Risk for pressure ulcer

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Submission Date Submission Type LABEL

1

DEFINITION
2

RISK FACTORS
4 1,2,26

4,5,6,22 4,20,24,26 4,20,24,26 19,20,22,24 9,24,26 10,19,24 22,23,24,26 22,23,24,26 1,2,3,8,11,20,22,23,2 4,25,26 11,12,13,14,18,22 20 20,24 26 8 20 21,25 1,2,7,11,18,20,23,24, 25,26 1,2,22,26

Is there a current diagnosis related to your submission? Yes LABEL / CURRENT RELATED DIAGNOSIS Risk for pressure ulcer Risk for impaired skin integrity DEFINITION / CURRENT RELATED DIAGNOSIS Increased vulnerability to localized injury to the skin and/or At risk for alteration in epidermis and/or dermis underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear (NPUAP, 2007) RISK FACTORS / CURRENT RELATED DIAGNOSIS --Chemical substance Use of linen with insufficient moisture wicking ability Dehydration Excretions Extremes of age --Humidity Elevated skin temperature by 12C Hyperthermia ---Hypothermia Shearing forces Mechanical factors (shearing forces, pressure, restraint) Surface friction Skin moisture ---Braden Scale score of <18 in adults Braden Q Scale of <16 in children Dry skin Scaling skin Decreased mobility (e.g., degenerative disease, spinal cord injury, Ventilator-dependent patients ) Decreased serum albumin level Decreased tissue oxygenation Decreased tissue perfusion Deficient caregiver knowledge regarding pressure ulcer prevention Depleted triceps skin fold Edema Extended period on hard surface (e.g., surgical procedures >2 hours in duration) Inadequate nutrition Circulatory abnormalities (e.g., Decreased arterial pressure, Moisture Radiation Secretions

04/01/2013 Risk Diagnosis: New

Changes in pigmentation Changes in skin turgor

Imbalanced nutritional state (e.g., obesity, emaciation) Impaired circulation

Risk for pressure ulcer

Diabetes mellitus) ----Sensory deficit (e.g., spinal cord injury, diabetes mellitus) Incontinence Impaired independence in activities of daily living Low score on Risk Assessment Pressure Sore (RAPS) Scale Lymphopenia Non-blanchable erythema Pharmaceutical agents (e.g., general anesthesia, vasoactives) Physical restraint Pressure over bony prominences Tobacco smoking Anemia Cardiovascular disease Cognitive decline Extremes of age Extremes of weight Female gender History of cerebral vascular attack History of resolved pressure ulcer Hip fracture ASA or NYHA level II or higher Previous trauma Impaired metabolic state Impaired sensation

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1,2,20,26 1,2,8,18,22,24,25,26 17,24 27,28,29 8 8 25,26 25 4,6 20,22 22 17,22 17,22,24,26 1,2,8,11,22,24,26 8,11,18 11,26 17,26 8,19 11,12,13,26 11 17

Medications Skeletal prominence

REFERENCES
1 2 3 4 5 6 7 8 9 Duncan KD. Preventing pressure ulcers: the goal is zero. Jt Comm J Qual Patient Saf 2007 Oct; 33(10):605-10. PMID: 18030862 Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue. In: Patient safety and quality: an evidence-based handbook for nurses. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Apr. p. 1-33. www.ahrq.gov/qual/nurseshdbk/docs/LyderC_PUPSI.pdf. Sullivan, N. Section E. General Clinical Topics. http://origin.www.ahrq.gov/research/findings/evidence-based-reports/patientsftyupdate/ptsafetyIIchap21.pdf. Yusuf, S., Okuwa, M., Shigeta, Y., Dai, M., Iuchi, T., Sulaiman, R., & Sanada, H. (2013). Microclimate and development of pressure ulcers and superficial skin changes. International Wound Journal. DOI: 10.1111/iwj.12048 (Early view on-line only). Sae-Sia W, Wipke-Tevis DD, Williams DA. Elevated sacral skin temperature (Ts): a risk factor for pressure ulcer development in hospitalized neurologically impaired Thai patients. Appl Nurs Res 2005;18:2935. Lachenbruch. C., Tzen, Y.T., Brienza, D.M., Karg, P.E., Lachenbruch, P.A. (2013). The Relative Contributions of Interface Pressure, Shear Stress, and Temperature on Tissue Ischemia: a Cross-sectional Pilot Study. Ostomy Wound Management, 59(3), 25-34. Brito, P.A., Generoso Sde, V., Correia, M.I. Prevalence of pressure ulcers in hospitals in Brazil and association with nutritional status: a multicenter, cross-sectional study. Nutrition, 29(4), 646-9. doi: 10.1016/j.nut.2012.11.008 VandenBosch, T., Montoye, C., Satwicz, M., Durkee-Leonard, K., & Boylan-Lewis, B. (1996). Predictive validity of the Braden Scale and nurse perception in identifying pressure ulcer risk. Applied Nursing Research, 9(2):80-86]. DOI: 10.1016/S0897-1897(96)80457-5 Souza, D.M.S.T, Santos, V.L.C.G., Iri, H.K., & Oguri, M.Y.S. (2010). Predictive Validity of the Braden Scale for Pressure Ulcer Risk in Elderly Residents of Long-Term Care Facilities. Geriatric Nursing, 31, 95-104

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