The prevalence of pressure injuries among certain high-risk patient populations has made pressure injury risk assessment a standard of care. When utilized on a regular basis, standardized assessment tools, along with consistent documentation, increase accuracy of pressure injury risk assessment, subsequently improving patient outcomes. Conversely, inconsistent and non-standardized assessment and poor documentation can contribute to negative patient outcomes, denial of reimbursement, and possibly wound-related litigation.

Pressure Injury Risk Factors and Assessment

Patients with immobility represent the overwhelming majority of individuals at risk for pressure injuries. Moisture-associated skin damage, medical devices, and incontinence increase propensity for development of pressure injuries and infections—increasing risk of irritation, sepsis, or death.^1,2 Certain medications and medical conditions can increase a patient's risk of developing a pressure injury, and patients with limited sensory perception often are unable to recognize the early stages of injury. Peripheral vascular disease, diabetic neuropathy, recent surgery, and advanced age are several factors that can increase the risk of pressure injuries.²

Series: Understanding the Braden Scale

Clinicians who are apprised of these risk factors are better equipped to evaluate patients. However, even among graduating medical students, studies have shown large discrepancies in the levels of competency in wound care.³

Standards in Pressure Injury Risk Assessment

Currently, there are more than 40 pressure injury risk assessment tools in use, but the Braden Scale for Predicting Pressure Sore Risk© (Braden Scale) is the assessment tool most commonly used in the United States. The Braden Scale assesses risk based on six factors: physical activity (1–4), mobility (1–4), moisture (1–4), nutrition (1–4), sensory perception (1–4), and exposure to friction and shear (1–3); 1 indicates the greatest risk in each category, with 3 or 4 indicating no risk or limitation. A patient with a score of 15–18 is considered "mild risk," 13–14 is "moderate risk," 10–12 is "high risk," and 9 or below is "severe risk". A basic skin assessment should include skin integrity (particularly in areas subject to increased pressure), color changes, variations in temperature, firmness, moisture, and patient-reported pain or discomfort.⁴ The National Pressure Ulcer Advisory Panel clearly states that initial assessment should be conducted as soon as possible—within eight hours of admission, and should be repeated as part of an ongoing risk assessment process. The condition of the patient's skin should also be recorded on discharge or transfer to another care setting.¹

Issues in Pressure Injury Risk Assessment Documentation

Inconsistencies in Braden Scale assessments are common because such assessments are led by clinical judgment and are thus open to an individual's interpretation of the items in the scoring system.⁵ They can also be the result of inadequate training or of assessments conducted by the night shift, who are at a disadvantage for assessing the sensory perception, mobility, or nutrition of a sleeping patient. Additionally, nurses tend to rely on their experience and knowledge when assessing patients, rather than using the standard risk assessment tools available. Although this clinical judgment may be as effective as using the Braden Scale or other risk assessment tools in determining appropriate care,⁶ the lack of documentation associated with this approach leaves no paper trail, thereby increasing vulnerability to litigation.

Conclusion

To avoid inconsistencies in the documentation of pressure injury risk, clinicians should be competent in pressure injury risk assessment. Poor communication and poor documentation are two of the key factors observed in cases that result in litigation,⁷ much of which results from the lack of a universal documentation system. Electronic patient record systems may allow for more complete, accurate, and current patient information, but they are not a substitute for training, risk assessment protocols, and strong staff communication. Using the Braden Scale to quickly assess newly admitted patients is the first step in establishing continuity of care and preventing pressure injuries. Clinicians must perform repeat risk assessments based on the individual patient's condition and circumstances. Experienced staff should review assessments and note inconsistencies in scores from shift to shift and communicate to resolve discrepancies in risk assessments. To reduce pressure injury risks, liability for lawsuits, and denial of medical billing claims, clinicians require training and competency in pressure injury risk assessment. Health care institutions would do well to focus on consistency in pressure injury risk assessment and documentation to reduce all associated risks—legal, financial, and physical.

References

1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler, ed. Osborne Park, Australia: Cambridge Media; 2014.
2. Primiano M, Friend M, McClure C, et al. Pressure ulcer prevalence and risk factors among prolonged surgical procedures in the OR. AORN J. 2011;94(6):555-566.
3. Kielo E, Salminen L, Suhonen R, Puukka P, Stolt M. Graduating student nurses' and student podiatrists' wound care competence: a cross-sectional study. J Wound Care. 2019;28(3):136-145.
4. National Institute for Clinical Excellence. Pressure Ulcers: Prevention and Management of Pressure Ulcers. Clinical guidelines CG179. London, United Kingdom: National Institute for Clinical Excellence; 2014. https://www.nice.org.uk/guidance/cg179. Accessed September 13, 2019.
5. Vowden K, Vowden P. Documentation in pressure ulcer prevention and management Wounds UK. 2015;11(3):6-9.
6. Saleh M, Anthony D, Parboteeah S. The impact of pressure ulcer risk assessment on patient outcomes among hospitalised patients. J Clin Nurs. 2009;18(13):1923-1929.
7. Lowson S.Getting the record straight: the need for accurate documentation. J Wound Care. 2004;13(10):427.