Skin integrity risk and fall risk scales

Bedside Assessment and Charting

• Overview

  • Focus on hands-on case study information.

  • Questions about bedside assessment and charting are welcome throughout the session.

Morse and Braden Scales

Morse Fall Scale

• Purpose

  • Determines a patient's fall risk.

  • Ideal to use prior to falling; assess patients upon admission or when deemed weak or unstable.

• Implementation

  • If the risk is low, preventative measures can be implemented to avoid falls.

  • If a patient has fallen, perform the scale regularly to ensure safety and prevent future falls.

Braden Scale

• Purpose

  • Assesses risk for pressure injuries (also known as pressure sores or pressure ulcers).

• Important Factors

  • Scale used when a patient first arrives or if they are assessed for risks of developing pressure injuries.

  • Next semester, more detail on staging pressure injuries with four levels of severity.

• Definition of Pressure Injury

  • Caused by prolonged pressure on the skin, cutting off blood flow to tissues, leading to tissue injury and breakdown.

  • Examples include pressure ulcers on buttocks and heels.

• Patient Sensation and Mobility

  • Healthy patients shift positions regularly to relieve pressure due to sensation (hypoxia or ischemia).

  • Patients who are immobile or lack sensation cannot shift, increasing fall risks.

Risk Factors for Pressure Injuries

• Key Factors Contributing to Risk

  • Immobility

  • Conditions: broken leg, osteoporosis, post-surgical weakness, ICU status.

  • Poor Nutrition and Hydration

  • Malnutrition, inadequate protein intake, and dehydration contribute to increased risk.

  • Chronic Conditions

  • Diabetes and peripheral neuropathy reduce sensory perception, leading to unnoticed injuries.

  • Smoking exacerbates these issues: constricts blood vessels and increases blood glucose levels.

  • Moisture

  • Wet skin from urinary or stool incontinence increases risk of skin breakdown.

  • Wet skin is at much greater risk for pressure injuries compared to dry skin.

Preventative Strategies for Immobile Patients

• Nursing Actions

  • Routine repositioning every 2 hours to relieve pressure.

  • Use of supportive devices such as pillows between knees and under heels.

  • Utilize airflow mattresses to alleviate pressure points by inflating and deflating different areas.

  • Maintain a nutrient-rich diet and ensure proper hydration for at-risk patients.

• Specific Recommendations

  • Create a toileting schedule to manage moisture exposure.

  • Implement physical therapy to encourage movement and reduce immobility risk.

  • Use draw sheets to minimize friction and shear during repositioning to prevent skin damage.

Case Study: William Harmon

• Patient Overview

  • Age: 78

  • Medical History: No previous falls, hip fracture, underwent hip surgery.

  • Condition on assessment: Alert, oriented, stable vitals, needing assistance with mobility.

  • Symptoms of concern: recent weight loss, depression, incontinence observed.

Braden Scale Assessment for William

• Sensory Perception: 0 (No impairment)

• Moisture: 2 (Very moist)

• Activity: 3 (Occasional walking with PT)

• Mobility: 2 (Very limited; cannot reposition independently)

• Nutrition: 2 (Inadequate intake, notable weight loss)

• Friction & Shear: 1 (High risk)

• Total Score: 14 (Moderate risk for pressure injuries)

Recommended Nursing Interventions

• Frequent repositioning and skin assessment.

• Toileting schedule implementation to reduce moisture exposure.

• Nutritional supplements to encourage adequate protein and nutrient intake.

• Ensure patient participation in therapy sessions to improve mobility and reduce dependency.

Case Study: Roland

• Patient Overview

  • Age: 66

  • Medical Risk Factors: Hypertension, cataracts, admitted for IV antibiotics due to lower extremity cellulitis.

Morse Fall Scale Assessment for Roland

• History of Falls: 0

• Secondary Diagnosis: 15 (Cataracts contributing to visual impairment)

• Ambulatory Aid: 15 (Uses a walker)

• IV Therapy: 20 (Risk of falls due to IV line)

• Gait: 15 (Impaired gait due to walker)

• Mental Status: 0 (Alert and oriented)

• Total Score: 60 (High risk for falls)

Recommended Nursing Interventions

• Use of assistive devices during ambulation

• Regular checks and availability of call light

• Maintain a clutter-free environment to minimize tripping hazards.

SBAR Communication Tool

• SBAR Breakdown

  • Situation: Clear description of current concerns.

  • Background: Relevant patient history and findings.

  • Assessment: Nursing interpretation of current issues based on assessment.

  • Recommendation: Proposed interventions and care plans.

• Importance

  • Enhances communication within healthcare teams, crucial for patient safety and effective outcomes.

  • Reduces errors during transfers of care or decision making by providing structured information.

  • Effective SBAR communication can significantly lower frustration and improve patient care quality.

Summary of Effective SBAR Example

• Positively influences both nurse and physician interactions, leading to better understanding and results for patient management.

• Vital to read back orders and recommendations to ensure accuracy and clarity during communication.

Closing Remarks

• Continuous practice with SBAR in clinical settings is encouraged for better outcomes in patient care.

• Emphasize the importance of effective communication in reducing medical errors and enhancing teamwork in healthcare settings.