Care Of Patient

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Care of patient with actual or risk for impaired skin integrity

Care of Patient With Actual Or Risk For Impaired Skin Integrity

Braden's Scale Assessment and Risk Prevention Measures

This is a clinical tool you can use to assess risk of a patient/client developing a pressure ulcer. Use this together with your clinical judgment. The primary aim of this tool is to identify patients/clients who are at risk, as well as determining the degree of risk of developing a pressure ulcer. The Braden Scale is a scale made up of six subscales, which measure elements of risk that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. These are: sensory perception, moisture, activity, mobility, friction, and shear. Each item is scored between 1 and 4, with each score accompanied by a descriptor. The lower the score, the greater the risk.

Complete Skin Assessment

The first complete professional skin assessment system:



Hair (Hinman & Maibach, 1963)

The innovations:

Scientific and objective assessment of the skin carried out with probes

Digital and visual assessment using a camera

Advice on the skin of the client and products and treatments to apply (Meraviglia, Becker, Grobe & King, 2002)

The only true stand alone system with integrated PC

Pressure Ulcers and Venous Ulcers

Pressure ulcers are areas of necrosis and ulceration where tissues are compressed between bony prominences and hard surfaces; they result from pressure alone or pressure in combination with friction, shearing forces, or both. Risk factors include old age, impaired circulation, immobilization, malnourishment, and incontinence. (Diekmann, 1984) Severity ranges from nonblanchable skin erythema to full-thickness skin loss with extensive soft-tissue necrosis. Diagnosis is clinical. Treatment includes pressure reduction, avoidance of friction and shearing forces, local care, and sometimes skin grafts or myocutaneous flaps. Prognosis is excellent for early-stage ulcers; neglected and late-stage ulcers pose risk of serious infection and nutritional stress and are difficult to heal.


An estimated 1.3 to 3 million patients in the US have pressure ulcers (PUs); incidence is highest in older patients, especially those who are hospitalized or in long-term care facilities. Aging increases risk, in part because of reduced subcutaneous fat and decreased capillary blood flow. Immobility and comorbidities increase risk further.

Patients who are cognitively impaired, immobile, or both are at increased risk. Immobility—because of decreased spontaneous movement (eg, due to stroke, sedation, or severe illness) or inability to change position frequently because of weakness—is the most important factor. (Diekmann, 1984) Other risk factors include urinary and fecal incontinence; poor nutritional status, including dehydration; diabetes; and cardiovascular disease. Clinical assessment is sufficient to identify patients at risk; several scales (eg, Norton, Braden—see Fig. 1: Bites and Stings: Identifying pit vipersFigures) are useful for predicting risk. The National Pressure Ulcer Advisory Panel has also issued guidelines for the prediction and prevention of PUs (see Table 1: Pressure Ulcers: Pressure Ulcer Staging Tables.) (See also the Agency for Healthcare Policy and Research guidelines for prediction and prevention of pressure ulcers in adults.)

The Norton Scale for Predicting Pressure Sore Risk*



Physical condition

4 = Good

3 = ...
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