Skin and Wound Care Assessment

Documenting Skin and Wound Status

• Nurses should document the status of a patient's skin and wounds on the standard agency form.
• Monitoring changes in skin and wound status over time is crucial.

Risk Assessment Tools for Pressure Injury Development

• Several risk assessment tools assist nurses in identifying patients at high risk for pressure injuries.
• These tools should consider factors such as mental status, moisture exposure, incontinence, device-related pressure, friction, and shear, immobility, inactivity, and nutritional deficits.
• The EPUAP, NPIAP, and PPPIA recommend using tools that encompass these factors (2019).

Braden Scale for Predicting Pressure Sore Risk

• The Braden Scale is widely used in the United States for assessing pressure injury risk.
• It was developed by Bergstrom and colleagues in 1987.
• The scale includes six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
• The maximum score is 23 points.
• Adults scoring below 18 points are considered at risk for pressure injury development.
• Nurses require proper training in utilizing the Braden Scale for accurate assessment.

Norton Scale

• Developed in the United Kingdom in 1962
•  Includes categories: general physical condition, mental state, activity, mobility, and incontinence
• In 1987, a medication category was added
• Maximum score: 24
• A score of 15 or 16 indicates risk but doesn't predict it
• Should be used upon patient admission to a healthcare facility and when their condition changes

Pressure Injury Risk Assessment

• Braden and Norton scales are common examples
• Performed routinely, typically weekly, in long-term care facilities
• Improves awareness of risk factors
• Facilitates goal-setting and intervention planning to protect skin integrity

Pressure Injury Risk Assessment Tools: Braden vs. Others

• Professional organizations recommend utilizing risk assessment tools
• Research suggests no statistically significant difference between using the Braden scale and other risk assessment tools in terms of pressure injury incidence

Pressure Area Assessment

• Inspect pressure areas for signs of discoloration, abrasion, and excoriation.
• A healthy pressure area will have brisk capillary refill or blanch response when gently palpated.
• The skin over the pressure area should be intact.
• Nonblanching erythema can indicate a pressure injury.
• Abrasions can occur in areas where the skin rubs on linens or bedding.
• Excoriations can occur in areas exposed to body secretions or excretions and in skinfolds.
• Older patients, even if in good overall health, may have mobility limitations, so it is important to not discount early signs of pressure injuries in this population.

Skin Temperature Assessment

• Palpate the surface temperature of the skin over the pressure area.
• Ideally, the temperature of pressure areas should be the same as the surrounding skin.
• An increased temperature indicates inflammation or trapping of blood in the pressure area.
• A decreased temperature indicates a lack of blood flow.
• Older patients may have trouble regulating body temperature due to decreased subcutaneous tissue, which can lead to cool skin on the extremities. However, cool skin alone does not necessarily indicate a problem – always compare the temperature to the surrounding skin.

Inspection of Bony Prominences

• Palpate the skin over bony prominences.
• Healthy tissue should be firm but not hard and have the same consistency as the surrounding area.
• Spongy or boggy tissue or skin is indicative of edema.
• Patients with spinal cord injuries who rely on wheelchairs are prone to pressure injuries over the bony prominences of the pelvic bones regardless of age.

This quiz focuses on the essential aspects of documenting skin and wound status, as well as risk assessment tools for pressure injury development. It also covers the widely used Braden Scale for predicting pressure sore risk. Understanding these topics is vital for effective patient care in nursing.