Pressure Ulcer Risk Assessment
5.3 Skin and Pressure Ulcer Risk Assessment .1 Definition.1 Definition
5.3.4 Risk Assessment
An accurate clinical evaluation is crucial to identify the patients at risk for PIs’ development [26], particularly for those with previous PIs’ history, who are considered at risk irrespective of the assessment score [27]. PIs’ risk is established combining the clinical judgment with the use of a reliable scale. The use of assessment tools to predict individual patient risk factors for
PIs’ development is routinely recommended in PIs’ prevention guidelines [15]. Studies suggest the adoption of the Braden scale that has been tested and validated in various settings of care (including ICUs) [28, 29]. The Braden scale takes into account six items scored from 1 to 4 points (sensory perception, moisture, activity, mobility) and is identified as the scale with the best combined sensitivity and specificity in predicting risk of PIs in general wards.
The lowest the score, the highest is the PIs’ risk, with a risk cutoff ≤16 points [30]. Despite its wide validation, a case- control study [31] suggested a low implementation rate in ICU (only 11.26% of hospital days), also highlighting a low to moderate positive predicting performance. Interestingly, a lower-risk cutoff (≤13) balanced the highest sensitivity and specificity (0.75 and 0.47, respectively). Similar results were found a few years later [32] in a large retrospective study, indicating a poor accuracy of the Braden scale in predicting PIs, mainly related to the lack of consideration for ICU- specific risk factors such as MV, hypotension, cardiovascular instability, and ICU-LOS.
The Braden scale does not identify hemodynamic instability as a risk factor for PIs’ development. This kind of clinical condi- tion is common in the ICU. One consequence of hemodynamic instability that may contribute to PIs’ development is the impos- sibility to accomplish patient repositioning [15].
Another available tool for PIs’ assessment is the Cubbin- Jackson scale, originally introduced in 1991 [33]. The first ver- sion of this scale was composed of ten items (age, weight, skin conditions, mental conditions, mobility, hemodynamics, respi- ration, nutrition, incontinence, and hygiene) [33]. Each item was scored from 1 to 4, and highest scores were associated with lower risk. Further improvements introduced oxygen require- ments, past medical history, and detrimental factors (surgery, transport for diagnostic imaging, need for hemotransfusion, or hypothermia) [34]. The risk cutoff, previously stated at 24
points, was moved on to 29. As for other tools, the Cubbin- Jackson scale showed an unsatisfactory performance in ICU populations, reaffirming the importance to use clinical judgment together with stratification tools [35] (Fig. 5.3).
Age (years)
Weight/tissue viability Respitation
No spontaneous breathing Oxygen requirements Past medical history
Nutrition General skin condition
Incontinence Mental condition
Hygiene Mobility
Deduct points
Spontaneous
Deduct 1 point, if patient has been in surgery or transported to CT, MRI or HBOT during the last 48 hours Deduct 1 point, if patient has required blood or clotting factors during last 24 hours
Deduct 1 point, if patient has hypothermia of 35°C or under (core temperature) Revised sections (marked as bolded) of the Jackson/Cubbin risk scale14 Utilized in this program to improve the clarity and reproducibility of the scale.
The maximum score is 48 (low risk) and the minimum score 9 points signifying high risk.
BMI = body mass index: CPAP= continuous positive airway pressure: BiPAP = bilevel positive airway pressure: ABQs = arterial blood gases: CT = com- puterized tomography: MRI = magnetic resonance imaging: HBOT = hyperbaric oxygen therapy
Average weight BMI 18-25.9 kg/m2 4
<40 4 Stable without inotropes 4
Stable with inotropes
40-54 3 3
Unstable without inotropes
55-70 2 2
Unstable with inotropes
>70 1 1
4 Non-nvasive, CPAP/BiPAP
Obese 26-39.9 kg/m2 3 3
Mechanical ventilation
Cachectic <18 kg/m2 2 2
Mechanical ventilation.
Any of the above plus severe edema or >40 kg/m2 1 1
Requires <40% O2, stable on movement
None 4 4
Requires 40%-60% O2, stable on movement
Mild 3 3
Requires 40%-60% O2, stable ABGs but desaturates on movement
Severe 2 2
Requires 60% O2 or above.lnability to maintain ABGs/desaturates at rest
Very Severe 1 1
Full diet + fluids
Intact 4 4
Clear IV fluids only
Red skin affecting areas prone to pressure 3 3
Light diet, oral fluids, enteral feeding
Grazed/excoriated superficial skin areas 2 2
Parenteral feeding
Deep wounds, necrotized or heavily exudating wounds 1 1
None/anuric/catheterized (urine and/or feces catheter)
Awake and alert 4 4
Urine/profound sweating
Agitated/restless/confused 3 3
Feces/occassional diarrhea
Apathic/sedated but responsive 2 2
Urine and feces/prologed diarrhea (≥3 times/day)
Coma/unresponsive/paralyzed and sedated 1 1
Independent
Walks with help 4 4
Needs assistance
Very limited, chairbound 3 3
Needs much assistance
Immobile but tolerates change of position 2 2
Fully dependent
Unable to tolerate moverment, nursed prone 1 1
Score
point Score
point Hemodynamics
Fig. 5.3 Cubbin-Jackson pressure ulcer risk scale [35] “used with permission”
Recently, the development and implementation of the COHMON (conscious level, mobility, hemodynamics, oxygen- ation, nutrition) index opened a new opportunity in the evaluation of PIs’ risk. This tool includes five items (level of consciousness, mobility, hemodynamic, oxygenation, and nutrition) scored from 1 to 4 points (the higher is the score, the higher is the risk). When compared with traditional scoring systems, the COHMON index showed a better sensitivity and specificity, positive and negative predictive values, and very good reliability both for single items and the global index [36]. When compared with Braden, Norton, and Waterlow scales, this index also showed the highest inter- rater reliability and agreement [37].
Irrespective of the chosen PIs’ risk assessment tool, use of vasopressors (vasopressin and norepinephrine), mean arterial pressure <60 mmHg, cardiac arrest, and prolonged MV (>72 h) has been associated with PIs’ development [38], thus suggesting the need for a higher vigilance in patients with those clinical and treatment features.
Currently, there is no strong evidence regarding optimal PIs’
risk reassessment intervals. Widely accepted and published clini- cal standards suggest a weekly revaluation. However, in certain clinical situations, risk assessment scales may have limits, since they don’t consider PIs’ risk associated with the use of devices.