Chapter 2: Patient Assessment

2.12 Head-to-Toe Assessment: Integument Assessment

Critical Thinking Exercises: Questions, Answers, and Sources / References

Critical thinking questions are in bold type, and the answers are italicized. Additional resources or references are provided below.

  1. Identify the six components of the Braden Scale that suggest risk of pressure injury. 
  • Activity: Degree of physical activity
  • Nutrition: Usual food intake pattern
  • Moisture: Degree to which skin is exposed to moisture
  • Mobility: Ability to change and control body position
  • Friction/Shear: The force of rubbing (friction) and the force of gravity from the patient’s weight bearing down on a surface, and the resistance created when attempting to move a patient over that surface (shear).
  • Sensory Perception: Ability to respond meaningfully to pressure-related discomfort

Source:

Chen, H., Cao, Y., Zhang, W., Wang, J., Huai, B. (2017). Braden scale (ALB) for assessing pressure ulcer risk in hospital patients: A validity and reliability study.  Applied Nursing Research, 33. pp. 169-174. https://doi.org/10.1016/j.apnr.2016.12.001

 

2. In five of those components, provide two possible preventative strategies to reduce risk of pressure injury.

 

Component Contributing to Risk of Pressure Injury

Potential Strategies
Activity
  • Consult physiotherapy.
  • Include activity in the plan of care by involving frequent, smaller exercise or activity opportunities as opposed to less frequent but longer activities.
Nutrition
  • Consult nutritionist.
  • Assess nutritional intake. High protein, high calorie foods unless contraindicated.
  • Monitor fluid intake to ensure adequate hydration.
Moisture
  • Consult ostomy, incontinence nurse, advanced practice nurse.
  • Use quality incontinent pads.
  • Use moisturizing creams to maintain skin integrity.
  • Provide care with pH balanced soap and warm water.
  • Barrier creams to prevent breakdown.
Mobility
  • Consult physiotherapy, occupational therapist.
  • Include mobility on plan of care.
  • Immobile patients should be assessed for alternative mattress surfaces that reduce risk of pressure injury.
Friction / Shear
  • Minimize force and friction by using specifically designed transfer sheets/surfaces.
  • Use mechanical lifts for shifting or repositioning. 
Sensory Perception
  • Assess reasons for altered sensory perception. Consult the primary prescriber to address modifiable risks that might be contributing to altered sensory perception (i.e., opioid use).

Sources:

Registered Nurses’ Association of Ontario (RNAO). (n.d.). Nursing best practice guidelines: Nutrition and hydration. https://bpgmobile.rnao.ca/content/minimizing-risk-entrapment

Registered Nurses’ Association of Ontario (RNAO). (n.d.). Nursing best practice guidelines: Proper positioning, transferring and turning techniques. https://bpgmobile.rnao.ca/content/timelines-when-pressure-ulcer-can-develop-specific-clinical-setting

Registered Nurses’ Association of Ontario (RNAO). (n.d.). Nursing best practice guidelines: Risk assessment and prevention of pressure ulcers. https://bpgmobile.rnao.ca/guideline-content/9

Registered Nurses’ Association of Ontario (RNAO). (n.d.). Nursing best practice guidelines: Skin integrity. https://bpgmobile.rnao.ca/content/risk-and-related-interventions

Sample Learning Activity

  1. Ask students to complete a Braden Scale assessment on a client they are caring for in practice, and document it on a Braden Scale assessment form.

Resource:

British Columbia Provincial Nursing Skin and Wound Committee. (2014)  Guideline: Braden Scale for Predicting Pressure Ulcer Risk in Adults and Children. https://www.clwk.ca/buddydrive/file/guideline-braden-risk-assessment/

  1. Ask students to begin developing a plan of care related to reducing risk of pressure injury.

The author suggest(s) not focusing on NANDA terminology because Schools of Nursing (and nurses) don’t all speak that language. Rather, the focus should be on strategies intended to address the issue and identifying how the nurse will know that the strategies are working.

 

Example:

 

Issue Contributing to Risk of Pressure Injury

Strategy

Evaluation (Is This Working?)
Poor nutritional intake
  • Consult dietician. (Done.)
  • Provide patient in hospital with high-protein, high-calorie foods. (Done.)
  • Have patient sitting-up in a chair for meal time.
  • Clear clutter to make eating space comfortable and clean.

 

 Patient is eating 50-75% of their meals.
etc. etc. etc.

 

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