Pressure Ulcer Risk Assessment vs. Clinical Judgment

The prevention of pressure ulcers should be of utmost importance to healthcare staff everywhere, no matter what type of facility. Performing a regular assessment of patients' propensity for the development of pressure ulcers should be a core component of the provision of healthcare. Communication and the transfer of data about the prevention of pressure ulcers is an area that needs much more research, even though the lack of research has been identified as a catalyst for PU incidents. Medical staff should always have a firm comprehension of what factors put a patient's skin integrity in danger of being compromised. Being able to perform patient risk assessments and implement justified interventions to effectively administer risk management over the development of pressure ulcers is imperative.

What is the Purpose of Assessing Risk?

There are patients in every arena of care with pressure ulcers. No care setting is immune, no age is immune. Pressure ulcers can be an issue from birth to death for patients. Assessing the risk isn't just important when a patient is so ill he/she requires hospitalization, certain levels of assessment should take place if social services are involved with a patient as well. The assessment that takes place on the social services level would be more along the lines of a verbal or written screening rather than a physically detailed assessment. Assessments will alert anyone involved with the patient of conditions that have changed and/or risk has increased.

• Assessing Pressure Ulcer Risk

  • Why assess?
    • The primary reason for doing a risk assessment is to identify patients that may need attention. Proper planning and implementation are needed to develop beneficial care interventions. Social services should consistently assess if clients are aware of and utilizing resources that are available to them.
  • Who should be assessed?
    • Any person who is receiving care from a healthcare professional in any facilitation should be assessed.
• Where should the assessment take place?
• • • Assessments can be administered in any healthcare facility or in a patient's home if they are receiving home healthcare.
• When is the proper time for an assessment?
  • • If a patient has been admitted to the hospital, the assessment should be performed within six hours of the time of admission. If in a clinic, an assessment can and should be performed upon initial face-to-face contact. If a patient has changed his/her setting such as going from one skilled nursing facility to another, an assessment should be performed.
• What methods can be used to assess a patient's risk for a pressure ulcer?
  • • There are a number of tools that can be utilized for assessments such as pre-screening and risk-assessment. Sometimes, the risk needs to come down to basal instinct and clinical judgment.
• When doing an assessment you should be sure to look, listen, and learn.
  • • Pay attention to your patient, the environment he/she is in, and the equipment that is being used in all scopes of treatment. Be sure to listen to him/her. You may need to hear what he/she is not saying. It's also important to heed the advice of colleagues. When performing an assessment be sure to read all of the clinical notes. Ask questions and take detailed notes regarding the answers.

If a risk is not assessed then a potential pressure ulcer could go unnoticed and thus untreated. Assessments decrease risk, therefore if they are not done the patient's risk increases if one is not done. Additionally, if the patient develops a pressure ulcer, he/she is at a heightened risk of infection setting in. This can lead to long hospital stays, decreased quality of life, and even death. Additionally, litigation could be in the foreseeable future for the team that neglects to assess.

The How To's for Assessing Risk

There is a variance of methods for assessing risk dependent on the setting where the assessment is to take place and the role of the assessment administrator. Caregivers can communicate any risk factor changes if they are given the knowledge to recognize said changes. This is if a patient cannot articulate this themselves. Patients should always feel that they have the power and control to participate in and give input toward their own care and the processes the care entails.

Assessments for pressure ulcers that identify the patients that are at the highest risk for developing a PU is the first step for preventing them. The assessment is the base for the formulation, implementation, and evaluation of a care plan. Keep in mind, a visual assessment of a patient can be done inconspicuously at any time during the caregiving process. It can be when bathing the patient, getting him/her on the toilet, moving the patient from bed to chair (or vice versa), or during therapy.

A risk assessment should be founded on basal clinical instincts and/or the use of available assessment tools. Some experts believe that using only clinical judgment is not adequate, others believe that assessment tools utilized as a stand-alone will not prevent pressure ulcers. If a risk assessment tool is validated it can provide structured logic in an assessment. It can, and should, be used in tandem with the clinical experience and knowledge of a healthcare professional's judgment.

What is Clinical Judgment?

Clinician's instinct is the same thing as clinical judgment. Most experienced clinicians will get an instinctive inclination to consider a patient as high risk for pressure ulcers. Medical practitioners often put this intuition to work by observing the patient, listening to what is said by the patient and/or caregivers and family members and learning. There must be an existing knowledge base to be aware of that includes known risk factors relating to how susceptible and/or tolerant the individual patient may be.

• Risk Factors for the Development of Pressure Ulcers

• • Susceptibility and tolerance of the patient
  • The mechanical properties of the patient's tissue (can the tissue cope with shear pressure or friction?)
  • The morphology (shape and size) of the patient's bones and tissue
  • Patient's physiology or repair
  • Transport and thermal properties of the patient
  • Nutrition and hydration habits of the patient
  • Is the patient diabetic?
  • What is the patient's build?
  • How old is the patient?
  • Does the patient have any sensory, mental, or cognitive impairments?
• Mechanical Boundary Conditions

• • What is the magnitude of the patient's mechanical load? (How much shear pressure or friction is being applied?)
  • How long is the mechanical load being applied?
  • What type of loading is the patient enduring?
    • Shear
    • Pressure
    • Friction
  • Moisture Levels
  • Mobility reduction
  • Mishandling and poor moving
  • Incontinence

If a practitioner has a sound clinical judgment there is the advantage of being able to do quick assessments and engage the patient in early intervention for preventative care. Through individualized assessment that is based on the clinician's knowledge of the particular patient and medical observations a risk can be assessed that may have gone unnoticed. The downside is that the informal measurement of a professional's knowledge and experience cannot be validated or replicated.

Risk Assessment Tools that are Validated

Risk assessment tools are formal tools that utilize point scales to determine a patient's risk factor score. They are also referred to as traffic-light systems. There are well over fifty risk scales and/or tools that are in use today by facilities. Some of the tools are generalized and others apply to specific groups of patients or care settings (pediatrics, ICU, surgery, etc.) There is no supportive evidence to show that one tool is better than the other or if the tools are more beneficial than a practitioner's clinical judgment.

The danger exists that these tools become a system of tick-boxes. The quality standards included often focus more on how long it takes to finish the risk-assessment instead of if there was a preventative care plan that was implemented. The notion has also been brought up that assessment tools possibly should be set aside because they make practitioners focus on metrics more than medicine. The positive aspect of risk assessment tools is that they can be validated, repeated, and their consistency is more reliable than waging whether or not a patient may develop a pressure ulcer on the intuition of a clinician. Clinical judgment has what tools do not, though. Clinical judgment is individualized for the patient. Risk-assessment tools aren't personalized. They are data, not human symptoms sitting before the clinician and many members of the healthcare industry can base their care on scores rather than the intuition that they have gathered throughout their career. There is value in holistic assessments. The best method for assessing pressure ulcer risk is by combining formal tools with sound clinical judgment.

Thorough documentation completed clearly and concisely in a timely manner is an integral key in assessing a patient's risk. This promotes the provision of care that is seamless for the patient and provides firm evidence that an assessment has been completed and care planning has been implemented. With malpractice suits due to pressure ulcers rising, it is crucial to be sure that documentation is stressed.

Tools for Pre-screening

The pressure placed on healthcare services has begun to increase. This has been a catalyst for some of the departments within the hospital setting that have quick turnovers such as the emergency room to find a way to manage the multiple priorities that arise in the assessment of a patient and care delivery. Risk assessment tools have emerged so that pressure ulcer risks can be quickly identified.

These tools are filters for those who are not at risk. This makes it possible for healthcare providers to focus their energy on cases that are a priority. The pre-screen assessment may trigger a full risk assessment due to a specific score range or certain yes or no answers on the screen. The pre-screen tools are efficient and user-friendly in addition to bringing the focal point back to the judgment of the clinician.

Implementation of a Care Plan

While risk assessment is the beginning of prevention of pressure ulcer occurrences, the identification of preventative actions is just as important. All patients will not be in agreement with the plan of care that is recommended. If they are not, they should be advised as to why these recommendations have been set in place and what the consequences will be if they refuse to follow them. Take the time and care to find out exactly why the patient doesn't wish to follow the care plan. Try to find a compromise. If a compromise cannot be reached, then it's urgent to fully document the steps that have been taken, documentation that the patient has refused to comply, and escalate concerns where it is appropriate.

ABOUT THE AUTHOR

Heidi West is a medical writer for Vohra Wound Physicians, a national wound care physician group. She writes about healthcare and technology in the medical industry.