Pressure Ulcer Basics: Assessment Case Study

There are three tabs available within the patient’s file. Firstly, click on the ‘Patient’s notes’ tab to review the patient’s notes, then complete the Braden Scale for Predicting Pressure Sore Risk© by clicking on the ‘Adapted Braden Scale’ tab. Lastly, click on the ‘RA Table’ tab to complete the RA table. These three tabs are accessible to you at any time during the completion of this task.

Mrs. Nguyen is a non-English speaking, 87 year old lady with a fractured left hip of femur. She attended theatre eight days ago and had a dynamic hip screw inserted to reduce her fractured hip.

Her past history includes dementia, anxiety, ischaemic heart disease, AMI in 1981, nephrectomy for cancer in 2001, and she recently has had several falls. She lives with her daughter and is on a waiting list for several high-level care facilities. At home she occasionally walks with the aid of a pick-up frame and spends most of the day immobile in bed or in a chair. She is incontinent of urine and faeces and wears a continence pad day and night. Her skin is intact but in poor condition and marking is noted at pressure area care turns.

Since admission Mrs. Nguyen has been verbally unresponsive. When moved, she will groan, otherwise is non-responsive. Nursing staff are providing oral Panadol 4/24, PRN. She requires maximum assistance in all aspects of her personal care. She does not attempt to move herself in bed. She is taking only small amounts of oral nutrition when fed by her family. She has been febrile in the past 24 hours and her most recent chest X-ray shows some left lower lobe consolidation for which she has commenced 24/24 hourly intravenous therapy and intravenous antibiotics.

Clinical RA

Risk Factor	Present
Risk Factor	Yes	No	Insufficient Information
Pressure-related
Reduced mobility
Factors that could result in low levels of physical activity
Sensory impairment
Level of consciousness
Pain
Tissue Tolerance-Related
Extrinsic
Conditions that could create moisture on the skin including continence, wound leakage, perspiration
Exposure to shearing/friction forces
Intrinsic
Demographics
Nutritional status (including hydration)
Medication that may lead to decreased sensory awareness, consciousness, blood circulation, reduced inflammatory response
Oxygen delivery impairment
Skin and body temperature
Acute illness
Chronic illness such as diabetes mellitus, metastatic cancer, renal impairment
Previous history pressure damage
General skin condition
General Risk Rating

BRADEN SCALE - FOR PREDICTING PRESSURE ULCER RISK

High Risk: Total Score <12 Moderate Risk: Total Score 13-14 Low Risk: Total Score 15-18
SENSORY PERCEPTION Ability to respond meaningfully to pressure-related discomfort.	1. COMPLETELY LIMITED Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation, OR Limited ability to feel pain over most of body surface.	2. VERY LIMITED Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR Has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body.	3. SLIGHTLY LIMITED Responds to verbal commands but cannot always communicate discomfort or need to be turned, OR Has some sensory impairment which limits ability to feel pain or discomfort to 1 or 2 extremities.	4. NO IMPAIRMENT Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
MOISTURE Degree to which skin is exposed to moisture.	1. CONSTANTLY MOIST Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.	2. OFTEN MOIST Skin is often but not always moist. Linen must be changed at least once a shift.	3. OCCASIONALLY MOIST Skin is occasionally moist, requiring an extra linen change approximately once a day.	4. RARELY MOIST Skin is usually dry: linen only requires changing at routine intervals.
ACTIVITY Degree of physical activity.	1. BEDFAST Confined to bed.	2. CHAIRFAST Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.	3. WALKS OCCASIONALLY Walks occasionally during day but for very short distances with or without assistance. Spends majority of shift in bed or chair.	4. WALKS FREQUENTLY Walks outside room at least twice a day and inside room every 2 hours during waking hours.
MOBILITY Ability to change and control body position.	1. COMPLETELY IMMOBILE Does not make even slight changes in body or extremity position without assistance.	2. VERY LIMITED Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.	3. SLIGHTLY LIMITED Makes frequent though slight changes in body or extremity position independently.	4. NO LIMITATIONS Makes major and frequent changes in position without assistance.
NUTRITION Usual food intake pattern. NPO: Nothing by mouth IV: Intravenously TPN: Total Parenteral Nutrition	1. VERY POOR Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR Is NPO and/or maintained on clear liquids or IV for more than 5 days.	2. PROBABLY INADEQUATE Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement, OR Receives less than the optimum amount of liquid diet or tube feeding.	3. ADEQUATE Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered, OR Is on a tube feeding or TPN regimen, which probably meets most nutritional needs.	4. EXCELLENT Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat or dairy products. Occasionally eats between meals. Does not require supplementation.
FRICTION AND SHEAR	1. PROBLEM Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down the bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.	2. POTENTIAL PROBLEM Moves freely or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.	3. NO APPARENT PROBLEM Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.


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Assessment Case Study - Conduct a Clinical RA