Pressure ulcer prevention and management for nurses

1. Pressure Ulcer Prevention and
Management
A.Deeparani.,DNS.

2. DEFINITION
‘A pressure ulcer is an area of localised
damage to the skin and underlying tissue
caused by pressure,shear,friction and
/or a combination of these’.

3. OBJECTIVES
• To assess all patients for risk of
developing a pressure ulcer
• To decrease the incident of
pressure ulcer development
• To provide general instructions for
skin care, pressure ulcer and wound
care management.
• To provide staff guidelines for
documenting, assessing and
preventing pressure ulcer.
• To Educate all patients and families
in the prevention of pressure ulcer.

4. SIGNS & SYMPTOMS
• Pain and discomfort
• Easily become infected fever and feel
unwell.
• Infected wound often smell.
• Serious (protein) leakage from
pressure sore protein deficiency in
blood leading to edema and infection
• skin is intact ,darker skin,appear
ashen, bluish or purple.
• The site may be painful, firm, soft,
warmer or cooler compared with the
surrounding skin.

5. SIGNS AND SYMPTOMS
• The skin appears red lighter skin color,
and the skin doesn't briefly lighten
(blanch) when touched.
• Ulcer may appear as a shallow, pinkish-
red, basin-like wound, as an intact or
ruptured fluid-filled blister.
• The wound may expose muscle, bone
and tendons.
• The bottom of the wound likely contains
slough or dark, crusty dead tissue
(Eschar).
• The damage often extends beyond the
primary wound below layers of healthy
skin.

6. CAUSES
• Pressure sores are caused by pressure not
adequate supply of blood to skin and underlying
tissues.
• factors related to limited mobility can make the
skin vulnerable to damage and contribute to the
development of pressure sores.
THERE ARE THREE PRIMARY CONTRIBUTING FACTORS:
• Sustained pressure. When your skin and the
underlying tissues are trapped between bone and a
surface such as a wheelchair or bed, the pressure may
be greater than the pressure of the blood flowing in
the tiny vessels (capillaries) that deliver oxygen and
other nutrients to tissues. Deprived of these essential
nutrients, cells of the skin and other tissues are
damaged and may eventually die. This kind of
pressure tends to happen in areas that aren't well
padded with muscle or fat and that lie just over a
bone,such as your spine, tailbone (coccyx)shoulder
blades, hips, heels and elbows.

7. CAUSES
• Friction. Friction is the resistance to
motion. When a person changes position or
is handled by care providers, friction may
occur when the skin is dragged across a
surface. The resistance to motion may be
even greater if the skin is moist. Friction
between skin and another surface may make
fragile skin more vulnerable to injury.
• Shear. Shear occurs when two surfaces
move in the opposite direction. For example,
when a hospital bed is elevated at the head,
a person can slide down in bed. As the
tailbone moves down, the skin over the bone
may stay in place - essentially pulling in the
opposite direction. This motion may damage
tissue and blood vessels, making the site
more vulnerable to damage from sustained
pressure

8. RISK FACORS
Anyone with limited mobility -
unable to easily change position
while seated or in bed -is at risk of
developing pressure sores.
• Immobility may be due to:
1.Generally poor health or weakness
2.Paralysis
3.Injury or illness that requires bed rest
or wheelchair use
4.Recovery after surgery
5.Sedation
6.Coma

10. NUTRITION & WOUND HEALING
Malnutrition results in prolonged healing and a
weaker wound

11. OTHER FACTORS THAT INCREASE THE
RISK OF PRESSURE SORES INCLUDE:
• Age/Lack of sensory perception..
• Weight loss/obesity
• Poor nutrition and hydration.
• Urinary or fecal incontinence.
• Excess moisture or dryness.
• Medical conditions affecting circulation.
• Smoking.
• Decreased mental awareness and muscle spasms.
Complications of pressure ulcers include:
• Sepsis..
• Cellulitis.
• Bone and joint infections..
• Cancer..

12. TESTS AND DIAGNOSIS
EVALUATING A BEDSORE:
To evaluate your bedsore, your doctor will:
• Determine the size and depth of the ulcer
• Check for bleeding, fluids or debris in the
wound that can indicate severe infection
• Determine if there are odors that indicate an
infection or dead tissue
• Assess the area around the wound for signs of
spreading tissue damage or infection
• Check for other pressure sores on the body
TESTS
Your doctor may order the following tests:
• Blood tests to assess your nutritional status and
overall health
• Tissue cultures to diagnose a bacterial or fungal
infection in a wound that doesn't heal with
treatment or is already a stage IV wound
• Tissue cultures to check for cancerous tissue if
it's a chronic, nonhealing wound

13. QUESTIONS FROM THE DOCTOR
Your doctor may ask you or your caregiver
questions such as:
When did the pressure sore first appear?
What is the degree of pain?
Have you had pressure sores in the past?
How were they managed, and what was the
outcome of treatment?
What kind of care assistance is available?
What is your routine for changing positions?
What medical conditions have been diagnosed,
and what is the current treatment?
What is your normal daily diet?
How much water and other fluids do you drink
each day?

14. PREVENTION
• Bedsores are Easier to prevent than to
treat, but that doesn't mean the process is
easy or uncomplicated. And wounds may still
develop with consistent, appropriate
preventive care.
• Your doctor and other members of a care
team can help develop a strategy that's
appropriate whether it's personal care with at-
home assistance or professional care in a
hospital or residential setting.
• Position changes are key to pressure sore
prevention. These changes need to be
frequent, repositioning needs to avoid stress
on the skin, and body positions need to
minimize the risk of pressure on vulnerable
areas. Other strategies include skin care,
regular skin inspections and good nutrition.

15. PREVENTIONRepositioning in a wheelchair
Self-care
Specialized wheelchair
Cushions
Repositioning in a bed
Repositioning devices
Special mattresses and support surfaces
Bed elevation
Skin care
Bathing
Protecting skin
Inspecting skin
Managing incontinence
Nutrition
Diet
Fluids
Feeding assistance
Other strategies
Quit smoking

16. BED SORE CLASSIFICATION
GRADE-I
GRADE-II
GRADE-III
GRADE-IV

17. Pressure ulcer classification
GRADE 1  In the iniital stage discoloration
of skin (Redness) warmth, edema
& hardness surrounding the skin.

18. GRADE I BED SORE

19. GRADE 2
• In the second stage there
may be a blister or a shallow
crater or a superficial ulcer.
• Partial thickness of skin loss
involving epidermis, dermis or
both.
PRESSURE ULCER
CLASSIFICATION

20. GRADE II BED
SORE

21. GRADE 3
• Full thickness skin
loss,damage&necrosis to
subcutaneous tissue that
extends down but not to
underlying fascia.
PRESSURE ULCER
CLASSIFICATION

22. Grade III Bed sore

23. GRADE 4
There is formation of Deep
ulcer involving muscles,
bones and tendons.
PRESSURE ULCER
CLASSIFICATION:

24. GRADE IV BED SORE

25. Pressure points

26. SUPINE POSITION
Elbow
Occiput
Dorsal thoracic area Sacrum
Heel

27. PRONE POSITION

28. SIDE LYING POSITION
Ankle
Perineum Ear
Outer aspect
of feet
Outer aspect of knee
Greater trochanter
Ribs
Shoulders

29. SITTING IN BED POSITION
Heels
Ischial tuberosity
Sacrum
Spine
Back of
head
Elbows

30. SEATING POSITION
Shoulder blades
Sacrum
Ischials tuberosities
Heels
Foot
Posterior knee
Heels

31. Factors
Extrinsic
• Pressure
• Shear
• Friction
• Restricted Mobility
• Moisture
• Surgery
• Poor moving and
handling
• Medication
• Inappropriate
positioning
• Poor hygiene
• Inappropriate clothing
Intrinsic
• Nutritional status
• Build
• Age
• Sensory impairment
• Incontinence
• Infection
• Reduced mobility
• Circulatory
disorders
• Dehydration
• Mental status
• Neurological
disease

32. PREVENTION OF BED SORE
• Early assessment and re-assessment

34. Provide Nutritionally balanced diet
with adequate fluid intake.

35. Skin Care - Provide regular bathing and
good perineal care,back care

36. Inspect the skin regularly

37. Blood circulation is very important
for preventing pressure sore

38. Clothing - Keep sheets dry and free of wrinkles

39. Manual Handling – Eliminate frictional shear
(don’t pull or tract the patient)

40. PROVIDE ALPHA BED

41. Positioning the patient
• Turning : Individualized reposition will be
done for the patient. (Unless the patient able
to reposition themselves) monitoring of
turning is the responsibility of the nursing
personnel.
• Proper positioning : Use of pillows, wedges &
padding devices (OT).

42. Maintain Personel Hygiene

43. Patient family Education

44. DOCUMENTATION

45. SKIN CARE ASSESSMENT
 Skin integrity assessment on
admission.
 Skin integrity check in each
shift and receiving
(or)handing over of patient from
one area to another area
 Pressure area care given and
documentation in each shift

46. Back care 4 steps
• Effleurage – stimulate
circulation
• Petri stage – breakup the
adipose tissue
• Kneeling - to stimulate
nerve endings
• Tapping – chest will be
clear

47. TURNING – IF YOU DON’T TURN THE PATIENT
Muscle atrophy
Joint contracture
Pneumonia
Renal stasis
DVT

48. Turning-If not turn the patient
Muscle atrophy joint contrature

49. Pneumonia Renal stasis DVT

50. Role of Surgery on Pressure sore
• Deep pressures sore may require plastic surgery to speed
up healing.
• Surgery involves removal of damaged & infected tissue
and repositioning of healthy skin, soft tissue and / or
muscles over bony prominences.
• This healthy extra padding helps in healing & protects
prominent bones .
• Helps in preventing breakdown. Pressure sores should be
prevented & if it occurs it should be detected early and
prevented from becoming deeper.

51. It should be detected early and prevented from becoming deeper.

52. SKIN INTEGRITY ASSESSMENT
• Baseline and Continual assessment
provide critical information about the
client’s skin integrity and the
increased risk for pressure ulcer
development.
• Assessment of risk or contributing
factors associated with skin
breakdown should be determined
from the patient’s history

53. SKIN INTEGRITY ASSESSMENT
The classification of skin integrity assessment for
the different age groups.
 5-18 yrs Braden scale
 1-5 yrs Braden Q Scale
 0-1 yrs Braden Q Scale

54. 5-18 AND ADULT - BRADEN SCALE

55. BRADEN SCALE
SCORE 1 SCORE 2 SCORE 3 SCORE 4
Sensory
perception
Completely
Limited
Very Limited Slightly Limited No impairment
Moisture Constantly
moist
Very Moist Occasionally Usually Dry
Activity ABR Chair Fast Ambulates
occasionally
Ambulate
frequently
Mobility Completely
immobile
Very limited Slightly limited No limitation
Nutrition Very poor Inadequate Adequate Excellent
Friction Problem Potential No apparent
Problem
Up AD lib

56. SCORES 4 3 2 1 DATE DATE DATE
Sensory
perception
No Impairment:
Able to verbalize feeling
and complaints.
Has no sensory deficit
Slightly Limited:
Responds to verbal commands but
cannot always communicate
discomfort or need to be turned
OR
Has some sensory impairment
which limits ability to feel pain or
discomfort in 1 or 2 extremities.
Very Limited:
Has a sensory impairment which
responsive to painful stimuli OR limited to
feel pain or discomfort over half of body.
OR paralysis present.
Completely Limited:
Unresponsive (does not moan, linch, or grasp) to
painful stimuli, due to diminished level of
consciousness or sedation
OR
limited ability to feel pain over most body surfaces.
Moisture Usually dry:
No extra line changes.
Occasionally Moist:
Skin is occasionally moist,
requiring an extra linen change
approximately once a day.
Very Moist:
Skin is often but not always moist. Linen
must be changed at least once a shift.
Constantly Moist:
Skin is kept moist almost constantly by perspiration,
urine, etc.
Activity Ambulates Frequently:
Walks outside the room
at least twice a day and
inside the room once
every 2 hours during
waking hours.
Ambulates Occasionally:
Walks occasionally during day, but
for very short distance, with or
without assistance Spends
majority of each shift in bed or
chair.
Chair fast:
Ability to walk severely limited or
nonexistent. Cannot bear own weight and /
or must be assisted in to chair or wheel
chair
ABR:
Absolute bed rest.
Mobility No Limitation:
Makes major & frequent
changes in position
without assistance.
Slightly Limited:
Makes frequent though slight in
body or extremity position
independently
Very Limited:
Makes occasional slight changes in body or
extremity position but enable to make
frequent or significant changes
independently.
Completely Immobile:
Does not make even slight changes in body or
extremity position without assistance.
Nutrition Excellent:
Eats most of every meal.
Never refuse a meal.
Usually eats total 4 or
more servings of meat
and dairy products.
Occasionally eats
between meals. Does
not require supplement.
Adequate:
Eats over half of the most meals.
Eats a total of 4 serving of protein
(meat, dairy product,) each day.
Occasionally will refuse a mean ,
but will usually take a supplement
if offered
OR
is on tube feeding or TPN regimen
which probably meets of
nutritional needs.
Probably inadequate:
Rarely eats a complete meal and generally
eats only half of any food offer. Protein
intake includes only 3 servings of meet or
dairy products per day. Occasionally will
take a dietary supplement
OR
Receives less than optimum amount of
liquid diet or tube feeding.
Very Poor:
Never eats a complete meal. Rarely eats more than
1/3 of any food offered. Eats 2 serving or less of
proteins (meat or dairy products) per day. Fluids
taken poorly. Does not take a liquid supplement
OR
is NBM and or maintained on clear liquids or IV's for
more than 5 days.
Friction No Apparent Problem:
Moves in bed and in chair
independently and has
sufficient muscle strength
to up completely during
move.
Maintains good position in
bed and chair at all times.
Potential Problem:
Moves freely or requires minimum
assistance. During a move skin
probably slides to some extend
against sheets, chair restraints or
other devices maintains relatively
good position in chair or bed most
of the time but occasionally slides
down.
Requires assistances in moving frequent
friction. History of skin tears or pressure
sores.
(Complete lifting without sliding against
sheets is impossible. Frequently slides
down in bed or chair, requiring frequently
repositioning with maximum assistance.
Spasticity, contractures or agitation leads
to almost constant friction.)

57. SCORES
DATE & TIME
Sensory
Perception
1 Completely
limited
2 Very Limited 3 Slightly Limited 4 No impairment
Moisture 1 Constantly
Moist
2 Very Moist 3 Occasionally
Moist
4 Rarely Moist
Activity 1 Bedfast 2 Chair fast 3 Walks
Occasionally
4 All patients too
young to ambulate
OR walks frequently
Mobility 1 Completely
immobile
2 Very limited 3 Slightly Limited 4 No Limitations
Nutrition 1 Very Poor 2 Inadequate 3 Adequate 4 Excellent
Friction –Shear 1 Significant
Problem
2 Problem: 3 Potential
Problem
4 No Apparent
Problem
TOTAL
STAFF NURSE SIGNATURE
Braden Scale
for adult
Braden Q
Scale(PAED)
Braden Q
Scale(NEW
BORN)
Risk
15-24 19-28 23-32 Mild (Low)
13 -14 17-18 21-22 Moderate (Medium)
<12 <16 <20 Severe (High)
Braden scale skin integrity score assessment tool (5 to 18 and above)

58. SCORES 4 3 2 1 DATE DATE DATE
Sensory
perception
No impairment:
Age appropriate
responsive to aversive
stimuli: alert, perceptive.
Slightly limited:
Easily agitated but calms with
comfort measures.
Very limited;
Not tolerant to stimuli (noise, lights &
touch ) easily agitated, difficult to
calm.
Completely Limited:
Unresponsive to environmental
or tactile stimuli.
Moisture Usually dry:
No extra line changes.
Occasionally Moist:
Skin is occasionally moist,
requiring an extra linen change
approximately once a day.
Very Moist:
Skin is often but not always moist.
Linen must be changed at least once a
shift.
Constantly Moist:
Skin is kept moist almost
constantly by perspiration,
urine, etc.
Activity No limitations:
Can be repositioned or
held freely.
Slightly limited:
Tolerates frequent position
changes, can be held and/or out
of bed, skin to skin care
Very limited:
Tolerates position changes, may be
lifted to reposition but it’s not out of
bed.
Bed fast:
Confined to bed, minimal
shifting of position.
Mobility No limitation:
makes major and frequent
changes in position,
moving all extremities,
turning head, positive
reflexes.
Slightly limited:
Makes frequently
changes in body or extremity
position, limited
extension/flexion of
extremities.
Very limited:
Makes occasional slight changes in
body or extremity position.
Completely immobile:
Food intake and
feeds
Excellent:
Normal diet
Adequate calories
Consistent weight gain.
Adequate :
Tube feeding or TPN
Adequate calories, stable
weight or weight gain.
Inadequate:
Tube feeding or TPN ,Inadequate
caloric's, trophic feeds, partial feeds
,Losing weight.
Very poor:
NPO,Clear liquids ,Iv fluids
,Losing weight.
Friction No apparent problem:
Able to completely lift
patient during a position
change.
Maintains good position at
all times.
Potential problem:
During a move skin slides to
some extent against sheets but
easily repositioned. Maintains
relatively good position.
Occasionally slides down.
Problem:
Complete lifting without sliding
impossible fragile skin. Requires
frequent repositioning
Significant problem:
Agitation leads to almost
constant
Tissue perfusion
and oxygenation
Excellent Normotensive;
SPO2 > 95% ,Hb > 10g/dl
CRFT<2 seconds
Adequate:
Normotensive ,SPO2 < 95%
Hb < 10g/dl ,CRFT>
2seconds,PH normal
Compromised:
Normotensive SPO2 < 95% ,Hb <
10g/dl
CRFT>2seconds,PH <7.40
Extremely compromised:
Hypertensive(MAP
<50mmHg<40 in a
newborn)The patient does not
physiologically tolerate
position changes
TOTAL SCORE

59. SCORES
DATE & TIME
Sensory
Perception
1 Completely
limited
2 Very Limited 3 Slightly Limited 4 No impairment
Moisture 1 Constantly Moist 2 Very Moist 3 Occasionally Moist 4 Rarely Moist
Activity 1 Bedfast: 2 Chair fast 3 Walks Occasionally 4 All patients too young
to ambulate OR walks
frequently
Mobility 1 Completely
immobile
2 Very limited 3 Slightly Limited 4 No Limitations
Nutrition 1 Very Poor 2 Inadequate 3 Adequat 4 Excellent
Friction –Shear 1 Significant
Problem
2 Problem: 3 Potential Problem 4 No Apparent
Problem
Tissue
Perfusion
and
Oxygenation
1 Extremely
Compromised
2 Compromised 3 Adequate 4 Excellent
TOTAL
STAFF NURSE SIGNATURE
Braden Score Braden Q Scale(PAED) Braden Q Scale(NEW
BORN)
Risk
15-24 19-28 23-32 Mild (Low)
13 -14 17-18 21-22 Moderate (Medium)
<12 <16 <20 Severe (High)
Braden Q scale skin integrity score assessment tool(1 to 5 years)

60. SCORES 4 3 2 1 DATE DATE DATE
Sensory
perception
No impairment:
Age appropriate responsive
to aversive stimuli: alert,
perceptive.
Slightly limited:
Easily agitated but calms with
comfort measures.
Very limited;
Not tolerant to stimuli (noise,
lights & touch ) easily agitated,
difficult to calm.
Completely Limited:
Unresponsive to
environmental or tactile
stimuli.
Moisture Usually dry:
No extra line changes.
Occasionally Moist:
Skin is occasionally moist,
requiring an extra linen change
approximately once a day.
Very Moist:
Skin is often but not always moist.
Linen must be changed at least
once a shift.
Constantly Moist:
Skin is kept moist almost
constantly by perspiration,
urine, etc.
Activity No limitations:
Can be repositioned or held
freely.
Slightly limited:
Tolerates frequent position
changes, can be held and/or out
of bed, skin to skin care
Very limited:
Tolerates position changes, may
be lifted to reposition but its not
out of bed.
Bed fast:
Confined to bed, minimal
shifting of position.
Mobility No limitation:
makes major and frequent
changes in position, moving
all extremities, turning head,
positive reflexes.
Slightly limited:
Makes frequently
changes in body or extremity
position, limited
extension/flexion of extremities.
Very limited:
Makes occasional slight changes in
body or extremity position.
Completely immobile:
Food intake and
feeds
Excellent:
Normal diet
Adequate calories
Consistent weight gain.
Adequate :
Tube feeding or TPN
Adequate calories, stable weight
or weight gain.
Inadequate:
Tube feeding or TPN
Inadequate caloric's, trophic feeds,
partial feeds
Losing weight.
Very poor:
NPO
Clear liquids
Iv fluids
Losing weight.
Friction No apparent problem:
Able to completely lift
patient during a position
change.
Maintains good position at
all times.
Potential problem:
During a move skin slides to some
extent against sheets but easily
repositioned. Maintains relatively
good position.
Occasionally slides down.
Problem:
Complete lifting without sliding
impossible fragile skin. Requires
frequent repositioning
Significant problem:
Agitation leads to almost
constant
Tissue
perfusion and
oxygenation
Excellent Normotensive;
SPO2 > 95% ,Hb > 10g/dl
CRFT<2 seconds
Adequate: Normotensive
SPO2 < 95% ,Hb < 10g/dl
CRFT> 2seconds,PH normal
Compromised:
Normotensive,SPO2 < 95%
Hb < 10g/dl ,CRFT>2seconds
PH <7.40
Extremely compromised:
Hypertensive(MAP <50mmHg,
<40 in a newborn)The patient
does not physiologically
tolerate position changes
Gestational Age >38 weeks >33 weeks to < 38 weeks > 28 weeks to &< 33 weeks < 28 weeks
TOTAL SCORE
BRADEN Q SCALE FOR NEW BORN (0 to 1year) -PRESSURE ULCER RISK ASSESSMENT

61. SCORES
DATE & TIME
Sensory
Perception
1 Completely
limited
2 Very Limited 3 Slightly Limited 4 No impairment
Moisture 1 Constantly Moist 2 Very Moist 3 Occasionally Moist 4 Rarely Moist
Activity 1 Bedfast: 2 Chair fast 3 Walks Occasionally 4 All patients too
young to ambulate
OR walks frequently
Mobility 1 Completely
immobile
2 Very limited 3 Slightly Limited 4 No Limitations
Nutrition 1 Very Poor 2 Inadequate 3 Adequate 4 Excellent
Friction –Shear 1 Significant
Problem:
2 Problem: 3 Potential Problem 4 No Apparent
Problem
Tissue
Perfusion
and
Oxygenation
1 Extremely
Compromised
2 Compromised 3 Adequate 4 Excellent
Gestational Age >38 weeks >33 weeks to < 38
weeks
> 28 weeks to &< 33
weeks
< 28 weeks
TOTAL
STAFF NURSE SIGNATURE
Braden Score Braden Q
Scale(PAE
D)
Braden Q Scale(NEW BORN) Risk
15-24 19-28 23-32 Mild (Low)
13 -14 17-18 21-22 Moderate (Medium)
<12 <16 <20 Severe (High)
Braden Q scale skin integrity score assessment tool(0 to 1 year)

62. Sensory Perception
Score 1 Score 2 Score 3 Score 4
Completely
Limited:
Unresponsive (does
not moan, linch, or
grasp) to painful
stimuli, due to
diminished level of
consciousness or
sedation
OR
limited ability to feel
pain over most body
surfaces.
Very Limited:
Has a sensory
impairment which
responsive to
painful stimuli OR
limited to feel pain
or discomfort over
half of body. OR
paralysis present.
Slightly
Limited:
Responds to verbal
commands but
cannot always
communicate
discomfort or need
to be turned
OR
Has some sensory
impairment which
limits ability to feel
pain or discomfort
in 1 or 2 extremities.
No
Impairment:
Able to verbalize
feeling and
complaints.
Has no sensory
deficit
Ability to respond meaningfully to pressure related discomfort.

63. Moisture
Degree to which skin is expose to moisture
Score 1 Score 2 Score 3 Score 4
Constantly
Moist:
Skin is kept moist
almost constantly by
perspiration, urine,
etc.
Very Moist:
Skin is often but not
always moist. Linen
must be changed at
least once a shift.
Occasionally
Moist:
Skin is occasionally
moist, requiring an
extra linen change
approximately once
a day.
Usually dry:
No extra line
changes.

64. Activity
Degree of physical activity
Score 1 Score 2 Score 3 Score 4
ABR:
Absolute bed rest.
Chair fast:
Ability to walk
severely limited or
non existent. Cannot
bear own weight and
/ or must be assisted
in to chair or wheel
chair.
Ambulates
Occasionally:
Walks occasionally
during day, but for
very short distance,
with or without
assistance Spends
majority of each
shift in bed or chair.
Ambulates
Frequently:
Walks out side the
room at least twice
a day and inside the
room once every 2
hours during waking
hours.

65. Mobility
Ability to change & control body position
Score 1 Score 2 Score 3 Score 4
Completely
Immobile:
Does not make
even slight
changes in body
or extremity
position without
assistance.
Very Limited:
Makes occasional
slight changes in
body or extremity
position but
enable to make
frequent or
significant changes
independently.
Slightly
Limited:
Makes frequent
though slight in
body or extremity
position
independently.
No
Limitation:
Makes major &
frequent changes
in position
without
assistance.

66. Nutrition
Usual food intake pattern
Score 1 Score 2 Score 3 Score 4
Very Poor:
Never eats a complete
meal. Rarely eats more
than 1/3 of any food
offered. Eats 2 serving
or less of proteins
(meat or dairy
products) per day.
Fluids taken poorly.
Does not take a liquid
supplement
OR
is NBM and or
maintained on clear
liquids or IV's for more
than 5 days.
Probably
inadequate:
Rarely eats a complete
meal and generally
eats only half of any
food offer. Protein
intake includes only 3
servings of meet or
dairy products per day.
Occasionally will take a
dietary supplement
OR
Receives less than
optimum amount of
liquid diet or tube
feeding.
Adequate:
Eats over half of the
most meals. Eats a
total of 4 serving of
protein (meat, dairy
products, ) each day.
Occasionally will
refuse a mean , but
will usually take a
supplement if offered
OR
is on tube feeding or
TPN regimen which
probably meets of
nutritional needs.
Excellent:
Eats most of every
meal. Never refuse a
meal. Usually eats a
total 4 or more
servings of meat and
dairy products.
Occasionally eats
between meals. Does
not require
supplement.

67. Friction
Score 1 Score 2 Score 3
Problem:
Requires assistances in
moving frequent friction.
History of skin tears or
pressure sores.
(Complete lifting without
sliding against sheets is
impossible. Frequently slides
down in bed or chair,
requiring frequently
repositioning with maximum
assistance. Spasticity,
contractures or agitation
leads to almost constant
friction.)
Potential Problem:
Moves freely or requires
minimum assistance. During
a move skin probably slides
to some extend against
sheets, chair restraints or
other devices maintains
relatively good position in
chair or bed most of the
time but occasionally slides
down.
No Apparent
Problem:
Moves in bed and in chair
independently and has
sufficient muscle strength to up
completely during move.
Maintains good position in bed
and chair at all times.

68. 1-5 yrs Braden Q Scale

69. BRADEN Q SCALE:
SCORE 1 SCORE 2 SCORE 3 SCORE 4
Sensory
perception
Completely
Limited
Very Limited Slightly Limited No impairment
Moisture Constantly
moist
Very Moist Occasionally Usually Dry
Activity ABR Chair Fast Ambulates
occasionally
Ambulate
frequently
Mobility Completely
immobile
Very limited Slightly limited No limitation
Nutrition Very poor Inadequate Adequate Excellent
Friction Problem Potential No apparent
Problem
Up AD lib
Tissue perfusion
and oxygenation
Extremely
compromised
compromised Adequate Excellent

70. FOR AGE GOUPS 1-5 YEARS, ADD
THE ABOVE SCORE TO THIS
SCORE 1 Score 2 Score 3 Score 4
Tissue
perfusion and
oxygenation
Extremely
compromised:
Hypertensive
(MAP
<50mmHg
<40 in a
newborn)
The patient does
not
physiologically
tolerate position
changes
Compromised:
Normotensive
SPO2 < 95%
Hb < 10g/dl
CRFT>2seconds
PH <7.40
Adequate:
Normotensive
SPO2 < 95%
Hb < 10g/dl
CRFT> 2seconds
PH normal
Excellent
Normotensive;
SPO2 > 95%
Hb > 10g/dl
CRFT<2 seconds

71. 0-1 yrs Braden Q Scale

72. Neonatal/Infant Braden Q scale
for < 1 year
Gestational
age
< 28 weeks > 28 weeks to
&< 33 weeks
>33 weeks to <
38 weeks
>38 weeks
Mobility Completely
immobile
Very limited Slightly limited No limitation
Activity Bedfast Very limited Slightly limited No limitation
Sensory
perception
Completely
limited
Very limited Slightly limited No impairment
moisture Constantly moist Very moist Occasionally
moist
Rarely moist
Friction& shear Significant
problem
problem Potential
problem
No apparent
problem
Food intake
pattern
Very poor Inadequate Adequate Excellent
Tissue
perfusion and
oxygenation
Extremely
compromised
Compromised Adequate Excellent

73. Gestational age:
Score 1 Score 2 Score 3 Score 4
< 28 weeks > 28 weeks to &<
33 weeks
>33 weeks to < 38
weeks
>38 weeks

74. Mobility
Score 1 Score 2 Score 3 Score4
Completely
immobile:
Very limited:
Makes occasional
slight changes in
body or extremity
position.
Slightly limited:
Makes frequently
changes in body or
extremity position,
limited
extension/flexion of
extremities.
No limitation:
makes major and
frequent changes in
position, moving all
extremities, turning
head, positive
reflexes.

75. Activity
Score 1 Score 2 Score 3 Score4
Bed fast:
Confined to bed,
minimal shifting of
position.
Very limited:
Tolerates position
changes, may be lifted
to reposition but its not
out of bed.
Slightly limited:
Tolerates frequent
position changes, can
be held and/or out of
bed, skin to skin care.
No limitations:
Can be
repositioned or
held freely.

76. Sensory perception:
Score 1 Score 2 Score 3 score4
Completely
Limited:
Unresponsive to
envirmental or
tactile stimuli.
Very limited;
Not tolerant to
stimuli (noise, lights
& touch ) easily
agitated, difficult to
calm.
Slightly limited:
Easily agitated but
calms with comfort
measures.
No impairment:
Age appropriate
responsive to
aversive stimuli:
alert, perceptive.

77. Moisture
Degree to which skin is expose to moisture
Score 1 Score 2 Score 3 Score 4
Constantly Moist:
Skin is kept moist almost
constantly by
perspiration, urine, etc.
Very Moist:
Skin is often but not
always moist. Linen
must be changed at least
once a shift.
Occasionally
Moist:
Skin is occasionally
moist, requiring an extra
linen change
approximately once a
day.
Rarely moist:
No extra
linen changes.

78. Friction & shear:
Score 1 Score 2 Score 3 Score 4
Significant problem:
Agitation leads to
almost constant
Problem:
Complete lifting
without sliding
impossible fragile
skin. Requires
frequent repositioning.
Potential problem:
During a move skin
slides to some extent
against sheets but
easily repositioned.
Maintains relatively
good position.
Occasionally slides
down.
No apparent
problem:
Able to completely lift
patient during a
position change.
Maintains good
position at all times.

79. Food intake pattern
Score 1 Score 2 Score 3 Score 4
Very poor:
NPO
Clear liquids
Iv fluids
Losing weight.
Inadequate:
Tube feeding or
TPN
Inadequate caloric's,
trophic feeds,
partial feeds
Losing weight.
Adequate :
Tube feeding or
TPN
Adequate calories,
stable weight or
weight gain.
Excellent:
Normal diet
Adequate calories
Consistent weight
gain.

80. Tissue perfusion and oxygenation:
Score 1 Score 2 Score 3 Score 4
Extremely
compromised:
Hypotensive
(MAP <50mmHg:
<40 in a
newborn)OR
The patient does not
physiologically
tolerate position
changes
Compromised:
Normotensive
SPO2 < 95%
Hb < 10g/dl
CRFT>2seconds
PH <7.40
Adequate:
Normotensive
SPO2 < 95%
Hb< 10g/dl
CRFT> 2 seconds
PH normal
Excellent
Normotensive;
SPO2 > 95%
Hb > 10g/dl
CRFT<2 seconds

81. High risk score for different age groups
5-18 yrs Braden scale - < 12
1-5 yrs Braden Q scale - < 16
0-1 yrs Braden Q scale - < 20

82. SKIN ISSUES DUE TO PLASTER
Skin peeling due to Tegaderm
Skin Peeling Due to Micropore

83. Skin peeling due to Dynaplaster

84. Skin peeling due to
Duropore
Skin peeling due to
Tracheostomy Tube Tie

85. Skin peeling due to
Bipap Mask
Skin peeling due to
Ted Stockings

86. Method of securing Plasters

88. Method of removing plasters

91. Achieve no skin peeling

93. QUESTIONS
1.How to identify the risk patients for developing pressure sore?
a. Nurses assessment form
b. Fall risk assessment
c. Skin integrity assessment scale (Braden scale, Braden Q Scale)).
d. None
2.Skin integrity assessment scale is used to identify
a. Sensory perception ,moisture
b. Activity ,mobility&Nutrition
c. Friction, Tissue perfusion and oxygenation
d. All of the above

94. QUESTION
3. Most common areas affected by pressure ulcer are.
a. Back of the head and shoulders
b.Sacrum
c.Hip and bony prominence
d.All the above
4. All the patients are at risk expect
a. Bed ridden patients
b.Post Operative patients
c. Thin or obese patients
d. Normal walk able patients whose skin integrity score is 24
5.If the skin integrity score is below 12 / 16 / 20 ( as per different age
groups) the nurse must
a. Apply alpha bed b. Back care and position changing
c. Documentation d. All the above

95. QUESTION
6. Explain Bed sore grades?
Grade I -
Grade II -
Grade III -
Grade IV -
7. Whom will you inform in case you have a bed sore or bedridden patient in
your ward?
a. Incharge b. Nursing supervisor
c. Skin Care nurse d. All the above
8. Effleurage means..
a. Stimulate circulation b. Break up the adipose tissue
c. Stimulate nerve ending d . Chest will be clear
9. What are the preventive measures for bed sore development?
a. Early assessment and documentation b. Air bed
c. Nutritional balanced diet d. All of the above

96. QUESTION
10. If the patient in side lying position which area will affect for
pressure sore except?
a. Ear b. Perineum
c. Ribs d. Sacrum
11. The high risk patients for developing bed sore are..
a. Traumatic brain injury b. Diabetic mellitus
c. COPD d. All of the above
12. Match the following
a. Effleurage – Chest will be clear
b. Petri stage – stimulate circulation
c. Kneeling - Breakup adipose tissue
d. Tapping - Stimulate never ending

97. QUESTION
13. What complications can expect if patient not position change for
long duration?
a. Joint contraction b. Muscle atrophy
c. A & B d. Muscle hypertrophy
14. In Braden scale – High risk score age between 5-18 yrs is …
a. <14 b. >12 c. <12 d. <16
15. Regarding treatment of pressure sore which is not correct?
a. Non –Expensive b. Time ensuring
c. Needs antiseptic ointment d. Pressure must be eliminated
from the area.
16. The following are the complications of pressure sore except?
a. Pain / Discomfort b.Infection
c. Hypoproteninemia d. Hypolipidemia

98. QUESTION
17. The intrinsic factors of the bed sore except?
a. Nutritional status b. Age
c. Incontinence d. Pressure
18. Causes of bed sore?
a. Redness b. Skin discoloration
c. Pressure, Shear, friction 4. None of the above
19. In braden Q scale – high risk score for the age 1-5 yrs is …
a. < 16 b. > 18 c. < 22 d. > 20
20. The pressure ulcer assessment is …
a. Location b. Grade
c. Size & status of surrounding skin d. All of the above

99. QUESTION
21. Pressure sores means …
a. Localized damage to the skin
b. Pressure ulcer damage
c. Decubitus ulcer damage
d. localized damage to the skin underlying caused by
pressure, shear, friction.
22.If patient lying in supine position which area will affect for
bed sore. ..
a. Occipital b. Sacrum c. A & B d. Chest
23. In Braden scale - high risk score for the age <1 yrs is…
a .< 22 b. <20 c. <16 d. 12

100. QUESTION
24. The extrinsic factors for bed sore are …
a. _______________________
b. _______________________
25. The initial pressure ulcer symptom is
a. Skin discoloration
b. Blister and skin peeling
c. Muscles and bony prominence
d. All the above.