A cHEcK LIST FOR PREVENTING PRESSURE ULCERs‘f-jj; '_ "
IN COMMUNITY DWELLING ELDERS

-

Scholarly Project for the Degree of M S N
‘ " SUSAN J ZEMKE '
‘ 1997

 

 

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A check list for preventing pressure ulcers in community dwelling elders

Scholarly Project
for the degree M. S. N.
Michigan State University
Susan J. Zemke

1997

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Table of Contents

Acknowledgments ..................................... 3
Introduction ......................................... 4
The problem ......................................... 8
Purpose and goals of the project .......................... 8
Literature review

Anatomy of the skin ............................... 9

Etiology of pressure ulcers .......................... 11

Staging of pressure ulcers .......................... 12

Risk factors associated with pressure ulcers .............. 14

Prevention of pressure ulcers ........................ 15

Reliability and validity of the Braden Scale .............. 17
Conceptual framework ................................ 19
Revised Health Promotion Model ........................ 22
Adapted Revised Health Promotion Model .................. 26
Methodology ........................................ 28
Conceptual model for the project ......................... 29
Checklist for preventing pressure ulcers in

community dwelling elders .......................... 30
Evaluation ......................................... 35
Implications of Advance Nursing Practice ................... 35
References ......................................... 38
Appendix A Braden Scale for Predicting

Pressure Sore Risk ............................... 41

Appendix B Letter of Permission to use the
Braden Scale ................................... 42

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Acknowledgments

I wish to thank the members of my Scholarly Project Committee,
Dr. Sharon King, Catherine Lein, and Brigid Warren for their support
and guidance through the development of this project. A special thanks
to Dr. Sharon King for her patience when I was changing themes and
working at less than a snail’s pace. It has been a long term goal of mine
to pursue a Master of Science in Nursing and to receive it from
Michigan State University has been a dream come true.

A special thank you goes out to Mary McCartney for assisting in
my dream come true. She shared my vision that an outreach Master of
Science in Nursing could become a reality in Muskegon. Thank you to
the entire faculty at Michigan State for their commitment to outreach
education. I would also like to thank my employer, Hackley Hospital
for their generous financial support for higher education.

My family must not be forgotten. Thank you to my husband for
his support and encouragement to reach my goal. Thank you to my two

children for their patience while mom pursued her goal.

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Introduction

The Agency for Health Care Policy and Research (AHCPR)
defines a pressure ulcer as "any lesion caused by unrelieved pressure
resulting in damage of underlying tissue" (AHCPR, 1994). The absolute
prevalence (a cross-sectional count of the number of cases at specific
point in time) and incidence (the number of new cases occurring during
a specified time) in the United States is unlmown. The terms tend to be
misunderstood and used interchangeably, making it difficult to
determine the prevalence and incidence of pressure ulcers.

Despite the confusion in terms, many researchers have attempted
to study the prevalence and/or incidence of pressure ulcers in the
United States. The prevalence of pressure ulcers among hospitalized
patients and nursing home type patients has been the most widely
studied.

The prevalence of pressure ulcers among hospitalized patients was
studied nationally by Support Systems International (881) in response to
the National Pressure Ulcer Advisory Panel’s (NPUAP) challenge in
1989. The first National Pressure Ulcer Prevalence Study was

conducted at 148 acute care facilities. Patients were jointly examined by

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nurses from the facility and 881 on the same day. The prevalence rate
for pressure ulcers within these acute care facilities was 9.2%. The
majority of the patients (58%) were in the 70-89 age group. The three
most common sites for pressure ulcers were the sacrum, heel and
ischium (Meehan, 1990).

881 repeated this National Pressure Ulcer Prevalence Study in
1993. Patients at 177 acute care facilities were examined by nurses from
the facility and $81 on a given day. This time the national prevalence
was found to be 11.1%. Again the majority of patients (54%) were in
the 7089 age group. The three most common sites were sacrum, heel
and malleolus ($81, 1993).

The prevalence of pressure ulcers among 159 residents in a long-
term care facility was found to be 23% (Langemo, Olson, Hunter, Burd,
Hansen & Cathcart-Silberg, 1989). The most common sites were the
sacrum followed by the elbow, heels, and ankles. Bergstrom, Braden,
Kemp, Champagne, and Ruby (1996), found the incidence of pressure
ulcers among 225 skilled care nursing residents in two facilities to be

23.9%.

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The prevalence of pressure ulcers among home care patients is not
as easy to identify. The studies done to date have only reported on
patients being cared for by nurses in the home. No data are available
on patients being cared for by their physician, family or lay home care
giver. Langemo, et a]. (1989), found the prevalence of pressure ulcers
in home health to be 19% and 13% in Hospice patients. The sample
populations were small, 26 patients and 8 patients, respectively.
Langemo, et al., (1991), found zero incidents of pressure ulcers in home
care and Hospice patients over a 3—week period of time. Again, the
population was small, 30 patients and 20 patients respectively. The
NPUAP (1980), has estimated the prevalence in the home setting to be
7% to 12%.

Pressure ulcers increase the cost of health care. The NPUAP
( 1989), estimates the cost of treatment in the acute care setting to be
$2,000-S30,000 per patient. The costs in home care are not very well
understood.

The non-financial costs of pressure ulcers must be also be

considered as stated by V. Alterescu (1989):

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The nurse who is emotionally drained because the pressure ulcer
patient requires frequent, difficult dressing changes contnhutes to
the non-financial cost of pressure ulcers. Other patients in the
facility pay the penalty of receiving less nursing care, or waiting
longer for certain services, when a person with a pressure ulcer
requires treatment. Most importantly, irrespective of the financial
costs to treat pressure ulcers, they are a source of anxiety and pain
for the patient, the family, and the staff.
The word "care giver" can be substituted for "nurse", and "home"
can be substituted for "facility" in the above statement. Caring for a
family member in the home with pressure ulcers is likely to cause the
same feelings of frustration to the care giver whether it be a nurse or a
family care giver. The family care giver may find more of their time
taken away from other family members and self as the care of pressure
ulcers demands more time.
Contrary to what most nurses have been told, not all pressure
ulcers are preventable, but a large number of them are. Teaching
patients and families prevention may help them avoid the burdens

associated with caring for pressure ulcers.

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Problem

The lay public is unaware of the causes of or ways to prevent
pressure ulcers in caring for an at risk family member.
Purpose] goals of the project

The purpose of this project is to design a check list that can be
used by the primary care provider to identify the preventive measures
needed to assist the patient and care giver in the prevention of pressure
ulcers. Two goals have been identified for this project: (1) pressure
ulcer free elder and (2) satisfied care giver.

Berlowitz & Wilking (1989), found that patients who developed
pressure sores were likely to be elderly, diabetic, and have a history of
cerebrovascular accident. Other conditions such as a contracted or
flaccid extremity, alteration in mental status, incontinence and poor
nutrition have been identified as risk factors in the development of
pressure ulcers.

The Advance Practice Nurse as a primary care provider has the
analytical skills to assess the patient’s risk for pressure ulcer and to
formulate a plan of action with the patient/care giver to prevent

pressure ulcers. The check list will be used to assist the patient, care

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giver, and nurse to identify support services needed in the home. Such
services may include: home nursing services, durable medical equipment,
and community service agencies. The Braden Scale for prevention of
Pressure Ulcers will be the tool used to identify the patient’s risk
factors.
Literature Review

Anatomy of the Skin

The skin is the largest organ in the body. It weighs six to eight
pounds and varies in thickness. Intact skin is essential for both
functional and cosmetic reasons. The skin is responsrble for the tactile
sensations of pain, temperature, touch, pressure, and pleasure. The skin
helps to maintain body temperature, fluid and electrolyte balance, and
aids in the prevention of infection. In our fashion-conscious society,
intact skin is important to our psycho social well being as well as our
physical well being.

The skin has three layers (Baron, 1983). The epidermis and the
dermis make up the true skin. The subcutaneous tissue lies just beneath

the dermis and is often considered part of the skin.

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The epidermis is made up of squamous epithelium, the same type
of cells that line the gastrointestinal, genitourinary and tracheobronchial
system. Epithelial cells have the ability to regenerate. When the skin
needs repair, these epithelial cells become mobile and spread across a
wound to make a new covering. Also in the epidermal layer are the
melonocytes that determine the color of our skin and protect us from
sunlight.

The dermis is made up of stronger collagen fibers that provide
elasticity. It contains blood vessels and nerves that nourish the
epidermis. Hair follicles, sweat glands and sebaceous glands are found
in the dermal layer. The dermal epidermal junction allows exchange of
fluids and cells between the layers. The surface is irregular, with finger-
like projections from both surfaces that help to anchor the two surfaces
together, preventing them from sliding back and forth on one another.
Subcutaneous tissue is adipose tissue and provides insulation and
cushioning for the skin. Just below the subcutaneous tissue is
connective tissue that covers muscles, tendons, bones and large blood

vessels.

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Skin changes with aging. The dermal epidermal junction begins to
flatten and decreases in thickness by one third, increasing the risk of
skin tears from separation of the skin layers (Baron, 1983). The
numbers of sebaceous and sweat glands decrease and the skin is drier.
The amount of adipose tissue on arms and legs decrease. These
changes result in thinner, drier, less elastic skin with less padding
(Fitzsimons, 1983).

Etiology of pressure ulcers

Blood supply to tissues is made up of the arterial system, the
capillary bed and the venous system. Blood flow at the arterial end of
the capillary system is about 32 mm hg and about 12 mm hg at the
venous end, making the average flow in the capillary bed about 20 mm
hg pressure (Landis, 1930). Pressure to soft tissue for long periods of
time can cause capillary vessels to thrombose and die, cutting off blood
supply and nourishment to soft tissue resulting in tissue death.

Two schools of thought exist on the cause of pressure ulcers; the
top to bottom theory and the bottom to top theory (Maklebust &
Sieggreen, 1996). The top to bottom theory is the more traditional

theory. This theory is based on the premise that pressure applied to the

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outer epidermal layer of the skin results. in pressure on lower tissues,
disrupting capillary flow and resulting in tissue death. This is clinically
apparent as non-blanchable erythema of the epidermis. Supporters of
the bottom to top theory believe that pressure from bones may cause
injury to subcutaneous tissue, resulting in disruption of capillary flow
and tissue injury. Therefore, the non-blanchable erythema of the
epidermis may be just the tip of the iceberg in assessing pressure ulcers.

Pressure ulcers can develop over any bony prominence or over any
soft tissue area that is subjected to prolonged pressure. This can
happen from pressure against the surface of the bed or chair, one body
part against another or from orthopedic support devices, foley catheters
and feeding tubes caught between the body and the bed or chair. The
most common sites for development of pressure ulcers are the scapula,
iliac crest, trochanter, sacrum, ischium, lateral malleolus, heel and the
edge of the foot (Maklebust & Sieggreen, 1996).
Staging of pressure ulcers

A staging system was developed to assist health care professionals
in assessment of pressure ulcers. Adopting a standardized system also

aids in communication about pressure ulcers among health care

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professionals. AHCPR (1994), adopted the staging system from the
NPUAP consensus Development Conference (NPUAP, 1989). The
stages are as follows:
Stage I: Nonblanchable erythema of intact skin, the heralding
lesion of skin ulceration. In individuals with darker skin,
discoloration of the skin, warmth, edema, induration, or hardness
may also be indicators.
Stage [1: Partial thickness skin loss involving epidermis, dermis, or
both. The ulcer is superficial and presents clinically as an
abrasion, blister, or shallow crater.
Stage 111: Full thickness skin involving damage to or necrosis of
subcutaneous tissue that may extend down to, but not through,
underlying fascia. The ulcer presents clinically as a deep crater
with or without undermining of adjacent tissue.
Stage IV: Full thickness skin loss with extensive destruction, tissue
necrosis, or damage to muscle, bone, or supporting structures (e.g.,
tendon, joint capsule). Undermining and sinus tracts also may be

associated with Stage IV pressure ulcers.

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There are a few limitations in the acceptance of this staging
system:

1. It is difficult to assess darker pigmented skin that is intact.

2. Wounds with eschar cannot be staged until they are debrided.

3. Skin that is not seen cannot be assessed, i.e., skin under casts
or other orthopedic devices.

4. This staging system is based on the top to bottom theory of
pressure ulcer development. If the bottom to top theory is also
accurate, there may be more extensive tissue damage under what
appears to be a Stage I ulcer.

Risk factors associated with pressure ulcers

There are several risk factors associated with the incidence of
pressure ulcers. Immobility, friction and shear are mechanical causes of
pressure ulcers.

Immobility is probably the highest risk factor in the development
of pressure ulcers. Patients that are bed or chair bound cannot move in
response to the sensation of pressure. Shear is defined as "mechanical
force that is parallel rather than perpendicular to an area" (Maklebust

& Sieggreen, 1996, p. 24). Tissues attached to bones are pulled in one

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direction while the skin tissues stick to the surface of the bed or chair.
Friction is caused by two surfaces moving across each other. This
occurs when patients are pulled across bed and chair surfaces. Persons
with spastic movements can have pressure ulcers resulting from friction.

Moisture, alteration in level of consciousness, nutrition, and aging
skin are contributing factors to the development of pressure ulcers.
Moisture softens connective tissue and makes tissues adhere to bed
linens. The most common moisture source is incontinence, but
diaphoresis and wound drainage must also be considered. Nutrition is
important in healthy skin. Healthy skin is less likely to breakdown.
Aging skin is drier, thinner, less elastic and has less adipose tissue for
padding.
Prevention of pressure ulcers

The underlying motivation for behaviors differs for health
promotion and health protection/prevention. "Health promotion is
motivated by the desire to increase well-being and actualize human
health potential" (Pender, p. 7). Health protection or illness prevention

as described by Pender is motivated by the "desire to actively avoid

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illness, detect it early, or maintain functioning within the constraints of
illness" (Pender, p. 7).

Much has been written about the prevention of pressure ulcers.
Prevalence and incidence have been well studied in the inpatient setting,
but few studies have been done in the outpatient setting. The Agency
for Health Care Policy and Research (1992), reviewed the literature
extensively and published guidelines for preventing pressure ulcers.
Their recommendations targeted assessment of risk factors and
education as key factors in the prevention of pressure ulcers. The check
list is designed to assist in meeting these goals.

Assessment I

Several risk assessment scales have been developed. The three
scales most often cited in the literature are the Gosnell Scale, the
Norton Scale and the Braden Scale (Gosnell, 1989). Activity, mobility,
and sensory perception are factors in determining intense or prolonged
pressure. Nutrition, friction, moisture and shear are factors in
determining tissue tolerance for pressure (Bergstrom, et al., (1987). A
comparison of these scales reveals that all three score activity, mobility,

continence, and the ability to relate to the environment (sensory

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perception). The Braden and Gosnell scales have indicators for
nutrition, the Norton Scale does not. The Braden Scale has indicators
for friction, shear and moisture unrelated to continence (Braden &
Bergstrom, 1989). The Braden Scale for predicting pressure sore risk
will be incorporated for use in the check list.

The Braden Scale for Predicting Pressure Sore Risk (Appendix A)
is comprised of six subscales; sensory perception, moisture, activity,
mobility, nutrition, and friction and shear. Each subscale is scored
numerically from 1 to 4 with the exception of friction and shear being
rated 1 to 3. The higher the score, the higher the level of functioning.
The maximum possrhle score is 23 (Bergstrom et al., 1987).

Reliability and Validity of the Braden Scale for Predicting Pressure
Sore Risk

Bergstrom et al., (1987), conducted three studies of interrater
reliability in different settings and geographic areas on the Braden Scale.
Groups studied were institutionalized elderly, rehabilitation, and skilled
nursing facility patients. Pearson product moment correlation between
observers ranged from r = .83 to r = .94 for nurses’ aides and licensed

practical nurses to r = .99 when used by registered nurses.

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Bergstrom et al., (1987), conducted two studies of validity on two
groups of 28 hospitalized medical surgical patients. At a cut-off score of
16, the Braden scale was 100% sensitive in both studies. Specificity was
64% and 90%. Ramundo (1995), found the mean score of 48 patients
confined to bed or wheelchair who developed a pressure sore to be 17
and the mean score of those who did not develop an ulcer to be 18.
Ramundo (1995), found the Braden Scale to be 100% sensitive and 34%
specific at a score of 18. Langemo et al., (1991), studied patients in
acute care, rehabilitation, skilled nursing facilities, home care and
Hospice. The mean Braden Scale score among 30 homes care patients
was 20, and 19.3 among 20 Hospice patients. Despite the fact that no
patients in either setting developed pressure ulcers, the recommended
cut-off scores were 20 and 18 respectively. Oot-Giromini (1993), found
the Braden Scale to be 53% sensitive and 90% specific at a cut-off score
of 16 among 103 home care patients. At a score of 18, the Braden
Scale was 70% sensitive. Specificity was not reported at a score of 18.

The relatively high sensitivity scores make the Braden Scale a
useful screening tool in identifying patients at risk for the development

of pressure ulcers. The individual care giver’s skills and availability may

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be a factor in the home care patient developing a pressure ulcer. The
check list can be used to assist in identifying the care giver’s individual
and community resources available to assist in the prevention of
pressure sores in the community dwelling individual that is at risk.
Conceptual Framework

The purpose of this project is development of a check list for
prevention of pressure ulcers in patients residing in the community.
Prevention is described in mental health and community nursing
literature as occurring at three levels: primary, secondary and tertiary.
Community health educators Shamansky & Clausen (1982), described
primary prevention as those actions directed at a generally healthy
population, before any pathology is involved. They descrrhe secondary
prevention as occurring when pathology is involved and state that
"secondary prevention emphasizes early diagnosis and prompt
intervention to halt the pathological process, thereby shortening its
duration and severity and enabling the individual to regain normal
function at the earliest possrhle point" (p. 106). Screening procedures of

any type are part of secondary prevention. Tertiary prevention occurs

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when a defect or disability is fixed, stabilized, or irreversible and
rehabilitation is the goal (Shamansky & Clausen, 1982).

The check list proposed in this project is a screening tool that fits
into secondary prevention, but could cross over into tertiary prevention.
Most patients for whom the tool will be used will have chronic illness.
Pathology puts the patient at risk for pressure ulcer. The tool will be
used to identify the risk(s) and assist the patient and family to modify
these risks. The prevention of pressure ulcers in persons with chronic
health problems fit appropriately into a health promotion/disease
prevention model.

The Health Promotion Model (HPM) developed by Pender first
appeared in 1987 as a competence or approach-oriented model. Fear or
threats are not used to motivate the individual toward healthy behaviors.
The HPM is based on action rather than reaction to the environment.
Variables of the HPM were researched by several researchers including
Pender, resulting in the Revised Health Promotion Model (RHPM).

The theoretical basis of the RHPM is Feather’s Expectancy-Value
theory and Bandura’s Social Cognitive theory (Pender, 1986).

Expectancy - Value theory is based on the premise that behavior is

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rational and economical. Individuals persist in behaviors that they have
the resources for, and that are likely to produce outcomes that are
beneficial to the individual (Feather, 1982). Social Cognitive theory
places emphasis on self direction, self regulation and perceptions of self-
efficacy (Bandura, 1986).,

Self-efficacy is a central construct in the RHPM. "Perceived self-
efficacy is a judgment of one’s ability to carry out a particular course of
action" (Pender, 1996, p. 54). The RHPM has been selected as the
conceptual model for this project because the check list proposed in this
project requires that the individual patient and family assess their ability
to carry out specific tasks necessary for the prevention of pressure
ulcers.

The RHPM is shown schematically in Figure 1. The RHPM has
three major concepts: (1) individual characteristics and experiences (2)
behavior-specific cognitions and effect (3) behavioral outcome. Each
concept has variables that either directly or indirectly affect the concept
or the outcome. The variables and their effects on the outcome are

described below.

Individual
Characteristics
and Experiences

 

Prior
related
behavior

 

 

 

 

Personal factors;
biological
psychological
sociocultural

 

 

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Behavior-Specific Behavior
Cognitions Outcome
and Affect
Perceived
benefits
of action . .
Immediate competing
———-' _ demands
. (low control)
Pm . and preferences
' l
to action (high contro )
_ Perceived self-
efficacy
Activity-related .
——~ .5... — 1
Commitment Health
__ to a promoting
plan of action behavior
Interpersonal
(family. peers. providers);
norms, support, models _.
Situational influences;
options
‘——“ demand characteristics —
aesthetics

 

 

 

 

 

 

Figure 1. Revised Health Promotion Model

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Individual characteristics and experiences

Prior related behavior has both direct and indirect effects on the
likelihood of practicing health promoting/disease preventing behaviors.
Prior behavior affects behavior-specific cognitions and affect. The direct
effect is in habit-forming past behavior that occurs automatically. Past
behavior has indirect effects through the perception of self-efficacy
(Pender, 1996). Personal factors are categorized as biologic, psychologic
and sociocultural. These factors have been proposed to directly
influence behavior-specific cognitions and affect health-promoting
behavior (Pender, 1996).
Behavior-Specific Cognitions and Affect

Perceived benefits of action are the individuals’s beliefs that
practicing health promoting behaviors will result in a positive outcome
(Pender, 1996). Perceived barriers to action are either imagined or real
perceptions that affect the individual’s ability to carry out the behavior
(Pender, 1996). Perceived self-efficacy motivates health promoting
behavior directly through personal expectations and indirectly by
affecting perceived barriers to action (Pender, 1996). Perceived self-

efficacy emphasizes the individual’s belief that he/she can accomplish the

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task (Pender, 1996). Activity related aflect is the emotional response
associated with the behavior; positive, negative, or a mixture of both
(Pender, 1996).

Interpersonal influences come from family, peers, and health care
providers. These interpersonal influences are described as norms or
expectations of others (Pender, 1996). Situational influences include the
individual’s perceptions of options available, demands of the behavior,
and the surrounding environment in which the change is to take place
(Pender, 1996).

Behavioral Outcome

Commitment to a plan of action implies that the individual has
made a commitment to carry out a specific action, and has identified
strategies for carrying out the behavior and for reinforcing the behavior
(Pender, 1996). Immediate competing demands and preferences are
alternative courses of action that come to mind before the behavior
change is to take place and alter the plan of action (Pender, 1996).
Health-promoting behavior is the outcome. It is directed at achieving

positive outcomes (Pender, 1996).

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Adaptation of the Revised Health Promotion Model

The adaptation of the RHPM is shown in Figure 2. The major
concepts of individual characteristics and experiences, behavior-specific
cognitions and affect, and behavioral outcome have been maintained.
The variables within each concept have been adapted to the patient/care
giver with pressure ulcer risk. Risk of pressure ulcer is determined by
assessment using the Braden Scale for pressure ulcer risk.
Individual characteristics and experiences

Prior related behavior has been changed to prior history of
pressure ulcers. Previous experience with the process of healing a
pressure ulcer may affect the patient/care giver’s compliance with a
prescription for prevention. Personal factors have been modified to
include the patient’s: (1) biologic factors of height, weight, age, mobility,
and underlying medical problems, (2) psychological factors include the
patient/care giver’s perception of competence, and (3) sociocultural
variables of race, education, and socioeconomic status. Biologic factors
are predictors of pressure ulcer risk. Although many personal factors
cannot be changed, they can directly influence behavior-specific

cognitions and affect health-promoting behaviors.

pressure 26

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Behavior-Specific Behavioral ,
Characteristics Cognitions Outcome
and Afl’ect
Optimism/feeling
positive
A . . . Hospitalization
I Optimism/feeling . . .
I negative care giver illness
Prior
”fee,” . , Self-confidence l ,
Patient/care giver v
Age, gender, race, feelings of ’ .
_, .............. .3... are.
socioeconomic plan of action behavior
status. education ,
Family/care giver/ A A
on behavior
Risk factors for pressure
ulcer, mobility, mentation,
'——' shear, friction, morsture' —
inconunence'

 

 

 

 

 

 

Figure 2. Adapted Revised Health Promotion Model

pressure 27

Behavior-specific cognitions and affect _

Perceived benefits of action has been adapted to the patient/care
giver beliefs that optimism will result in positive outcomes. Pessimism is
a barrier to positive outcomes. Perceived self-efficacy is the patient/care
giver belief that health-promoting behaviors can be instituted and
maintained. Activity related affect is the satisfaction that comes with
practicing health promoting behaviors. Interpersonal influences are
those that come from family members, peers and health care
professionals involved in the plan of care. Situational influences are
those factors that predispose the patient to pressure ulcers such as:
immobility, mentation, friction, shear, continence, nutrition, and
moisture. The variables in this category are the most amenable to
change with assistance from the nurse. The nurse can assess and
intervene to set mutual goals with the patient/care giver to affect a
positive behavioral outcome.

Behavior outcome

This concept has not been adapted. Commitment to a plan of

action is the patient/care giver strategies for carrying the plan of action

and for reinforcing the behavior. The desired health-promoting

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behaviors are those actions resulting in the prevention of pressure
ulcers.
Discussion

Use of the RHPM is appropriate to guide development of a check
list (shown schematically in Figure 3) for assessing skin integrity and
preventing pressure ulcers. The check list will require that the
patient/care giver assess their ability to modify risk factors to affect a
positive behavioral outcome. Assessment of risk factors will be done by
the nurse using the Braden Scale for assessing pressure ulcer risk to
identify those patients at risk for pressure ulcers.
Methodoloy

The check list (pages 30-33) for preventing pressure ulcers in
community-dwelling elders is designed to be used by the primary care
provider along with the patient and care giver. Other health care
professionals may be involved as needed as pressure sore prevention is
often a team approach. Patients scoring 18 or less on the Braden Scale
for Predicting Pressure Sore Risk should have the check list completed
in order to design a plan of care for the patient and care giver. A score

of 18 is based on the research of Oot-Giromini and Ramundo.

pressure 29

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prior Risk factors
pressure ulcer (Braden Scale)
Health
promoting
behavior
Prior
pressure ulcer

 

 

 

Figure 3. Conceptual model for the check list for prevention
of pressure ulcers in community dwelling elders

NP‘MPVNZ‘

339°

10.

11.

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Check List for Preventing Pressure Ulcers in Community Dwelling Elders

 

 

 

 

 

 

 

 

 

 

Name
Male Female
Age
Diagnosis
Primary care giver
Braden Scale Score If score is 18 or less proceed with check list
Prior pressure ulcer Yes No Location(s)
Place a Check (V) on the figure in Question 11 near the anatomic location(s).
Can patient be left alone in the home during errands? Yes __ No
Is respite care available? Yes___ bywhom?
No __ Plan for respite care

Services in the home at the time of assessment. Check (V) all that apply

None

Nursing agency __ times per week

Occupational therapy _ times per week

Physical therapy __ times per week

Speech therapy __ times per week

Meals on wheels _ times per week

Other

 

Durable medical equipment in use at the time of assessment. Check (V) all that
apply. ”Need" column will be assessed at the completion of the check list.
Current Need Current Need

U D wheelchair D D removable arms
D D removable legs
E] D leg lifts

cane

bedside commode

walker

Hoyer lift

mattress overlay / specialty bed

chair pad

tube feeding pump

DDEJCIEIDL—JE]
DDDDDDDD

other

 

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12. Daily skin assessment by: Check (V) appropriate

[:1 care giver - report any redneSs that persists after repositioning or injury
to skin to your health care professional within 24 hours
I] health care professional

13. Identify area(s) that patient is at risk for developing pressure ulcer(s) by placing a
Check (V) next to the anatomical location. Consider area(s) of prior pressure ulcer(s)
alteration in mobility, sensory impairment and activity. Review areas of risk with the
patient / care giver.

 

 

US. Department of Health and Human Services (1992). Pressure ulcers in adults:
Preventing pressure ulcers (AHCPR Publication No. 92-0048). Rockville, Md: Author.

14. Activity / mobility Check (V) appropriate

D partial immobility - write prescription for prevention and place on plan
B immobile - write prescription for prevention and place on plan
I] chair bound - write prescription for prevention and place on plan

Yes No

D D independent transfer

D D care giver assist transfer

D D other transfer

independent with repositioning

CID

repositions self when instructed to - write prescription on plan

15.

16.

17.

18.

pressure 32

Nutrition Check (V) appropriate
[I requires assistance with meals
D tube feeding

independent with feeding

Moisture Check (V) appropriate
wound - write prescription on plan
incontinence - write prescription on plan

diaphoresis - write prescription on plan

CIDEJD

no problem

Friction and shear Check (V) appropriate

D bed / chair bound - write prescription on plan
B no problem

Return to number 11 and reassess need for durable medical equipment

pressure 33

Care giver

  
    

  

   

Health Care Family / Social

    

Need Ability / Professional Support System
. Responsibility Responsrbility Responsibility

  

 

 

     

Turning prescription

 

 

Activity prescription

 

 

Feeding prescription

 

 

 

Skin assessment
l prescription

 

 

 

Q Bathing prescription

 

 

g Moisture/toileting/
; incontinence
. prescription

 

 

g Friction/shear
, prescription

 

 

 

Respite prescription

 

 

 

 

 

I understand the above plan

 

Care Giver Provider

pressure 34

Oot-Giromini (1993), found the Braden Scale for Predicting Pressure
Sore Risk to be 70% sensitive at a score of 18. Ramundo (1995), found
the. Braden Scale to be 100% sensitive when the cut-off score was 18.

The variables of prior pressure ulcer and risk factors from the
Braden Scale for Predicting Pressure Sore Risk have been incorporated
into the check list. The first three questions relate to demographic
information. The variables of prior ulcer, designated primary care giver
and diagnosis are identified in questions 4-7. Questions 8 & 9 pertain
to care giver satisfaction. Current support services and durable medical
equipment are identified in questions 10 & 11. Questions 12-18 are
related to variables from the Braden Scale for Predicting Pressure Sore
Risk. Sensory perception has been incorporated into the activity/
mobility question.

Upon completion of the check list the primary care provider is
asked to re-examine the durable medical equipment for changes or
additional needs. The provider is also asked to discuss prevention with
the patient/care giver and write a mutually acceptable prescription for
prevention related to each variable. The prescriptions are written on a

plan that designates responsibility for each prescription. Completion of

pressure 35

the check list and plan of action is designed to meet the goals of a
pressure-free elder and a satisfied care giver.

A copy of AHCPR Publication No. 92-0048 Preventing Pressure
Ulcers: Patient Guide can be given to the patient/care giver as an
educational tool to assist the care giver in carrying out the prescriptions.
Evaluation

The check list for preventing pressure ulcers in community-
dwelling elders can be evaluated on the basis of the proposed behavioral
outcomes (1) pressure sore free elder and (2) satisfied care giver.
Evaluation methods may include a comparison of pressure sore
incidence between groups of elders using the check list and elders not
using the check list. A survey of care givers could be done to determine
care giver feelings of competence in carrying out the prescriptions
related to prevention of pressure ulcers.

Implications for Advanced Nursing Practice

Further research is indicated in the prevalence and incidence of
pressure sores in patients cared for in the home. More research needs
to be done on the Braden Scale cut-off score for homebound patients.

Costly preventive prescriptions for durable medical equipment may not

pressure 36

be required, but at this time empirical evidence does not exist to refute
or substantiate the point at which equipment is required to prevent
pressure ulcers. Such research is within the role of the Advanced
Practice Nurse (APN).

The APN as an educator can have an impact on prevention of
pressure ulcers. Educational programs taught at different levels for
different groups of patients and care givers need to be designed. It is
within the role responsrhility of the APN to provide education to care
givers of the elderly and provide tools such as the prevention check list
to ensure that appropriate preventive behavior occurs. It is vital that
basic'nursing education contain content relevant to skin assessment and
current principles of wound healing. Continuing education is needed for
the APN working with elders and their care givers related to current
principles of wound healing.

The APN acts as the collaborator among the patient, care giver,
health care providers and social support systems when completing the
check list and outlining the plan of care. Coordination of the services

these participants provide is the responsibility of the APN.

pressure 37

The APN as a health care provider must make skin assessment
and prediction of potential patients at risk for pressure ulcers part of
daily practice. Assessment of care giver ability and their understanding
of physical needs of the elder is the role of the APN.

This check list can also be used to advocate for the client.
Prevention of pressure ulcers and a satisfied care giver are the outcomes
for this project. Completion of the check list can provide the

information needed to advocate for home care or extended care.

pressure 38

References
Alterescu, V. (1989). The financial costs of inpatient pressure
ulcers to an acute care facility. Decubitus 2(3), 14-23.
Baron, M.C. (1983). The skin and wound healing. fIfopics m’
Clinical Nursing, 5(2), 11-21.

Bandura A. (1986). Social foundations of thought and action: A

social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall, Inc.

Bergstrom, N., Braden, B., Kemp, M., Champagne, M., & Ruby, E.
(1996). Multi-site study of incidence of pressure ulcers and the
relationship between risk level, demographic characteristics, diagnoses,
and prescription of preventive interventions. Joumal of flerican
Geriatrics Society, 44(1), 22-30.

Bergstrom, N., Braden, B., Laguzza, A., & Holman, V., (1987).
The braden scale for predicting pressure sore risk. Nursing Research,
36(4), 205-120.

Braden, BJ. & Bergstrom, N. (1989). Clinical utility of the braden
scale for predicting pressure sore risk. Decubitus, 2(3), 44-51.

Berlowitz, D.R. & Wilking, S.V. (1989). Risk factors for pressure

sores. Journal of the American Geriatric Socieg, 37(11), 1043-1049.

pressure 39

Feather, N.T. (Ed.). (1982). E_xpectations and actions: E_xpectang-
value models in psychology. Hillsdale, NJ: Lawrence Erlbaum

Associates Inc.

Fitzsimons, V.M. (1983). The aging integument: A sensitive and
complex system. Topics in Clinical Nursing, 5(2), 32-38.

Gosnell, DJ. (1989). Pressure sore risk assessment: A critique
part I: The gosnell scale. Decubitus, 2(3), 32-38.

Landis, E. (1930). Studies of capillary blood pressure in human
skin. Hear_t, 15, 209-215.

Langemo, D.K., Olson, B., Hunter, S., Burd, C., Hansen, D., &
Cathcart-Silberg, T. (1989). Incidence of pressure Sores in Acute Care,
Rehabilitation, Extended Care, Home Health, and Hospice in one
Locale. Decubitus, 2(2), 42.

Langemo, D.K., Olson, 3., Hunter, S., Hanson, D., Burd, C. &
Cathcart-Silberg, T. (1991). Incidence and prediction of pressure ulcers
in five patient care settings. Decubitus, 4(3), 25-33.

Maklebust, J ., & Sieggreen, M. (1996). Pressure ulcers: Guidelines

for prevention and pursing management (2nd ed.). Springhouse, PA:
Springhouse Corp.

pressure 40

Meehan, J., (1990). Multisite pressure ulcer prevalence survey.
WM), 14-17.

Ramundo, J .M., (1995). Reliability and validity of the braden
scale in the home setting. Journal of Wound Ostomy Conp'pence
Nursing, 22(3), 128-134.

Shamansky, S.L. & Clausen, CL. (1980). Levels of prevention:
Examination of the concept. Nursing Outlook, 28(2), 104-108.

Pender, NJ. (1996). Health promotion in nursing practice (3rd
ed.). Stamford, CT: Appleton & Lange.

The National Pressure Ulcer Advisor Panel. (1989). Pressure
ulcers prevalence, cost and risk assessment: Consensus development
conference Statement. Decubitus, 2(2), 24-28.

U.S. Department of Health and Human Services. (1992). M
ulcers in adults: Prediction and prevention (AHCPR Publication No.
92-0047). Rockville, MD: Author.

U.S. Department of Health and Human Services. (1994).
Treatment of pressure ulcers (AHCPR Publication No. 95-0652).

Rockville, MD: Author.

pressure 41

 

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Office of the Dean

Date: VIM ’2 7/ /997

APPENDIX B

  

pressure,42

  

IGHT
UNIVERSITY
Graduate School

10:59.1.00/9' Z‘Z’Mé,‘ /(/‘/

From: Barbara Braden, Ph.D., R.N. & Nancy Bergstrom, Ph.D., R.N.

Re: Permission to use the Braden Scale

As holders of the official copyright for the Braden Scale for Predicting
Pressure Sore Risk, we hereby grant permission for the use of the Braden Scale

in *

 

 

9;; W

Barbara J. Braden, Ph.D., R.N., F.A.A.N.

Associate Professor
Creighton University
School of Nursing
Omaha, NE 68178

71.

/ V

Nancy ergstrom, Ph.D., R.N.

Professor '

University of Nebraska
Medical Center

College of Nursing

Omaha, NE 68105

 

 

*We request that the name of the instrument and the indication that the copyright
belongs to Braden and Bergstrom remain on any copies and that you do not make any
substantial changes to the wording or the order, etc., of this tool.

2500 California Plaza

Omaha, Nebraska 68178 (402) 280-2870

 

31293 02331 0133