OASIS Alert

Be sure you don't overlook these five pressure ulcer risk factors?

The pressure ulcer assessment scales are quick and easy -- but if you stop there you'll miss a lot of at-risk patients.

The Braden scale is one of the most widely used tools for assessing pressure ulcer risk, according to Elizabeth Ayello of the Excelsior College School of Nursing in Albany, N.Y. It 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, in Omaha, Neb., 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 [you] identify [patients] 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.

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. Blood pressure. The Braden scale does not take into account blood pressure. Research shows that a diastolic below 60 is a risk factor for skin breakdown, experts say.

3. Diabetes. The Braden tool doesn't include someone who is diabetic with serious peripheral vascular disease. "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," Braden 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. The Braden instrument does address mobility. But people with depression can be reluctant to move even when they are able to.

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, Braden says. Serious pain increases cortisol levels, she notes. And nurses may not want to disturb the patient once the pain medicine is working because he's finally getting some relief. That period of immobility can lead to skin breakdown in an otherwise mobile person, experts agree.