. Adv Skin Wound Care 2012; 25(4):167-88. Rapp MP, Bergstrom N, Padhye NC. Contribution of skin temperature regularity to the risk of developing pressure ulcers in nursing facility residents. Adv Skin Wound Care 2009;22(11):506-13. Shanks HT, Kleinhelter P, Baker J. Skin failure: a retrospective review of patients with hospital- acquired pressure ulcers. World Council Enterostomal Ther J 2009;29(1):6-10. Wong VK, Stotts N, Hopf HW, et al. Changes in heel skin temperature under pressure in hip surgery patients. Adv Skin Wound Care 2011;24(12):562-70. EPUAP, NPUAP, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. 2014. NPUAP.org: “The Unavoidable Outcome: A Pressure Injury Consensus Conference” Published: J Wound Ostomy Continence Nurs. 2014;41(4):1-22 Cock, K. Anti-embolism stockings: are they used effectively and correctly? Bri Jour Nsg 2006:Vol 15 No 5