Pressure Injury Assessments: Prevention Methods
Are pressure injuries really preventable, or just part of aging? Many nursing home residents suffer from these painful wounds, but proper assessments and early action can stop them before they start. Knowing what to look for is key to protecting vulnerable patients. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Brenda Johnson, RN to talk about the best methods for assessing and preventing pressure injuries in nursing homes.
Johnson:
What we do is we look at the level of their risk, and then from there we can create an individualized care plan that is specific to their needs, specific to their risk. We use those numbers to help us formulate what interventions and what type of care we’re going to plan for the resident.
Schenk:
Hey, out there everybody. Welcome back to the Nursing Home Abuse podcast. My name is Rob. I will be your host for this particular episode. Today we are talking about. Assessing an individual’s resident’s risk for developing pressure injuries specifically, we really get into the Braden scale, how the Braden scale.
The data goes in, spits out a number, and then from the number you get interventions. But we’re not doing that alone. We have a fantastic and absolutely fantastic guest today. And that is Brenda Johnson. So she’s gonna be sharing her knowledge with us about. Assessing pressure injury risk in long-term care.
This week, as I mentioned, we have the fantastic Brenda Johnson joining us.
Brenda has 12 years of diverse nursing experience from corrections to wound care in 2022. She founded Sustainable Legal Nurse Consulting, assisting attorneys with personal injury, nursing home negligence in medical malpractice cases. Passionate about patient advocacy. She brings medical expertise to the legal field originally from South Texas.
Brenda now lives in. Oklahoma with her husband, dogs, horses, and chickens. She enjoys cooking Mexican meals, dance, fitness, and true crime shows, and we are so happy to have her on the show this week. Brenda, welcome to the show.
Johnson:
Hi. Thank you for having me. Appreciate it.
How is pressure injury prevention assessed?
Schenk:
So Brenda, I’m gonna give you a, a softball question here, and that is.
How? How do we assess an individual resident for their risk of pressure injury?
Johnson:
That’s a great question. So one of the first ways we assess a resident for pressure injury prevention is using a standardized tool like the Brayden Scale, or the Norton Scale is the first thing that comes to mind. So that’s targeted risk assessment.
So the brain and scale, for example, it’ll. Consist of six categories. So we look into the residents mobility and activity, their sensory perception, nutritional status, and friction and sheer in, in bed. So we score that the lower the the score, the higher the risk. The Norton scale is similar. The difference with that one is it will look into the resident’s cognitive ability.
So that’s a difference there because that’s also important when it comes to pressure injury prevention. So these tools are just a very good. Systematic standardized way to quickly assess their risk.
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What factors are assessed for pressure injury prevention?
Schenk:
Do do, if a nursing home uses the, the Braden Scale or the Braden assessment, do they in turn not use the Norton, or are they, do, do, do you find that they’re using both or one or the other?
Johnson:
I, in my experience, I have usually found that it’s either one or the other. So the one that I’m most experienced with is the Bray and Scale. So in reviewing records medical records, nursing home charts, I find that the more common one is the braid and scale.
Schenk:
So let’s, let’s, let’s talk from a general perspective, what are those factors?
In the Braden scale, for example, like what are, what, what, what are the, what are the, what are you looking at? Like for example, when you’re talking about cognitive capacity, like what are some of the things that you’re looking at that would then translate into interventions?
Johnson:
Oh, okay. Great. So in regards to cognitive status or cognitive ability, what we look at is the, is the resident able to.
Articulate their needs, right? So are they able, are they cognitively intact to state, I’m in pain, I’m uncomfortable, I need help moving in bed. So patients may be with, cognitive impairment due to a stroke, dementia, Alzheimer’s disease. We really wanna hone in on their abilities or inabilities so that then we can intervene and figure out, okay, so this patient can’t really verbalize or tell us their physical needs or, or needs in general, but in, in this context related to, let’s say, moving around in their chair or in their bed.
So we look at that and then we can figure out, oh, okay, well this resident has, you know, moderately impaired cognition due to dementia. So we wanna make sure that maybe we’re providing prompting regular check-ins to go in and say, Hey, you know, it’s time to reposition you in bed, or Let’s get you in your chair.
Interventions like that, that would assist the resident in, with the verbalization of their needs.
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How long does nursing home staff spend assessing for pressure injury prevention?
Schenk:
How, and so kind of kind of like a two for question here. So typically in your experience, how long does that, does the Braden assessment last? Like, like, you’re, you, you walk into the room, there’s the resident, you’re gonna do the Braden assessment.
How, how long are you in that room doing it?
Johnson:
Okay. Well that kind of depends too. So if it’s the first time, if the resident is at it’s day one on admission to the facility, right. We’re gonna do a more in the weeds comprehensive initially evaluation, right? And then. A component of that would be the brain and scale, for example.
So it can take, you know, when we’re admitting a resident to the facility, it’s gonna be a while because we’re looking at everything. So it could be maybe 20, 30 minutes, maybe a whole hour that we’re in there. But the, for the comprehensive eval, but the, the, the scale itself.
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Schenk:
Mm-hmm.
Johnson:
Can take, you know, a few minutes, you know, depending on the, the level of care that the resident, you know, is requiring or just their, their comorbidities, just whatever the patient or the resident has going on.
So, to answer your question, the scale itself as a, as a sole tool that we’re like in the room to do, it may take. Several minutes, you know, 5, 10, 15, 20 minutes.
Walk us through the typical, comprehensive, pressure injury prevention assessment.
Schenk:
Can you walk us through, just in general, like, let’s just imagine in our heads, let’s, let’s, let’s, let’s play, pretend what, what are you, what are you doing during that time?
Like what, what are the, like, if you’re gonna do the Brad and scale just kind of walk us through that process.
Johnson:
Sure. Yeah. So I’m in there and, you know, I have my little brain scale or my computer there with the resident. So the first thing I’m gonna look at is their sensory perception. So asking the resident you know, are you able to feel pain, discomfort?
Are you able to do, you know, have feelings? Do you have a history of maybe some nerve impairment? Muscle impairment, anything that’s going to affect. Their, their senses, the ability to feel discomfort and pain. So I’ll, I’ll look at that. I’ll also compare what they’re telling me with maybe their medical conditions, so like diabetes, peripheral neuropathy, any spinal cord injuries.
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Do they need assistive devices like. A walker, a wheelchair, a a lift sheet, a mechanical lift. So there’s so much involved activity. What’s their ambulatory status? Are they able to walk? How often do they walk? So that movement is really assessing. We’re comparing. What the patient can do while in bed and while out of bed, because the longer they’re in bed, the longer they’re in a chair.
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The risk goes up for pressure injuries. Then I look at bowel and bladder or mo or moisture. Are they continent? Are they incontinent? If they’re incontinent, okay, then we need to figure out keeping the skin clean and dry. Barrier creams brief toileting a toileting. Schedules. So to really minimize that risk or the time that the patient is going to be either wet or soiled, we don’t want that because that impairs their skin integrity and increases their risk of, of developing wounds in the, in the peri area.
Then I go into nutritional status. So their weight do they have any other conditions that are affecting their nutrition? So recent infections, recent surgeries. Diabetes is, is always a big one. You know, are they, are they coming in already, you know, malnourished or they’re lacking protein? Look at that.
What is their appetite like? What diet are they on? And then again, friction and shear. So figuring out how we’re going to help them with that constant rubbing against surfaces, whether they’re in bed or in a chair. And then the shearing forces that can cause skin tears. As you know, we slide the sheets and they’re moving around in bed.
That friction and that shearing can really damage the skin.
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Schenk:
So you, you, you’ve, you’ve gone head to toe with the resident, you’ve gone through these categories and you’ve input all this data. Mm-hmm. At the end of the day, what happens? Like, what’s the, what is the, is you, is there a number that’s assigned?
Johnson:
Yes. Yes. It’s a scale, so, you know, they each, each of these categories, so mobility, activity, the sensory, the moisture, nutrition, and friction and shear, we assign like one to four points according to what they answer. And then we tally the total score and the scale gives us a low risk, a mild, moderate, and then high risk.
So the lower they score on the scale, the higher the risk. They have for the, the development of pressure injuries.
Schenk:
All right, so you’ve input all the data. Boop, boop, boop, boop, boop. We get a number. Lower the number, the higher the risk, the higher the number, the lower the risk. We’ll, we’ll talk to, you know, Ms.
Braden about why that’s the case. But how do we get Brenda from a number to what actually should be done for this specific resident?
Johnson:
I love that question because. The, the number, you know, it, it, it is a number, right? So as the, the providers or the, the nurses there that are doing the assessment, we, we want to look at the number, but we also don’t wanna put all of our value or all of our trust in just the number, right?
So, because we are the ones that are looking, physically, looking at the resident head to toe, comparing all of our data with how they scored, but. Typically what we do is we look at the level of their risk, and then from there we can create a, an individualized care plan that is specific to their needs, specific to their risks.
So we, we use those numbers to help us formulate what interventions and what type of care we’re going to plan for the resident.
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When does a pressure injury prevention asssessment take place?
Schenk:
So now we’ve got, we’ve have the number, we have their level of, of risk. We have interventions that we’ve decided based on the level of risk. How often is that happening? Like, is this something that’s, that’s twice a shift, once a shift, once a week?
How, how often are you doing this process typically? Mm-hmm.
Johnson:
Typically. So it’s an ongoing process. I mean, we are, the, the, our nurse assistants, the LPNs, or LVNs and the RNs, we are constantly, should be constantly assessing as part of our daily care throughout our shifts. So what that includes is. We go in anytime we’re toileting, anytime we’re doing brief changes.
Peri care, incontinent care, dressing, and grooming. Ot. If, if they’re getting therapy and the occupational therapist is in there and they help them with dressing, bathing, and grooming, they’re also part of the team that can help assess skin. And so it should be a constant, ongoing daily evaluation of their skin integrity.
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And monitoring for any skin impairment, any changes to the skin. Now, backtracking from that, you know, we always do the initial assessment, what they are at baseline. So did they come to the facility with. Clean, drying, intact skin. Yes. Right. And then two weeks later they have a skin tear. So we, we note that and we go back to the drawing board and try to figure out, you know, how did this happen?
Why did this happen? What do we need to do now to prevent that from getting worse? So we have our initial assessment, our daily ongoing monitoring and evaluation. And then a lot of facilities will have. Weekly skin checks in place that nursing will document and chart on, and sometimes for our very high risk patients or, or patients that already have wounds, it may require daily, on a daily basis because it, for the resident that already has a wound and they’re getting daily dressing changes, then it’s a daily thing that we are looking into.
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Who typically performs pressure injury prevention assessments?
Schenk:
Something that, that I would, I would love to get your opinion on is and, and, and again for, we we’re talking about the Braden scale, and you have these categories, and then you have the characteristics for each of these categories that spit out an individual number. How much discretion do you have?
Like how much discretion do you as a professional have? Or is it just literally, like, if it’s, if, if x then y if, if one, then two, like, or is it, are you using more of your brain power? Like I get that’s a dumb question, like mm-hmm. I feel like how much are, do you feel like you’re acting as a nurse versus just like data goes in and it spits out an inter a a, an integer, right?
Johnson:
Yes. I love that question because what this reminds me of is, you know, in nursing school we, one of the things we’re taught of, we’re taught is utilizing our nursing judgment. Right. We wanna have good judgment. So these are just tools. These are, these are tools that were created by, you know, very intelligent people, experienced people that create these, these scales and these tools for us to utilize.
So it is very helpful for us to get, be like a, a sounding board or a, a good jumping ground towards helping us really figure out the patient specific needs. So, personally, just in my experience, you know, when, when I use a bra and scale and they score we were talking about this earlier, a low risk, right?
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Low risk on the scale, but then I look at the patient or the resident, excuse me. Then, you know, I wanna utilize my judgment and, and all nurses wanna utilize their, their nursing judgment and their experience to say, well. You know, Ms. Doe is scoring low as far as pressure injury, but she has these risks. So we wanna be able to balance both out and not just say, oh, well they’re low risk, we’re not gonna plan any interventions.
You know, we, we wouldn’t wanna do something like that.
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How often do pressure injury prevention assessments take place?
Schenk:
Alright. So again, taking us, taking us to the scene, you’ve done the assessment you’ve crunched the number. And there’s interventions based on the number. What are some of those interventions and are there any interventions that, that seem to occur more often than other ones?
Johnson:
Thank you for asking that. Because I feel like sometimes you know, people that aren’t in a, in the know, right? They we, we do plan. We do plan, and, and that’s the whole point of the care plan. So some of the interventions that, again moisture you, for example, and for incontinence care, we’re gonna plan, routine toileting, toileting checks, barrier cream brief, frequent, brief changes of their incontinent. Anything that’s gonna keep the skin clean and dry. We’re gonna plan those things to help that. Right. Mobility. If they’re bedbound, this is a big one. If they’re bedbound or if they have weakness on one side of the body or other because of a stroke, then it is crucial that we plan a turning and repositioning program that is consistent, routine, systematic, nicely laid out.
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You know, in my perfect world care planning, you know, in the, in the care plan. So all care team members are aware. So that we can redistribute that pressure and offload that pressure from the more high prone areas like the sacrum, the elbows, the, the heels, hips, even. The back of the knee sometimes. So a turning and repositioning program is another big intervention that should be in place for our really high risk patients.
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Low air loss mattress, heel protectors, elbow protectors those are all examples of interventions. One, one of my that I feel my experience that when I’m reviewing records for nursing home cases is the. The nutritional interventions. I, in my experience so far, I feel sometimes is lacking. Nutrition is huge.
Hydration. So are they on the multivitamin? You know, if, if it’s, if it’s, if it’s safe for the patient, right? So, you know, with, with medications, what medications are they on that are going to impair wound healing, like maybe some blood thinners or and maybe some antibiotics or something like that.
So we wanna counteract that with really good quality nutrition and maybe supplements, protein multivitamin, vitamin C, zinc, anything to really amp up that wound healing and stack things in the, in the residents favor so that we can help them prevent it completely or. Give, improve the healing process.
You know, they do develop a wound. So nutrition is a big one that that I like to see as far as interventions.
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Schenk:
It used to be in Will of Fortune when you were on the final puzzle, like it was just you and Pat Saje and they would say, Hey, what letters do you want? And you, you started from scratch. Okay. So like you, you know, but after I guess 30 years, they realized that everybody was picking RSTL and n an E.
Right? So then they started just giving those to you. Right? So then you, you picked an additional think three or four letters over the, I mean, that’s how it works now. I think. I feel like that’s how it works now. It’s like it’s person centered, but if the individual’s a high risk, it’s almost always gonna be the case that there should be an offloading program.
It’s, that’s your, that’s your R-S-T-L-N-E on the Will of Fortune. That’s a really roundabout, very robust analogy, but I think it’s fitting there. But anyway sorry, I digress again. Well, Brenda, that was fantastic. I really, really appreciate you coming on the show and sharing your knowledge with us today.
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Johnson:
Oh, I really appreciate you inviting me and asking me to be on this. I enjoyed it. I had fun. It was a nice conversation and I just really appreciate it.
Schenk:
Awesome. Well, folks, I hope that you found this episode educational. I know that I did. If you have an idea for a topic that you would like for me to cover, please let me know.
If you have an idea for a guest that you would like for me to talk to, please let me know that as well. New episodes of the Nursing Abuse Podcast come out every single Monday, hopefully, knock on wood. With that folks. We will see you next time.
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