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Risk Factors of Pressure Ulcers


Patient History and Physical Examination to Identify Risk Factors

Complete a patient history and physical examination to determine general health and to identify risk factors that may affect healing of existing ulcers or that may lead to pressure ulcer formation1. A pressure ulcer is defined as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Risk can be either intrinsic or extrinsic2. An intrinsic factor is based on the composition of the individual, and include physical and psychological characteristics that cannot be altered independently.

Examples of Intrinsic Risk Factors:

  • Impaired tissue oxygenation/Cardiopulmonary dysfunction (e.g. vasopressor drugs in critically ill patients, hypotension, hypoxemia, anemia, hypoventilation, congestive heart failure)
  • Hypovolemia (E.g. infection, sepsis, hypo-albuminemia and systemic inflammatory response syndrome)
  • Body edema / anasarca
  • Peripheral vascular disease: lower extremity arterial and venous disease (includes chronic kidney disease, hepatic dysfunction, sensory impairment/altered level of consciousness, multiple sclerosis, stroke, coma, spinal cord injury, anesthesia/ operating room time)
  • Age (e.g. extremes of life cycle: prematurity and advanced age, end of life [see section 3.4], end-stage dementia)
  • Other (e.g. skin failure, multiorgan dysfunction syndrome, critically ill/Critically injured status, burns)
  • Body Habitus (e.g. increasing obese body mass index)

Extrinsic factors are external to the individual and, in many instances, can be altered to decrease the risk.

Examples of Extrinsic Risk Factors:

  • Immobility [being limited or unable to move independently] (e.g. bed rest, head of bed elevation greater than 30◦, chair sitting for prolonged times, hip fractures, supine or prone positioning)
  • Malnutrition
  • Hospital length of stay combined with immobility and multiple comorbid conditions
  • Smoking
  • Medical devices (e.g. CPAP, bidirectional positive airway pressure, oxygen tubing and masks, percutaneous endoscopic gastrostomy tubes, endotracheal tubes, nasogastric tubes, pelvic binders, pulse oximetry probes, tracheostomy faceplates and ties, sequential compression devices, external fixators and limb mobilizers)
  • Behavioural risk factors (e.g. non-adherence to prevention and the plan of care, dementia, uncontrolled body movements, chronic pain that limits positioning options and pain at end of life)
  • Unresolved moisture on skin (e.g. bladder and bowel incontinence, wound or fistula exudate, diaphoresis)
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 1.1

Documentation of Pressure Ulcer/Sore Risk

Note of caution: Not all intrinsic risks are captured by risk-assessment tools (e.g. Braden Pressure Sore Risk Assessment Tool) , and not all pressure ulcer risk factors can be removed or modified3.

Assessment and Documentation of Pressure Ulcer/Sore Risk

For all settings, a trained professional should assess and document PU risk within 72 h of admission or on change of any PU risk factor, using a valid, reliable scale with good predictive validity for the setting and for patient age and cognition4 such as one of the following5:

  1. The Braden Scale for Predicting Pressure Sore Risk (http://bradenscale.com/)
  2. The Norton Pressure Sore Risk Assessment Scale (Norton Scale for Assessing Risk of Pressure Ulcers*)
  3. interRAI Pressure Ulcer Risk Scale (long term care) (http://pda.rnao.ca/content/interrai-pressure-ulcer-risk-scale)
  4. The Waterlow Score (http://www.judy-waterlow.co.uk/waterlow_score.htm)
  5. The Gosnell Scale (http://www.scireproject.com/outcome-measures-new/gosnell-measure)
  6. The Knoll Scale (VALIDITY AND RELIABILITY OF AN ASSESSMENT TOOL FOR PRESSURE ULCER RISK. Towey, Anne P. MS, RN; Erland, Shirley M. MS, RN Decubitus. 1(2):40-50, May 1988.)
  7. SCIPUS (Spinal Cord Injury Pressure Ulcer Scale) (http://www.scireproject.com/outcome-measures-new/spinal-cord-injury-pressure-ulcer-scale-scipus-measure)

You should also assess environmental/physical/medical/psychosocial factors, patient end-of-life goals body mass index, skin, friction/shear potential, note surgical procedures, age of individual (extremes of age increase PU risk, especially for those over 62 years of age and neonates.)

RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 1.1
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 1.2
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 1.3

Avoidable and Unavoidable Pressure Ulcers

In some jurisdictions in Canada, the occurrence of pressure ulcers is seen as a critical incident. As of April 2014, Pressure Ulcer Prevention is a Required Organizational Practice (ROP) with Accreditation Canada6. It is accepted in the medical community that the greater the number of risks, the greater the challenge can be in preventing new pressure ulcer development and deterioration of existing pressure ulcers7. The following definition is from the National Pressure Ulcer Advisory Panel Consensus conference in 20118, to be applicable in all care settings:

Avoidable pressure ulcer: An avoidable pressure ulcer can develop when the provider did not do one or more of the following:

  • evaluate the individual’s clinical condition and pressure ulcer risk factors;
  • define and implement interventions consistent with individual needs, individual goals, and recognized standards of practice;
  • monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.

Unavoidable pressure ulcer: An unavoidable pressure ulcer can develop even though the provider:

  • evaluated the individual’s clinical condition and pressure ulcer risk factors;
  • defined and implemented interventions consistent with individual needs, goals, and recognized standards of practice;
  • monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.

A second international consensus panel in 20149 further identifies that pressure ulcers can be unavoidable because of the magnitude and severity of risk being overwhelmingly high, and when preventive measures are either contraindicated or inadequate, given the magnitude and severity of risk. They agreed that unavoidable pressure ulcers do occur, and developed the following Consensus Statements regarding Unavoidable Pressure Ulcers:

  • When an individual’s cardiopulmonary status is significantly altered and recovery to baseline does not occur within minutes, an unavoidable pressure ulcer can occur.
  • When an individual is repositioned and alterations in hemodynamic stability require ongoing vasopressor support, an unavoidable pressure ulcer can occur.
  • When sustained head-of-bed of greater than 30° elevation is medically necessary, an unavoidable pressure ulcer can occur.
  • Septic shock and/or systemic inflammatory response syndrome increase(s) the likelihood that an unavoidable pressure ulcer can occur.
  • Extensive body edema increases the risk of an unavoidable pressure ulcer occurring.
  • Severe burn injury increases the likelihood of developing an unavoidable pressure ulcer.
  • In hemodynamically unstable or critically ill/critically injured individuals, when management of life-threatening conditions must take precedence over skin-preservation interventions, development of an unavoidable pressure ulcer can occur.
  • Immobility can increase the likelihood of developing an unavoidable pressure ulcer.
  • When life-sustaining, vascular access, or other medical devices preclude turning and/or repositioning, the likelihood that an unavoidable pressure ulcer can occur increases.
  • An unstable pelvic fracture or spinal cord injury that precludes turning an individual increases the likelihood of an unavoidable pressure ulcer occurring.
  • Terminally ill individuals who become immobile are at increased risk for unavoidable pressure ulcers.
  • Individuals with malnutrition in combination with multiple comorbidities are at increased risk for the development of unavoidable pressure ulcers.
  • Individuals with cachexia are at increased risk for the development of unavoidable pressure ulcers.
  • A medical device–related unavoidable pressure ulcer can occur in situations where it would be medically contraindicated to adjust, relocate or pad underneath a therapeutic medical device.

Skin Changes At Life’s End (SCALE)

Kennedy’s Terminal Ulcer (KTU) is a type of pressure ulcer that some individuals develop as they are dying. These are considered skin changes at life’s end. It can be shaped like a pear, butterfly, or horseshoe, usually on the coccyx or sacrum but can occur in other areas. The ulcers can appear as red, yellow or black, occur suddenly, and usually indicate that death is imminent10. While skin deterioration at the end of life may be normal, it should not be accepted as inevitable without palliation of symptoms, provision of optimal care, and using appropriate pressure-relieving equipment11.

Common Locations for Pressure Ulcers

Common Locations for Pressure Ulcers

An illustration of common locations for pressure ulcers

RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 1.9
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 2.1
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 2.2
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 2.3
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 2.4

Pressure Reduction and Relief
  1. Edsberg et al . Unavoidable pressure injury: state of science and consensus outcomes. Wound Ostomy Continence Nurs. 2014;41(4):313-334.
  2. Lyder, 2003
  3. Lyder, 2003
  4. Association for the Advancement of Wound Care Guideline of Pressure Ulcer Guidelines. Accessed from http://aawconline.org/professional-resources/resources/
  5. Accreditation Canada Required Organizational Practices Handbook 2014. Available at: http://www.accreditation.ca/sites/default/files/rop-handbook-2014-en.pdf
  6. Required Organizational Practices Handbook 2014. Accreditation Canada, 2013. Page 66. www.accreditation.ca
  7. WOCN http://www.wocn.org
  8. Black, J. et al. Pressure Ulcers: Avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Management 2011;57(2):24–37
  9. Sibbald RG, Krasner DL, Lutz JB et al (2009) The SCALE Expert Panel: Skin Changes At Life’s End. Final Consensus Document. Available at: http://www.nursingcenter.com/prodev/ce_article.asp?tid=1005418
  10. Sibbald RG, Krasner DL, Lutz JB et al (2009) The SCALE Expert Panel: Skin Changes At Life’s End. Final Consensus Document. Available at: http://www.nursingcenter.com/prodev/ce_article.asp?tid=1005418
  11. Belden, P. Wound Essentials: Managing Skin Changes at Life’s End. Wounds UK. 2011. 6: 76-79.

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