Preventing Pressure Ulcers in Hospitals

3.4 How should pressure ulcer care planning based on identified risk be used?

Knowing which patients are at risk for a pressure ulcer is not enough; you must do something about it. Care planning provides the guide for what you will actually do to prevent pressure ulcers. Once risk assessment has helped identify patient risk factors, it is important to match care planning to those needs. This includes planning for any risks found on the risk assessment tool, such as nutrition, activity, mobility, moisture, and friction/shear, as well as any additional risk factors.

A score that indicates a patient is not at risk does not guarantee that the patient will not develop a pressure ulcer. While the total score may help prioritize your use of resources, think beyond the score on the overall risk assessment tool and address all areas of potential risk in every patient. This means addressing at-risk scores on each subscale, as well as other risk factors not quantified on the subscales.

3.4.1 What is pressure ulcer care planning?

Pressure ulcer care planning is a process by which the patient's risk assessment information is translated into an action plan to address the identified patient needs. Its specific purpose in this case is to implement care practices so that the patient does not develop a pressure ulcer during the hospitalization. It takes into account multiple factors that pertain to the patient's problems, some of which may be obvious and others that may not. This synthesis of multiple types of patient data requires the clinician to take a holistic approach rather than just relying on one specific piece of patient information. Because each person has a unique risk profile, the care plan should be individualized for each patient.

The care plan is a written document that ensures continuity of care by all staff members. All staff members should follow the care plan. The care plan is a legal document designed to guide the treatment plan, to keep the patient safe and comfortable, and to educate the patient and family prior to discharge.

The care plan is also an active document. It needs to incorporate the patient's response to the interventions as well as any changes in his or her condition.

3.4.2 How should care planning address risk of pressure ulcer development?

The care plan should indicate specific actions that should, or should not, be performed. All care planning needs to be individualized to fit the patient's needs. Any area of risk should have a corresponding plan of care regardless of the overall risk assessment scale score. In fact, when developing the plan of care, it is important to think beyond just a risk assessment scale score to include all the patient risk factors.

To illustrate this point, consider a patient whose overall Braden Scale is 19, indicating not at-risk for pressure ulcer development. However, in examining the subscales, the nurse notes that the patient is very moist (moisture subscale of 2) and there is a potential problem with friction and shear (subscale score of 2). These two subscales need to be addressed in the care plan despite the overall score. The subscales are important indicators of risk.

In another scenario, a patient has an overall Braden Scale score of 19, but this patient has a history of a healed sacral pressure ulcer. Despite the score, this patient is at particular risk for developing a pressure ulcer on the sacrum and needs a care plan that reflects this risk factor.

Patients and their families should understand their pressure ulcer risk and how their proposed care plan is addressing this risk. Specific aspects of the care plan that patients and families can help implement should be identified. If learning needs have been identified, teaching about knowledge gaps can occur. Use of educational resources, such as appropriate-level written materials, can augment but not take the place of instruction. Patients and their significant others need to understand the consequences of not following a recommended prevention care plan as well as suggested alternatives offered and possible outcomes.

Every patient has the right to refuse the care designed in the care plan. In this case, staff are responsible for several tasks, including:

• Documenting patient's refusal.
• Trying to discover the basis for the patient's refusal.
• Presenting a rationale for why the intervention is important.
• Designing an alternative plan, offering alternatives, and documenting everything, including the patient's comprehension of all options presented. This revised strategy needs to be described in the care plan and documented in the patient's medical record.
• Update the care plan to reflect any changes in the patient's risk status. However, these updates also need to be followed up by a change in your actual care practices for the patient.

Action Steps

Assess whether all areas of risk are addressed within the care plan.

Tools

• A sample initial care plan for a patient based on Braden Scale assessment that can be modified for your specific patients is available in Tools and Resources (Tool 3F, Care Plan).
• A sample patient/family education pamphlet on the care plan is also available (Tool 3G, Patient and Family Education Booklet).

Practice Insights

Most patients do not fit into a "routine" care plan. Here are some common problems and how care plans can address them:

• Patients with feeding tubes or respiratory issues need to have the head of the bed elevated more than 30 degrees, which is contrary to usual pressure ulcer prevention care plans. Care plans and documentation in the medical record will need to address this difference.
• Preventing heel pressure ulcers is a common problem that must be addressed in the care plans. Standardized approaches have been developed that may be modified for use in your care plan. These are described using mnemonics such as HEELS (© 2005 by Ayello, Cuddington, and Black) or using an algorithm such as universal heel precautions.
• Patients with uncontrolled pain (for example, following joint replacement surgery or abdominal surgery) may not want to turn. Care plans must address the pain and how you will encourage them to reposition. Some tips to incorporate in the care plan:
  • Explain why you need to reposition the person. Try having several pillows placed under the patient’s shoulder and back. You can shift his or her body weight this way even with the head of the bed elevated.
  • Sit the person in a chair. This maintains the more elevated position and allows for small shifts in weight every 15 minutes.
  • Try having patients turn toward their stomach at a 30 degree angle. They can be propped up or leaning on pillows.
  • Ask the patient what his or her favorite position is. All of us have certain positions we prefer for sleep. After surgery or injury, the favorite may not be possible. For example, after knee replacement surgery the person cannot bend that leg to curl up. Try to find an alternative that the patient will like.
• Frequent small repositioning shifts can help prevent pressure ulcers. Care plans should acknowledge the need for patients to shift their weight a little each time you enter the room (at least 15 to 20 degrees if possible). If they are on their side, pull the pillow out just a little. Bend or straighten the legs just a little, using care not to hyperextend the knee.
• Dehydration is a common problem predisposing patients to pressure ulcers. Care plans may suggest offering a sip of a beverage each time you enter the room.

Additional Information

Read more about universal heel pressure relief: Cuddigan JE, Ayello EA, Black J. Saving heels in critically ill patients. World Council Enterostomal Ther J 2008;28(2):16-23.  

3.4.3 How should care planning be documented and communicated?

Documentation of care planning is essential to ensure continuity of care and staff knowledge of what they should be doing. Most hospitals choose to have a dedicated care plan form within the medical record. Responsibility for generating the care plan and incorporating the input from multiple disciplines needs to be delineated.

The plan of care is also a communication tool. Information is then available for other staff and disciplines to see what needs to be done. The care plan also needs to be shared through discussion in all shift reports, during patient assignments, during patient handoffs, and during interdisciplinary rounds.

3.4.4 What are barriers to care planning?

Sometimes, putting together all the discrete parts of the patient risk factors can be akin to putting together a puzzle. It takes time and the ability to see the whole picture, and it definitely requires patience and skill. There are many potential barriers to accurately completing care planning. Some that should be considered include:

• Time: Acuity of the patient population may mean the staff's time must be spent at the bedside and the development and documentation of care planning is delayed, thus increasing the chances of missed information.
• Expertise: Staff may not have the needed expertise to know what interventions to include or what they can do without a health care provider's order.
• Value of care plan: There may be a prevailing attitude that taking the time to write the care plan is not a priority. This is a unit or facility culture issue that needs to be addressed systemwide.
• Responsibility: The plan of care should be interdisciplinary. It is not just the nursing staff that develops and implements treatment plans. Physical and occupational therapists, dietary staff, and others are important contributors to pressure ulcer prevention and need to be an integral component of the care planning process.
• Information technology: Some facilities have computerized charting that prompts care planning based on risk. These care plans may not be sufficiently individualized to the needs of the patient. With other systems, the staff have to go to multiple screens, which can be time consuming and increases the chance of overlooking key elements.

3.4.5 How can we improve care planning?

Planning care is essential to quality. The plan of action needs to be based on the assessment data gathered but has to be adaptable to changing needs. The complexity and importance of integrating all the information to render appropriate care to the patient cannot be overemphasized.

• Ensure that staff appreciate the value of care planning. All levels of staff need to be empowered and understand what portion of the care they are responsible for and the value they bring to the overall care of the patient.
• Use or create systems that make care planning more streamlined by linking to the assessment task. Computer documentation that ties assessment directly to the care plan is time saving for staff and facilitates comprehensive information. Having prompts to update the plan as the patient's condition changes helps ensure that needs will continue to be met. For example, patients who are in the OR for more than 4 hours could generate a reminder to the staff to do a pressure ulcer risk assessment. Patients who are identified as at risk may generate an automatic order for support surfaces and skin care products, avoiding delays arising from care planning.
• Link the care plan to routine practice. The plan of care, including addressing pressure ulcer risk, should be routinely included in shift reports and patient handoffs. All levels of staff should know what is required daily or by shift and automatically do it. Prompts may be needed at first to incorporate the prevention program into everyday care practices.

Additional Information

Read more about delays in implementing the care plan: Rich SE, Shardell M, Margolis D, et al. Pressure ulcer prevention device use among elderly patients early in the hospital stay. Nurs Res 2009;58(2):95-104. 

Return to Contents

3.5 What items should be in our bundle?

The sections above have outlined best practices in pressure ulcer prevention that we recommend for use in your bundle. However, your bundle may need to be individualized to your unique setting and situation. Think about which items you may want to include. You may want to include additional items in the bundle. Some of these items can be identified through the use of additional guidelines (go to the guidelines listed in section 3.6).

Action Steps

Identify your bundle of best practices.

3.5.1 How do we customize the bundle for specific work units?

Patient acuity and specific individual circumstances will require customization of the skin and pressure ulcer risk assessment protocol. It is imperative to identify what is unique to the unit that is beyond standard care needs. These special units are often the ones that have patients whose needs fluctuate rapidly. These include the operating room, recovery room, intensive care unit, emergency room, or other units in your hospital that have critically ill patients. In addition, infant and pediatric patients have special assessment tools, as discussed in section 3.3.5.

Skin must be observed on admission, before and after surgery, and on admission to the recovery room. In critical care units, severity of medical conditions, sedation, and poor tissue perfusion make patients high risk. Research has shown that patients with hypotension also are at high risk for pressure ulcer development. In addition, patients with lower extremity edema or patients who have had a pressure ulcer in the past are high risk. Therefore, regardless of their Braden score, these patients need a higher level of preventive care: support surface use, dietary consults, and more frequent skin assessments. Documentation should reflect the increased risk protocols.

Action Steps

• Identify the units that will require customization of the skin and risk assessment protocols.
• Modify the bundle, the assignment of roles, and the details of the unit to meet these special features.

Additional Information

Read more about how critically ill patients have factors that put them at risk for developing pressure ulcers despite implementation of pressure ulcer prevention bundles: Shanks HT, Kleinhelter P, Baker J. Skin failure: a retrospective review of patients with hospital-acquired pressure ulcers. World Council Enterostomal Ther J 2009;29(1):6-10. 

Return to Contents

3.6 What additional resources are available to identify best practices for pressure ulcer prevention?

A number of guidelines have been published describing best practices for pressure ulcer prevention. These guidelines can be important resources to use in improving pressure ulcer care. In addition, the International Pressure Ulcer Guideline released by the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel is available. A Quick Reference Guide can be downloaded from their Web site at no charge.

Resources

Clinical Practice Guideline 3: Pressure ulcers in adults: prediction and prevention. Rockville, MD: Agency for Healthcare Policy and Research; May 1992. AHCPR Pub. No. 92-0047. Archived at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409.

Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health-care professionals. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. J Spinal Cord Med 2001 Spring;24 Suppl 1:S40-101.

National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP). Quick Reference Guide version of the NPUAP/EPUAP International Pressure Ulcer Prevention Guidelines: Available at: http://www.epuap.org and http://www.npuap.org.

The following guidelines are available for a fee:

American Medical Directors Association: Pressure Ulcers in the Long-Term Care Setting. Available at: http://www.amda.com

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; October 2009. Available at: http://www.npuap.org.

Wound, Ostomy and Continence Nurses Society. Pressure ulcer assessment: best practices for clinicians. Available at: http://www.wocn.org. 

Return to Contents

3.7 Checklist for best practices

3. Best Practices Checklist