MDS Alert

Look for the 'rest of the story' in assessing a resident's risk.

A risk score on a standardized risk assessment tool gives you a ballpark estimate of a resident's likelihood of developing a pressure ulcer. But don't count on it too heavily if you want to win against skin breakdown and F314 tags.

"Facilities need to use a standardized assessment, but a tool can never capture all [risks] for all residents," says nurse attorney Janet Feldkamp with Benesch, Friedlander, Coplan & Aronoff LLP in Columbus, OH. Instead, "you use the tool as a baseline."

Proactive strategy: Take a close look at your standardized tool to identify areas where you need to fill in the gaps for an individual resident.

Example: The Braden Scale addresses six broad categories of risk (sensory perception, skin moisture, activity, mobility, nutrition and friction/shear). But it doesn't specifically address the following areas, notes Barbara Braden, PhD, RN, FAAN, in Omaha, NE, who co-created the assessment scale in 1987.

1. Weight. The Braden Scale looks at a person's nutrition, but not weight. "Combining the Braden Scale with weights helps the staff identify residents who may be showing the effects of poor nutritional intake," says Braden. "Weight loss will confirm there's a problem. "Or the person may be gaining weight due to fluid retention from undetected congestive failure," Braden adds.

Tip: A diagnosis of congestive heart failure places a person at higher risk for developing skin breakdown, notes Peggy Dotson, RN, principal of Healthcare Reimbursement & Strategy in Yardley, PA.

Beware this combination of risks: An extremely obese person confined to a bed that's too small for him may have a "fairly decent score on the Braden Scale," says Braden. "But the person's excess weight--and his inability to shift that weight in the bed--may pose additional risk," she notes.

2. Low blood pressure. The Braden Scale doesn't take into account blood pressure. "Our research shows that a diastolic below 60 is a risk factor for skin breakdown," says Braden.

3. Diabetes with peripheral vascular disease (PVD). The Braden tool doesn't include someone who is diabetic with serious PVD. Braden notes that "our research didn't find diabetes to be an independent risk predictor for pressure ulcers. But certainly we saw patients who were diabetic and developed pressure ulcers on their heels lose their limbs," she says. "So even though the Braden Scale doesn't identify diabetes with PVD as a risk, if someone has diabetes, you have to protect their heels from breakdown."

4. Depression. Depression becomes a risk factor only when it impacts a person's mobility, says Braden. And the Braden instrument does address mobility, she notes.

5. Pain. Braden has seen people with low-risk scores above 18 on the Braden instrument who are mobile and active but develop pressure ulcers due to pain. For one, serious pain increases cortisol levels, she notes. Also, someone in serious pain may receive medications that "essentially knock the person out," she notes. "And nurses are reluctant to disturb the person" because he's finally getting some relief. "But during that period of immobility, the person can develop skin breakdown--even though he is mobile when awake," says Braden.

What about the Norton scale? Facilities also use the Norton Scale as a standardized tool to assess a resident's risk of skin breakdown (see the box on the right). The Norton doesn't look at nutrition, says Barbara-Bates Jensen, PhD, RN, CWOCN, at the ULCA Borun Center for Gerontological Research at the Los Angeles Jewish Home for the Aging. Meal intake is one way to assess nutritional status, she says. "Anyone who isn't consuming at least 50 percent of their meals should be assessed further for nutritional issues."

Tip: "For residents who are losing weight or have inadequate meal intake, a pre-albumin can identify the person's visceral protein stores," says Jane Belt, RN, MSN, a consultant with Plante & Moran Clinical and Reimbursement Group in Columbus, OH.