How do you know if your resident is at risk of pressure injury?

Statistics show that immobility is a primary factor in the development of pressure injuries. Being able to identify the warning signs early is a critical skill for any caregiver. Here is how you know if your resident is at risk of pressure injury, enabling proactive prevention and improved resident outcomes.

Quick Summary

A resident's risk of pressure injury is determined by evaluating several factors, including immobility, nutritional status, skin moisture, and sensory perception. Use validated tools like the Braden Scale alongside regular, diligent skin inspections to catch early warning signs such as non-blanchable redness, temperature changes, and compromised skin integrity.

Key Points

• Immobility is a Major Factor: Limited ability to move independently is a primary risk for pressure injuries, necessitating regular repositioning.

• Use a Standardized Tool: The Braden Scale is a widely used assessment tool that evaluates six key risk areas to provide a numerical risk score.

• Perform Daily Skin Inspections: Look for early signs like non-blanchable redness, purple/maroon discoloration, and changes in skin temperature or firmness, especially over bony areas.

• Prioritize Nutrition and Hydration: Adequate protein, calories, and fluid intake are essential for maintaining healthy skin and preventing tissue breakdown.

• Check Medical Devices: Be aware that medical devices such as oxygen tubing or catheters can create pressure points and increase risk.

• Tailor Interventions to Risk: A comprehensive care plan should address specific risk factors identified through the assessment, not just the overall score.

Understanding the Core Risk Factors

Understanding why a resident is vulnerable to pressure injuries is the first step in effective prevention. The underlying cause is prolonged, unrelieved pressure, but several factors exacerbate this risk, making certain individuals more susceptible.

Immobility

Limited mobility is one of the most significant risk factors. Residents who are confined to a bed or chair for long periods are unable to make the small, frequent position changes that naturally relieve pressure. This can be due to various conditions, including neurological impairments, recovery from surgery, or general weakness.

Lack of Sensory Perception

Nerves normally signal discomfort when pressure builds up, prompting a person to shift position. Conditions like diabetes, spinal cord injuries, or cognitive impairment (such as dementia) can decrease or eliminate this sensation. Without this crucial warning signal, a resident may not feel the need to move, leading to tissue damage.

Moisture and Incontinence

Excessive moisture on the skin, often from incontinence or perspiration, increases the risk of skin breakdown. Moist skin is more fragile and susceptible to friction and shear, accelerating the potential for injury. Proper incontinence management and diligent skin hygiene are essential for prevention.

Poor Nutrition and Hydration

Healthy skin requires proper nourishment. A resident with poor nutritional intake, particularly low protein, calories, vitamins, and minerals, is at higher risk for tissue breakdown and impaired wound healing. Dehydration can also negatively impact skin elasticity and overall health. A registered dietitian can help tailor nutritional plans for at-risk residents.

Medical Conditions Affecting Blood Flow

Underlying health issues that affect circulation, such as diabetes and vascular disease, can increase pressure injury risk. Impaired blood flow limits the oxygen and nutrients supplied to tissues, making them more vulnerable to damage from pressure. Additionally, older adults, particularly those over 70, are at a higher risk.

Leveraging Clinical Tools for Accurate Assessment

To formalize the assessment of risk, caregivers should use a structured, evidence-based tool in conjunction with their clinical judgment. These tools provide a standardized method for evaluating key risk factors.

The Braden Scale: A Comprehensive Tool

The Braden Scale is one of the most widely used and validated tools for predicting pressure injury risk. It assesses six key areas, with a lower total score indicating a higher risk. The scale should be completed upon a resident's admission and repeated regularly based on acuity.

The Six Braden Scale Subscales:

• Sensory Perception: Ability to respond meaningfully to pressure-related discomfort.
• Moisture: Degree to which skin is exposed to moisture.
• Activity: Degree of physical activity.
• Mobility: Ability to change and control body position.
• Nutrition: Usual food intake pattern.
• Friction and Shear: The amount of rubbing and sliding force on the skin.

The Crucial Role of Detailed Skin Assessment

In addition to using a risk assessment tool, a thorough and regular skin inspection is non-negotiable. Early signs of pressure injury can be subtle and require careful observation.

What to Look For During Inspection

• Non-Blanchable Redness: In lighter skin tones, look for a persistent red area over a bony prominence that does not turn white when gentle pressure is applied. This is a sign of underlying tissue damage.
• Discoloration in Darker Skin Tones: Redness may not be visible. Instead, look for persistent areas of purple, maroon, or darker pigmentation compared to the surrounding skin. Moistening the skin can help identify color changes more clearly.
• Temperature Changes: Palpate the skin for localized areas that feel warmer or cooler than the surrounding skin.
• Tissue Consistency: Feel for changes in tissue firmness. A firm, hard, or boggy area could indicate deep tissue injury.
• Pain or Tenderness: Always ask the resident if they feel any discomfort, pain, burning, or itching in a specific area, especially over bony areas.
• Existing Injuries: Note any prior history of pressure injuries, as a healed or existing pressure injury increases the risk of new ones.

Comparing Risk Assessment Tools

Feature	Braden Scale	Norton Scale
Subscales	Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction & Shear	Physical Condition, Mental Condition, Activity, Mobility, Incontinence
Scoring Range	6 to 23 (Lower score = higher risk)	5 to 20 (Lower score = higher risk)
Strengths	Comprehensive, widely-researched, includes specific friction/shear component	Broad initial screening, simple to use, focuses on five key risk factors
Key Differences	Integrates friction and shear, a critical component of pressure injury etiology.	Uses broader categories and is one of the earliest tools developed for risk prediction.

Creating a Proactive Prevention Plan

Once the risk has been identified, a targeted plan of care is crucial. Prevention is a multi-faceted approach that requires a consistent effort from all caregivers.

1. Scheduled Repositioning: Following a regular turning and repositioning schedule is the most effective intervention. Aim for at least every two hours for bedbound residents and every hour for those in a wheelchair. Ensure heels are elevated off the bed with pillows or specialized devices.
2. Use Appropriate Support Surfaces: Utilize pressure-redistributing mattresses, overlays, and chair cushions to reduce and redistribute pressure, particularly for high-risk residents.
3. Optimize Nutrition and Hydration: Monitor fluid and food intake and consult a dietitian if malnutrition is a concern. Ensure sufficient protein, vitamins, and calories to support skin integrity.
4. Maintain Skin Integrity: Keep skin clean and dry, especially after incontinence episodes. Use pH-balanced cleansers and apply moisturizing creams and skin protectants as needed. Avoid aggressive scrubbing.
5. Educate Staff and Family: All care team members and family should be trained on the importance of pressure injury prevention, proper assessment techniques, and early warning signs.
6. Regularly Check Medical Devices: Inspect the skin under and around medical equipment for any signs of irritation or pressure, as these can be a source of injury.

Conclusion: Prioritizing Proactive Care

Identifying if a resident is at risk for pressure injury is a fundamental aspect of senior care that demands a proactive, systematic approach. Combining the use of validated assessment tools, such as the Braden Scale, with consistent, attentive skin inspections is key. By understanding the core risk factors—immobility, compromised sensation, moisture, and poor nutrition—caregivers can implement targeted preventative strategies. A comprehensive care plan that includes repositioning, appropriate support surfaces, proper skin care, and nutritional support can significantly reduce the risk and ensure the resident's skin health and overall well-being. Regular education for all care staff and collaboration with residents and families further strengthens prevention efforts. For more information on causes and symptoms, visit the Mayo Clinic website.

Frequently Asked Questions

What are the first signs that a resident might be at risk of pressure injury?

Early signs often involve subtle changes in the skin over bony prominences. Look for areas of persistent redness that do not blanch (whiten) when pressed, or patches of maroon or purple discoloration. The area might also feel warmer, cooler, firmer, or softer than the surrounding tissue.

How frequently should a resident be assessed for pressure injury risk?

Risk assessment should be performed upon a resident's admission and repeated at regular intervals. The frequency depends on their acuity level, but it is generally recommended at least weekly in long-term care settings and with any significant change in their condition.

Does a higher Braden scale score mean higher pressure injury risk?

No, the opposite is true. On the Braden scale, a lower total score indicates a higher risk for developing pressure injuries. Scores range from 6 to 23, with scores of 18 or lower typically indicating some level of risk.

What should be done for a resident with high pressure injury risk?

For a high-risk resident, a personalized care plan should be implemented. This includes a strict repositioning schedule, using specialized pressure-redistributing support surfaces, ensuring proper nutrition and hydration, and maintaining diligent skin care.

How can caregivers check for pressure injuries on residents with dark skin tones?

In residents with darker skin tones, visual redness may not be apparent. Caregivers should rely on other indicators, such as localized changes in skin temperature (warmer or cooler), tissue consistency (firm or boggy), and reports of pain or discomfort in a specific area.

Are older residents automatically at high risk for pressure injuries?

While advanced age is a risk factor, it doesn't automatically mean a resident is at high risk. Factors like mobility, nutrition, and comorbidities play significant roles. A comprehensive assessment is always necessary to determine individual risk.

Can medical devices cause pressure injuries?

Yes, device-related pressure injuries are a concern. Caregivers should regularly inspect skin under or near medical equipment like oxygen tubing, catheters, and splints, as prolonged pressure from these devices can cause tissue damage.

What is 'shear' and why is it a risk factor for pressure injuries?

Shear occurs when two surfaces move in opposite directions, such as when a resident slides down in bed while their skin remains in place. This distorts and damages underlying tissue and blood vessels, increasing the risk of injury.