The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [131]
Norton scale
Using the Norton scale (Table 4.3) patients with a score of 14 or below are considered to be at greatest risk of pressure ulcer development. A score of 14–18 is not considered at risk but will require reassessment and a score of 18–20 indicates minimal risk.The ‘cut-off’ point for ‘at-risk’ patients was later raised to 15 or 16 by Norton (Norton et al. 1985, Anthony et al. 2008). Norton acknowledged that the scale was not intended as a universal tool and age and nutrition are not included.
Table 4.3 The Norton Scale
Waterlow scale
The Waterlow scale (Figure 4.3) defines a score of 11–15 as being ‘at risk’, 16–20 as ‘high risk’ and over 20 as ‘very high risk’ (Waterlow 2005). In a study of the Norton and Waterlow scales, 75.7% of patients identified as ‘at risk’ by the Waterlow scale developed a pressure ulcer, whereas 62% of those with a score of 16 or less on the Norton Scale developed ulcers (Smith et al. 1986) This may suggest that the Waterlow Scale gives a more accurate prediction of patient risk.
Figure 4.3 Waterlow pressure ulcer risk assessment. Adapted from the Waterlow Pressure Sore/Ulcer Risk Assessment Scoring System, available from www.judywaterlow.fsnet.co.uk, with permission and acknowledgement of the copyright holder, J. Waterlow, 1991, revised 1995, 1998 and 2005.
Braden scale
The Braden scale (Table 4.4) is based on six subscores (sensory perception, activity, moisture, nutrition, mobility, and friction and shearing) which are scored from 1 to 4 depending on the severity of the condition (with the exception of friction and shearing which is scored 1–3). The total score is then added up with a possible range of 6 to 23. The lower the score, the higher the risk of developing a pressure ulcer. Hospital patients are considered to be at risk if their score is 16 or below.
Table 4.4 Braden Scale for predicting pressure sore risk
The Braden Scale was originally designed as a pressure ulcer predictor, unlike the Norton and Waterlow Scales which assess risk (Waterlow 2005).
Postprocedural considerations
Ongoing care
Treatment of pressure ulcers is the same as for any other wound. The aetiology and underlying or related pathology, as well as the wound itself, must be assessed in order to provide the most appropriate treatment. Care should be aimed at relief of pressure, the minimization of symptoms from predisposing factors and the provision of the ideal microenvironment for wound healing.
When positioning patients, prolonged pressure on bony prominences must be minimized. An awareness of interface pressures, for example creased bedlinen and night clothing, is also important to avoid increased friction and further skin breakdown. Regular repositioning is recommended after assessing other factors such as patient’s medical condition, comfort, overall plan of care and the support surface. Where appropriate or possible, patients and their families should be familiarized with the importance of pressure ulcer prevention.
For management see Chapter 15.
Prevention of falls
Related theory
In the UK the average rate of falls in acute hospitals in 2008 was 5.4 incidents per 1000 bed-days (NPSA 2009). This equates to 30 falls per week in an 800-bed acute trust. The physical and psychological costs to the patient and financial costs for the health economy are high. Falls may result in a loss of confidence or independence which, in turn, may lead to a need for increased or extended support from the NHS (Ward et al. 2010). Preventing falls in the older person has been well described in national guidance