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Pressure Ulcers: Risk Factors, Risk Assessment and Prevention of HAPU


The increasing incidences of hospital acquired pressure ulcers is becoming a great concern for health care professionals. Pressure ulcers refer to localized injuries to the skin or the underlying tissue, which occur over a bony prominence because of pressure. The condition remains a key issue affecting about 3 million adults. Further, the Centers for Medicare and Medicaid Services reported that it would not cover the extra costs incurred for hospital-acquired ulcers. The announcement by the Centers for Medicare and Medicaid Services has led to an increased focus on the preventive strategies and inspection of pressure ulcers developing in patients after admission. An evidence-based nursing practice can be used in preventing hospital acquired pressure ulcers. Against this backdrop and based on evidence provided by previous literature, this paper develops a plan on the prevention of HAPU using the Braden Scale Tool.

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Review of Sources: What is Known

Risk Factors

Some of the risk factors that increase the vulnerability to hospital acquired pressure ulcers comprise of peripheral vascular disease, diabetes mellitus, sepsis, cerebral vascular accident, and hypertension. Therefore, Anthony, Papanikolaou, Parboteeah, & Saleh (2010) hypothesized that these factors increase patient’s vulnerability to pressure ulcers because of the impairment of microcirculation system. Other risk factors include age, behavior, body mass index and malnutrition among others (Brem et al., 2011). Moreover, their study affirmed that individuals, aged 70 years and above, are highly susceptible to pressure ulcers. Despite studies of Cox (2011) and Jaul (2010) revealing that the white race is a predictor of pressure ulcers, the comparatively smaller number of non-white Americans in several researches raises questions concerning the role played of race in pressure ulcers. Few investigations, which have incorporated adequate number of African Americans, have revealed that African race suffers more severe hospital acquired pressure than any other race (Kottner & Dassen, 2010). Only Noonan, Quigley & Curley’s (2011) investigation revealed that African Americans have higher occurrence rate of hospital acquired pressure ulcers. Incidence Rates

Studies reveal an uneven rate of incidence of HAPU. According to Moore, Cowman & Conroy (2011), the incidence rates of the condition differ significantly with the health care settings. As of 2011, according to Moore, Cowman & Conroy (2011), the incidence varied between 0.4% and 38% in hospitals, between 2.2% and 23.9% in facilities with effective nursing facilities, and between 0% and 17% for home healthcare agencies. Besides the effect of health care settings, Moore, Cowman & Conroy (2011) found out that most of the HAPU incidences happen comparatively during the early times of hospital admission. In consensus with Moore, Cowman & Conroy’s (2011) findings, McInnes, Bell-Syer, Dumville, & Cullum (2011) argued that HAPU occurs during the first two weeks of admission for hospitalized patients. However, with the increasing acuteness of elderly patients and reduced hospital stay duration, McInnes, Bell-Syer, Dumville, & Cullum (2011) further pointed out that elderly patients might experience the condition within the first week of hospital admission.

Morbidity Rates

The morbidities linked to HAPU represent a crucial health care problem, especially when healing does not take place. About 50% of stage II and 95% of stage III HAPU do not heal in 8 weeks (Brienza et al., 2010). Commonly associated morbidities include depression, pain, local infection, anemia, sepsis, and osteomyelitis (Kottner & Dassen, 2010). Noonan, Quigley, & Curley (2011) also argued that HAPU can cause various ailments because hospitalized patients are suffering, and are very expensive to treat. Noonan, Quigley & Curley (2011) further stated some form of complications caused by the disease, such as autonomic dysreflexia, pyarthroses, urethral fistula, amyloidosis, and an extremely malignant transformation. In concurrence with Noonan, Quigley, & Curley (2011), Jaul (2010) added that individuals suffering from paralysis are more vulnerable to the recurrence of bedsores than any other group. However, despite the varying viewpoints concerning the morbidities linked to the condition, most researchers, including Brienza et al. (2010) and Cox (2011), agree that most popular fatalities result from amyloidosis and renal breakdown.


Majority of the studies have found a significant association between HAPU and death. Kottner & Dassen’s (2010) study reports a direct correlation between HAPU and death rate. Because there were no database to assist in the determination of the incidence rates of the disease among hospitalized patients, Kottner & Dassen (2010) utilized data from medical records. Kottner & Dassen (2010) stated that HAPU resulted in approximated 43000 mortalities universally as of 2010. Kottner & Dassen’s (2010) investigation stated that rates of mortality due to HAPY are as high as 60% for elderly patients with HAPU within one year of hospital discharge. Brem et al. (2011) argued that HAPU does not frequently cause death; instead, HAPU develops after a series of deterioration in health status. Consequently, Brem et al. (2011) study concluded that the development of HAPY could be a forecaster of death.


Various studies report different figures linked to the cost of treating HAPU. Some scholars, such as Anthony, Papanikolaou, Parboteeah, & Saleh (2010) pointed out that the actual cost of treating pressure ulcer is not known because it is not unclear what costs can be included as estimates. With few records of nursing care costs, material costs, and added acute care delays, McInnes, Bell-Syer, Dumville, & Cullum (2011) also pointed out that the actual cost of the condition cannot be determined. Investigations conducted by McInnes, Bell-Syer, Dumville, & Cullum (2011) made approximations of the costs. McInnes, Bell-Syer, Dumville, & Cullum (2011) claimed that the cost of stage III or IV HAPU might range from US $ 5000 and US $ 50000.

One study aimed at finding the cost of stage IV HAPU by examining 11 hospitals. According to Kottner & Dassen (2010) study, the cost for HAPU patient was about $127185 within a period of 29 months. The study also revealed that the cost for community acquired pressure ulcer (CAPU) was about $ 124327 within the same period. From these findings, Kottner & Dassen (2010) concluded that HAPU is more costly than the CAPU.

Prevention of HAPU

The deterrence of HAPU has been considered as a nurses’ duty for many years. Nonetheless, certain researchers, such as Jaul (2010) and Cox (2011), consider that the incidence of pressure ulcers is not only due to the letdown of nursing, but also due to the fault of the entire health care system. Therefore, Jaul (2010) regarded it as failure in the cooperation and skill of the complete healthcare personnel, which comprises of physicians, nurses, dietitians, and physical therapists among others. According to Cox (2011), nurses have a crucial responsibility despite the prevention of hospital acquired pressure ulcers being multidisciplinary responsibility. Jaul (2010) pointed out that much of the proof on the prevention of pressure ulcers was linked to level 3 evidence, panel consensus, and expert opinion. He identified particular process, such as risk assessment, skin care, mechanical loading, patient and staff education, which if implemented to decrease the development of the condition during hospital admission.

Various studies have pointed out varying prevention strategies. The first prevention strategy is skin care (Cox, 2011). Despite expert opinion maintaining that there is an association between HAPU development and skin care, there seems to be scarcity of study supporting that (Brienza et al., 2010). However, how the skin is cleansed has been found to contribute to low occurrence of the condition. Several skin care recommendations are based on expert opinion. Some of the recommendations include avoiding the use of hot water, using only mild skin cleaning agents that minimize skin dryness and irritation, avoidance of low humidity since it facilitated the development of scales, and avoidance of vigorous massage (Jaul, 2010).

The second popular prevention mechanism quoted by many researchers, including Brienza et al. (2010) and Cox (2011), is mechanical loading. Cox (2011) argued that patients who are unable to reposition themselves are very susceptible to HAPU. Consequently, Brienza et al. (2010) pointed out that it is crucial for health care professionals to assist in reducing the mechanical load for patients. Cox’s (2011) randomized investigation comprising of about 46 elderly patients pointed out that a single lateral turn need not to exceed 300.

Other prevention mechanisms include support surfaces and nutrition. According to Brienza et al. (2010), support surfaces assist in the redistribution of pressure. The main objective of support surfaces is to obtain the optimal pressure redistribution for the patient. There have been disagreements concerning the use of nutrition as a prevention mechanism. Literatures differ concerning the use of serum albumin. Some researchers, including Anthony, Papanikolaou, Parboteeah, & Saleh (2010) and McInnes, Bell-Syer, Dumville, & Cullum (2011), report that low levels of serum albumin increase the susceptibility to the condition. On the other, Brienza et al. (2010) argued that having serum albumin of less than 3.5 gm/dl increases the patient’s vulnerability to the condition.

Review of Source: What is Not Known?

Having reviewed different literatures, it is evident that the hospital acquired pressure ulcer to be intensively explored. Some of the areas that have been investigated included risk factors, morbidity, mortality rates, incidence rates, costs and prevention mechanism. However, despite the vast information concerning the condition, few literatures have integrated the Braden Scale in the assessment of risk factors and prevention mechanisms. The Braden scale can bring down the costs related to the treatment of patients with HAPU.

The area of weakness in literature was identified as the lack of appropriate use of risk assessment tools to leverage the intervention strategies. In an attempt to identify and validate how studies determined risk factors, it was clear that they majorly relied on health records. The proposed use of Braden scale in assessing risk factors identified quite different risk factors from the ones provided by most literatures. The Braden scale identifies seven crucial and undisputed risk factors, which include sensory perception, moisture, activity levels, mobility, nutrition and friction. Whilst the literature review presents appropriate intervention strategies, these strategies do not precisely target the risk factors.

HAPU Nursing Policy

Purpose of the Policy

  1. To identify patient’s risk of developing hospital acquired pressure ulcer;
  2. To implement interventional strategies for identified risks.


Patient(s) – for this patient, the term patient will refer to a hospitalized person (Cox, 2011);

Risk Assessment – this will refer to the identification of latent risk that the patient might develop pressure ulcer (Cox, 2011);

Intervention(s) – this refer to the necessary steps taken by health care providers to provide effective skin care, to distribute optimally pressure, to provide healthy diet, and to reposition patients (Cox, 2011).


Risk Assessment
  1. For all patients, the Braden Scale will be used to assess the risk of developing hospital acquired pressure ulcer. This is to encourage a structure way of identifying the risks. The Braden scale should be utilized in conjunction with clinical experience and judgment of the nurse (Noonan, Quigley & Curley, 2011);
  2. When performing risk assessment, the following will be put into consideration: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
2.1. Sensory Perception

All persons with an impaired sensory mechanism are vulnerable to HAPU. Some of the signs to consider with respect to this category of the Braden Scale include patient’s responsiveness to painful stimuli, or limited ability to feel pain (Moore, Cowman & Conroy, 2011). On a scale of 1-4, the RN will award the appropriate score.

2.2. Moisture

With respect to this category, the RN should consider the level to which the skin is exposed to moisture (Jaul, 2010). Patients with constantly moist skin because of perspiration or urine are very susceptible to HAPU. On a scale of 1-4, the RN will assess the risk stemming from moisture.

2.3. Activity

With regard to this category of risk factor, the RN will examine the level of the patients’ physical activity. Patients confined to bed are likely to be highly susceptible to HAPU than any other category of patient in relation to this risk factor (Cox, 2011).

2.4. Mobility

The RN should consider the ability of the patient to change and control body position in case of any discomfort. Completely immobile patients are at higher risk of acquiring HAPU (Brienza et al., 2010).

2.5. Nutrition

The food intake pattern can be a predictor of HAPU. Using the Braden Scale, patients with very poor nutrition habit, such as eating less meal and taking small amounts of fluids are vulnerable to HAPU (Noonan, Quigley & Curley, 2011).

2.6. Friction & Shear

The movement of the patient during reposition by himself or herself can predict the likelihood of HAPU. Patients who slide their body parts against sheets are vulnerable to the condition (Cox, 2011).

  1. The total marks awarded by the nurse will define the patient as at risk (Braden score 15-18), moderate risk (Braden score 13-14), high risk (Braden score of 10-12), or very high risk (Braden score =9 and below) (Noonan, Quigley & Curley, 2011).


Based on the scores, the RN will use appropriate intervention strategies as listed below:

  • At Risk - Braden score 15-18

Some of the interventions include reposition the patient regularly; helping the patient be very active by encouraging them to walk; covering patient’s heel; using pressure distribution surfaces; and managing friction & shear (Brienza et al., 2010).

  • Moderate Risk

Interventions for this patient category include using similar interventions for patients categorized as ‘at risk.’ The RN should also incline the patient at 30 degree using foam wedges (Brienza et al., 2010).

  • High risk

Interventions for this patient category include using similar interventions for patients categorized as ‘moderate risk’. Besides reposition the patient, the nurse should make small changes in their position (Brienza et al., 2010).

  • Very high risk

Interventions for this patient category include using similar interventions for patients categorized as ‘high risk.’ The nurse should also use pressure-redistribution surfaces, such as the low-air-loss bed, for individuals with pain (Cox, 2011).

Discussion on Proposed Policy

The author of this paper formulated a current policy for assessing the risk of suffering from hospital acquired pressure ulcer. In comparison with the national guidelines, it is evidence that the guidelines had been adhered to although they were not documented in the formulated policy. The proposed HAPU Nursing Policy integrated the Braden Scale in identifying the risks linked to the HAPU. Evidence-based references were also noted in the parenthesis.


This paper has used evidence-based practice to develop a policy for preventing HAPU. The area of weakness in literature was identified as the lack of appropriate use of risk assessment tools to leverage the intervention strategies. Consequently, the paper used the Braden Scale. The risk factors identified by the policy are the critical elements encompassed in the Braden Scale, and they included sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The use of evidence-based information in the development of this policy offered nurses the confidence that they are offering the best care possible. Since the policy is based on evidence, it is possible that it will reduce the costs related to the treatment of HAPU.