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Speaker Name: Zena Moore

Pressure ulcer risk assessment Prof. Zena Moore Royal College of Surgeons in Ireland (RCSI), Ireland. Declaration of Financial Interests or Relationships. Speaker Name: Zena Moore

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Speaker Name: Zena Moore

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  1. Pressure ulcer risk assessmentProf. Zena MooreRoyal College of Surgeons in Ireland (RCSI), Ireland

  2. Declaration of Financial Interests orRelationships Speaker Name: Zena Moore I have the following financial interest(s) or relationship(s) to disclose with regard to the subject matter of this presentation: The School of Nursing & Midwifery, RCSI, has an industry collaborative agreement with Bruin Biometrics

  3. Learning objectives At the end of this lecture, participants will be able to: • identify risk factors for pressure ulcer development • evaluate pressure ulcer risk assessment methods and procedures

  4. What is it we are trying to prevent?

  5. Definition of a pressure ulcer A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Reference:NATIONAL PRESSURE ULCER ADVISORY PANEL, EUROPEAN PRESSURE ULCER ADVISORY PANEL & PAN PACIFIC PRESSURE INJURY ALLIANCE 2014. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, Perth, Australia, Cambridge Media.

  6. Riskand Cause are not the same thing Reference: Rifkin E, Bouwer E (2007) The Illusion of Certainty Health Benefits and Risks. Springer

  7. Available from: http://www.plasticisers.org/en_GB/health/risk-vs-hazard. Accessed 21st feb 2019

  8. What is it a risk factor? “A risk factor is any attribute,characteristic or exposure of an individual that increases the likelihood of developing a disease or injury” http://www.who.int/topics/risk_factors/en/

  9. Cause of a pressure ulcer A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear……………. Reference:NATIONAL PRESSURE ULCER ADVISORY PANEL, EUROPEAN PRESSURE ULCER ADVISORY PANEL & PAN PACIFIC PRESSURE INJURY ALLIANCE 2014. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, Perth, Australia, Cambridge Media.

  10. How does risk relate to pressure ulcers? Attribute/Characteristic/Exposure of an individual that increases the likelihood of them developing a pressure ulcer http://www.who.int/topics/risk_factors/en/

  11. Image courtesy of Dr Ana Oliveira 2019

  12. Which risk factors?

  13. Which risk factors?

  14. Which risk factors?

  15. Which risk factors? Source: http://www.safefood.eu/Healthy-Eating/What-is-a-balanced-diet/The-Food-Pyramid.aspx

  16. Which risk factors?

  17. Which risk factors?

  18. Which risk factors? 37% of general female population suffer with some form of urinary incontinence Reference: AVELLANET, M., FITER, M., CIRERA, E. & COLL, M. 2003. Prevalence of urinary incontinence in Andorra: impact on women's health. BMC Womens Health, 3, 5.

  19. So……….Which factor is most important?

  20. To sustain a pressure ulcer, what do I have to be exposed to? ………………………….. as a result of pressure, or pressure in combination with shear…………….

  21. Images courtesy of Mr Menno van Etten 2011

  22. What factors predispose someone to pressure and shear?

  23. Mobility Usually a painful response to immobility stimulates movement Seminal work of Exton Smith & Sherwin (1961) >Movements < Pressure ulcers Influenced by: Ability to feel pain & ability to reposition Reference: EXTON-SMITH, A. N. & SHERWIN, R. W. 1961. The prevention of pressure sores significance of spontaneous bodily movements. The Lancet, 2, 1124-6.

  24. Mobility Seminal work of Keane (1978) Minimum physiological mobility requirement (MPMR) to maintain healthy tissue, whilst lying on a soft mattress, is one gross postural change every 11.6 minutes Reference: KEANE, F. X. 1979. The minimum physiological mobility requirement for man supported on a soft surface. Paraplegia, 16, 383-9.

  25. Mobility • 36 studies entered one or more mobility or activity related variables into their statistical models • In 29 (80.5%) of studies a mobility/activity related variable emerged as statistically significant Reference: COLEMAN, S., GORECKI, C., NELSON, E. A., CLOSS, S. J., DEFLOOR, T., HALFENS, R., FARRIN, A., BROWN, J., SCHOONHOVEN, L. & NIXON, J. 2013. Patient risk factors for pressure ulcer development: Systematic review International Journal of Nursing Studies, 50, 974-1003.

  26. Mobility • Variables that emerged most consistently were mobility sub-scales; mobility/activity ADL; activity (bedfast/chairfast/immobile descriptors) • The direction of the relationship: • mobility/activity risk of pressure ulcer Reference: COLEMAN, S., GORECKI, C., NELSON, E. A., CLOSS, S. J., DEFLOOR, T., HALFENS, R., FARRIN, A., BROWN, J., SCHOONHOVEN, L. & NIXON, J. 2013. Patient risk factors for pressure ulcer development: Systematic review International Journal of Nursing Studies, 50, 974-1003.

  27. Cause Pressure and Shear Immobility

  28. Hierarchy of Risk Factors Prime cause of pressure ulcers Prime factor exposing individual to pressure & shear Factors influencing tolerance of pressure & shear Reference: MOORE, Z., COWMAN, S. & CONROY, R. M. 2011. A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. J Clin Nurs, 20, 2633-44.

  29. Theoretical schema of proposed causal pathway for pressure ulcer development • Direct causal factors • Immobility; Skin/PU Status; Poor Perfusion • Key indirect causal factors • Moisture; sensory perception; diabetes; low albumin; poor nutrition • Other potential causal factors • Age; medication; pitting oedema; factors relating to general health; infection; acute illness; raised body temperature; chronic wound. Reference: COLEMAN, S., NIXON, J., KEEN, J., WILSON, L., MCGINNIS, E., DEALEY, C., STUBBS, N., FARRIN, A., DOWDING, D., SCHOLS, J. M., CUDDIGAN, J., BERLOWITZ, D., JUDE, E., VOWDEN, P., SCHOONHOVEN, L., BADER, D. L., GEFEN, A., OOMENS, C. W. & NELSON, E. A. 2014. A new pressure ulcer conceptual framework. J Adv Nurs, 70, 2222-34.

  30. Mobility • Describes the 24-h physical activity patterns of hospitalized patients at risk of PU • Each participant (n=84) wore a physical activity monitor continuously for 24 h • On average patients changed their position just over 90 times, which reflects ≈ 3.8 times per hour • Unable to tell to what extent patients moved themselves and how much movement was initiated by nursing staff Reference: CHABOYER, W., MILLS, P. M., ROBERTS, S. & LATIMER, S. 2015. Physical activity levels and torso orientations of hospitalized patients at risk of developing a pressure injury: an observational study. Int J Nurs Pract, 21, 11-7.

  31. Mobility • Spontaneous movements among patients (n=52) were registered continuously using a specific monitoring system • The nursing staff documented each time they repositioned the patient • Patients spontaneous movements were compared with nursing staff induced repositionings • There were large variations in the patients’ spontaneous repositioning frequency during both days and nights Reference: KALLMAN, U., BERGSTRAND, S., EK, A. C., ENGSTROM, M. & LINDGREN, M. 2015. Nursing staff induced repositionings and immobile patients' spontaneous movements in nursing care. Int Wound J. DOI: 10.1111/iwj.12435

  32. Mobility • Although immobilised, some patients frequently reposition themselves • Analgesics were positively related to the movement frequency and psycholeptics were negatively related • Nursing staff more often repositioned the patients assessed as high risk than those assessed as low risk • The patients’ spontaneous movement frequency was not correlated to the risk score Reference: KALLMAN, U., BERGSTRAND, S., EK, A. C., ENGSTROM, M. & LINDGREN, M. 2015. Nursing staff induced repositionings and immobile patients' spontaneous movements in nursing care. Int Wound J. DOI: 10.1111/iwj.12435

  33. Mobility • Observational study of n=241 participants with reduced mobility • 66.4% were able to move themselves in bed, either independently or with the assistance of bed mechanics • Participants moved once every 1. 7 hours, but not necessarily to good PU prevention positions • Older patients and males were repositioned less frequently Reference: LATIMER, S., CHABOYER, W. & GILLESPIE, B. M. 2015. The repositioning of hospitalized patients with reduced mobility: a prospective study. Nursing Open, 2, 85-93.

  34. Risk Assessment

  35. Risk Assessment

  36. 13 Moderate Risk

  37. 16 Mild Risk

  38. Who is really at risk?

  39. Risk Assessment Mild Risk Image courtesy of Dr Aglecia Budri 2019

  40. Mobility Assessment • Patient #1 (No PU) • Patient #2 (PU) Image courtesy of Dr Aglecia Budri 2019

  41. Risk Assessment Mean Waterlow Scores Reference: Molloy S, Moore Z, O’Connor T, Patton D (2015) The Relationship between Risk Assessment Tools and Sub-Epidermal Moisture Measurement . MSc Thesis RCSI

  42. Risk Assessment Mean Braden Scores Reference: Molloy S, Moore Z, O’Connor T, Patton D (2015) The Relationship between Risk Assessment Tools and Sub-Epidermal Moisture Measurement . MSc Thesis RCSI

  43. Risk Assessment Risk estimates are even more important in evaluating screening and preventive care, since individuals are counselled to seek these services. For this counsel to be ethical, not only must the action not be harmful, but it must have a reasonable chance of benefiting the person. • Reference: Lester B. Lave cited in Rifkin E, Bouwer E (2007) The Illusion of Certainty Health Benefits and Risks. Springer

  44. Risk Assessment Reference: Molloy S, Moore Z, O’Connor T, Patton D (2015) The Relationship between Risk Assessment Tools and Sub-Epidermal Moisture Measurement . MSc Thesis RCSI

  45. Risk Assessment Reference: PANCORBO-HIDALGO, P. L., GARCIA-FERNANDEZ, F. P., LOPEZ-MEDINA, I. M. & ALVAREZ-NIETO, C. 2006. Risk assessment scales for pressure ulcer prevention: a systematic review. Journal of Advanced Nursing 54, 94-10.

  46. Risk Assessment • We are uncertain whether use of the Braden risk assessment tool and training makes any difference to pressure ulcer incidence, compared to risk assessment using clinical judgement and training • (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.53 to 1.77; 150 participants), or compared to risk assessment using clinical judgement alone (RR 1.43, 95% CI 0.77 to 2.68; 180 participants). • We assessed the certainty of the evidence as very low (downgraded twice for study limitations and twice for imprecision). • Reference: Moore  ZEH, Patton  D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub4.

  47. Risk Assessment • Risk assessment using the Ramstadius tool may make little or no difference to pressure ulcer incidence, or to pressure ulcer severity, when compared to risk assessment using clinical judgement • (pressure ulcers of all stages: RR 0.79, 95% CI 0.46 to 1.35; 820 participants; • stage 1 pressure ulcers: RR 0.90, 95% CI 0.48 to 1.68; 820 participants; • stage 2 pressure ulcers: RR 0.50, 95% CI 0.15 to 1.65; 820 participants). • We assessed the certainty of the evidence as low (downgraded once for study limitations and once for imprecision). • Reference: Moore  ZEH, Patton  D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub4.

  48. Risk Assessment • Risk assessment using the Waterlow tool may make little or no difference to pressure ulcer incidence, or to pressure ulcer severity, when compared to risk assessment using clinical judgement (pressure ulcers of all stages): • RR 1.10, 95% CI 0.68 to 1.81; 821 participants; stage 1 pressure ulcers: RR 1.05, 95% CI 0.58 to 1.90; 821 participants; stage 2 pressure ulcers: RR 1.25, 95% CI 0.50 to 3.13; 821 participants), • or risk assessment using the Ramstadius tool (pressure ulcers of all stages: RR 1.41, 95% CI 0.83 to 2.39; 821 participants; stage 1 pressure ulcers: RR 1.16, 95% CI 0.63 to 2.15; 821 participants; stage 2 pressure ulcers: RR 2.49, 95% CI 0.79 to 7.89; 821 participants). • Reference: Moore  ZEH, Patton  D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub4.

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