Assessment of Risk for Pressure Ulcers in Critical Patients: Nursing Practice and Reflections in the Context of Multidisciplinary Communication

Monday, 9 November 2015

Josilene de Melo Buriti Vasconcelos, PhD, RN, RN
Health Sciences Center, Federal University of Paraíba (UFPB), Campus I João Pessoa, Brazil, João Pessoa – PB, Brazil
Maria Helena Larcher Caliri, PhD, RN
School of Nursing, University of Sao Paulo at Ribeirao Preto, Ribeirao Preto, Brazil




Pressure ulcers (PU) constitute a serious problem, considered as an adverse result of healthcare that compromises patient safety; however, they are preventable in most cases. The incidence of PU stands out as an important indicator in the quality of care in hospitals, where the reference sector for calculation is the intensive care Unit, and its monitoring is the responsibility of nursing. Several risk factors have been reported in the literature because they are associated with the development of PU and, among them, are highlighted the general state of health: diabetes, stroke, multiple sclerosis, cognitive deficit, cardiopulmonary disease, malignancy, hemodynamic instability, peripheral vascular disease, malnutrition and dehydration; premature neonate; history of smoking; history of previous UP; increased length of stay; significant weight loss; extended time on stretchers; medications: sedatives, analgesics and anti-inflammatory drugs; and refusal of care (WOCN, 2010). Depending on the risk factors to which they are exposed, the patient may present greater or lesser vulnerability to the development of PU. However, for the risk assessment the international guidelines recommend the use of risk assessment scales, and highlight the Braden and Norton scales as the ones that have been most studied in the adult population, and are considered valid for PU risk prediction in a variety of healthcare facilities. In these scales, Braden's is the most utilized in Brazil, being applied in most cases by the nurses. The risk determination for developing PU through a specific scale must be associated with the clinical observation to evaluate other related factors that are not addressed in these tools. The results of this evaluation should provide the framework for the development of an individualized care plan, centered on the patient, which presupposes a collaboration process between the patient, family and healthcare professionals (REGISTERED NURSES ASSOCIATION OF ONTARIO, 2011). Based on these, the importance of risk assessment for PU is noted in view of establishing appropriate preventive measures; proper registration of this assessment in medical records it is paramount for facilitating team communication and ensuring appropriate care planning.



Identifying on patient´s records, documentation of nursing actions related to risk assessment for PU; Analyze the perception of members of multidisciplinary health team about risk assessment for pressure ulcers and the interdisciplinary communication process.


Descriptive study, with quantitative and qualitative approach, carried out in the ICU of teaching hospital, in João Pessoa/PB, Brazil after approval by the ethics and Research Committee of the institution. Data collection was done initially by a review of 38 patient’s records using a structured tool. After  that a focus group was conducted with members of the ICU’s  multidisciplinary team to discuss the results regarding the risk assessment practice for PU and to identify the difficulties and strategies that could be used to improve this practice, considering it within the interdisciplinary communication process. Four focus groups were conducted, three of them with the nursing staff, and one with representatives from all of the ICU's health professionals. For analysis of the results, the descriptive statistics and content analysis technique proposed by Bardin were used.


The risk assessment for developing PU on admission was documented by the nurses in the medical records of 57.9% patients and all used the Braden Scale. Risk assessment was not documented by the nurses in any patient records on the days following admission. Analysis of discussions on the focal group produced a category “practice of pressure ulcer risk assessment” that originated three subcategories. The first subcategory called “risk assessment using the Braden Scale”, revealed that this scale is the risk assessment tool used in intensive care, and nurses are responsible for its implementation and they do the evaluation only at the time of patient´s admission, and that the results obtained are not used for the planning of care but for administrative purposes. The second subcategory “barriers to completion of the risk assessment for development of PU” identified the lack of knowledge to perform the risk assessment for PU with the Braden scale, ignorance of the professional standards for nursing practice and regulation and nurse´s responsibility for patient care. Nurses prioritize bureaucratic activities over the actions of direct care with the patient, overwork and complain of fatigue due to long working hours in different hospitals. The statements from the nurses have reinforced the importance of subsequent evaluations, as it is presented on international PU prevention guidelines. In the third subcategory- “strategies for assessing the risk for development of PU” it was evident that the Braden scale should be used as a standard tool for PU risk assessment and that the  nurses could continue to apply it daily and document the obtained scores on patients chart. Also, they emphasized that the results of the total score and sub-scores should be known by the other members of multidisciplinary team and be used to plan the preventive measures. However all professionals should be educated about the importance of the tool and trained on how to use the  Braden scale also have enough time during their work to do the assessment and to plan the adequate care. In this context, it is important to highlight that, considering the multiple causes of PU, each member of the multidisciplinary team has a responsibility for its prevention, and needs to observe the standards of their professional practice as well as to document properly their actions.  However, despite the studies that show that prevention of PU goes beyond nursing actions, it was perceived that nurses continue to be responsible for its occurrence and, therefore, its prevention. Regarding the second category “documentation of evaluations in the patient  records” there are two subcategories. The first – “the importance and practice of documentation”, where the nurses showed the importance of the documentation  related to the risk assessment; however, they recognized that there was underreporting of those in the ICU. The nutritionist stressed the importance of nursing records as a source of information to support the nutritional interventions, so once again the importance of the nursing notes as a source of communication tool between team members. Nevertheless, the physician valued not  the risk assessment, but the documentation about characteristics of the wound when present, recognizing that there are gaps in the record of the occurrence of these, and that sometimes the nursing professionals do the documentation but the other members of the team do not value the information received. The second subcategory- “strategies for improving the documentation” highlighted the need to design an appropriate form to be included on patient´s chart in order to document the risk assessment and for monitoring the skin conditions during hospitalization.


The results of this study shows that in order to improve the quality of care in the setting where the study was done it is necessary to use strategies to modify working conditions as well as to educate professionals about how to use the Braden scale do the PU risk assessment and to use the results of evaluation to do the planning of preventive care in a multidisciplinary perspective. It is necessary also to focus on how to increase the documentation of  professionals  actions on patient’s records as a way to improve team communication and to prevent PU.