PCS Clinical Competencies for RNs
A pressure ulcer develops from constant pressure applied to skin over a bony prominence when pressure reduction measures (such as shifting one's weight) have not been taken to relieve the constant pressure. Blood flow into the area is not available causing a lack of oxygen and nutrients to the tissues.This causes localized tissue damage or necrosis.
- All wounds, including pressure ulcers, which develop while the patient is at Harborview require that a PSN report be filed.
- Beginning June 7, 2006, state law requires that hospitals report any Stage III and Stage IV pressure ulcer acquired after admission to the Department of Health within 48 hours of discovering the wound. In addition, within 45 days of discovering the pressure ulcer, HMC must investigate why the pressure ulcer occurred and develop an action plan for implementing any necessary changes.
Pressure ulcers are found on an individual whose mobility or sensation is limited or absent, or whose cognitive ability does not support adequate movement. Risk Factors for developing a pressure ulcer include individuals with the following:
- Impaired sensory perception : Lacking mental ability or neural connection to understand and respond to pressure related discomfort.
- Immobility : lacking ability to move or is confined to a bed or chair.
- Frequent moisture exposure causing maceration of the skin: Irritants in liquids can cause tissue damage.
- Friction/ Shear: abrades the skin.
- Poor Nutrition and/or dehydration: alters tissue regeneration and impaired inflammatory response.
- Elderly and infants/young children : Have thinner skin and less competent immune systems
- Other names for pressure ulcers include pressure sore, bed sore and decubitus ulcer.
The Braden Scale is a validated risk assessment tool used to identify individuals who are at-risk for developing pressure ulcers. Pressure ulcer assessment is done on admit and then daily utilizing the Braden Scale.
The scale has six general risk factors in individual CIS cells: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
There is a pop-up assessment scale for each risk factor on the Braden scale. The nurse selects the descriptor on each pop-up scale which best describes the patient status at the time of assessment. A numeric value is give to each chosen descriptor.
Once a numeric value for each of the six general risk factors has been selected, CIS will generate a total Braden score. A total score 16 or less on the Braden Scale identifies individuals who at higher risk for developing pressure ulcers. Low scores in any of the risk factors indicate where interventions would need to be focused to decrease the risk.
Pressure ulcers are staged based on the level of destruction to the layers of skin and underlying tissues. Once a pressure ulcer has been staged, it stays at that stage as the ulcer healing either stays the same or improves. However, should the ulcer become worse, it is restaged to match that current level of destruction.
Last modified: 5/30/2006 8:49 AM