the revised jackson/cubbin pressure area risk calculator

The revised Jackson/Cubbin Pressure Area Risk Calculator Christine Jackson

Christine Jackson Intensive Care Unit, Royal Liverpool & Broadgreen University Trust, Prescot Street, Liverpool L7 8XP, UK

Manuscrip t accepted 25 May 1999

The revised JacksonlCubbin Pressure Area Risk Calculator for intensive care patients

In 1989, my colleague, Beverly Cubbin, and I began to search the literature for a pressure area risk-assessment tool to suit the patients in our Intensive Care Unit, and were amazed to find there was little of use to us. Although many such tools had aspects that were useful, none was sufficiently detailed for our intensive care patients. "For maximum effectiveness, the risk assessment tool needs to be carefully selected. It should be appropriate for the patients with whom it is used'. (Dealy 1997). Therefore, a new scale was developed (Table 1) and information about it was published Jackson & Cubbin 1991. That search was almost 10 years ago.

It has always been our aim to design a risk- assessment tool for intensive care patients that is quick and simple to use - not something complicated and time-consuming for the nurses involved. Feedback from a multitude of sources nationwide indicates that some of our aims have been accomplished. The tool devised is quick and easy to use, based on the original Norton Scale format (Norton et al. 1962).

A number of studies have been carried out in many other hospitals. Two papers reporting such work were received, one from Maria White of St Albans and Hemel Hempstead Hospital and another from Mandy Lowery of the City Hospitals, Sunderland (Lowery 1995). Beverly Cubbin and I also attended a number of seminars in order to listen to feedback from others using the calculator. The Risk Assessment Workshop

organized by SSI Medical Services was particularly helpful. Discussion of the calculator with a hospital manager from Brussels revealed that it has also been adopted outside the LVK.

However, it does have a number of shortfalls. For this reason, a number of amendments have been made with the addition of two new categories in order to update the system and, it is hoped, increase its accuracy and effectiveness.

Many nurses questioned the need for a section concerned with the age of the individual. The authors believe this to be a relevant factor as skin condition and elasticity alters with age. As Tortora and Grabowski (1993) stated: 'Aged skin is thinner than young skin' and 'also heals poorly and becomes more susceptible to pathological conditions such as pressure sores'. ~Ihe section assessing the patient's weight also remains unchanged.

The sections for assessing the individual's mental condition, respiratory support, nutrition, incontinence and hygiene have all remained fundamentally unchanged apart from small changes in wording for clarification (Table 2).

Although there is a section which identifies the cardiovascular status of the patient and the use of inotropic support, the authors realize that this does not entirely cover skin perfusion. Vasoconstriction due to inotropic support is considered, but not pre-ex is f ig chronic illnesses, although their detrimental effects on tissue viability may be exacerbated by the acute illness an d /o r inotropic support. Consequently, a new category has been introduced to highlight the patient's past medical history. It would be

© 1999 Harcour l : Publ ishers Ltd IntensiveondCriticalCareNursing(1999) 15, 169-175 169

Intensive and Critical Care Nursing

Table 1

Age

The Jackson/Cubbin Pressure Area Risk Calculator (Reproduced with permission from Cubbin & Jackson 1991) I

Weight General skin Mental condition Mobility condition

<40

40-54

55-70

>70

Haemodynamic status

4 Average Intact 4 Awake and alert 4 Fully ambulant weight 4

3 Red skin 3 Agitated/restless/ Walks with slight Obese 3 confused 3 help

2 Grazed/excoriated/ Cachectic 2 skin 2 Apathetic/sedated Very limited/

I but responsive 2 chairbound Any of the Necrosislexuding I above Coma/unresponsive/ Immobile/bedrest and oedema I unpurposeful

movements 1 I ' [ I I ql l . . . . . . . . . . i i I I . . . . . . . . . . . . . . . . . . I I

Respiration Nutrition Incontinence Hygiene

Stable without inotropic support 4

Stable with inotropic

support 3 Unstable with inotropic support 2

Critical with inotropic support 1

Spontaneous 4 Full diet + fluids 4 None/anuric/ 4 Competent in maintaining catheterized own hygiene 4

CPAPT/-piece 3 Light diet/oral fluids/ Urine 3 Maintaining own hygiene enteral feeding 3 with slight help 3

Mechanical Parental feeding 2 Faeces 2 Requires much assistance 2 ventilation 2

Breathless at Clear IV fluids only 1 Urine + faeces 1 Fully dependent 1 rest/on exertion 1

Possible score 40•40; high-risk level 24•40.

unreasonable to list all diseases that undermine tissue viability, and problems could arise if some were inadvertently overlooked. Therefore, it seems reasonable to rely on the nurse's clinical judgement to determine the appropriate score, with input from other members of the team involved in the care of the patient, and some guidelines provided to assist with the assessment of past medical history.

Diseases which affect pressure areas in a similar way to those conditions identified may be scored similarly (Table 3).

This could take into account all relevant pre- existing disease but continue to keep the system simple. The nurse would investigate the past medical history on admission, therefore no extra work would be involved.

It was identified that the section for assessing the patient's mobility was inadequate. This has been altered to include the worst possible scenario of a patient too unstable to move in bed. Also, as a procedure used more frequently in the intensive care unit today, nursing a patient in the 'prone position' has been included (Table 4).

It was noted that, in the previous calculator, the authors failed to include a score for a patient who was unstable without inotropes in the category for assessing the patient's haemodynamic status. This has now been amended (Table 5). This section is considered to be vital for the assessment of our patients. Nurses all need to be aware that 'Positioning of critically ill patients affects haemodynamic and cardiopulmonary parameters'. (Doering 1993)

The next new category introduced is for assessing oxygen requirements. Although there was already a category identifying the patient's mode of respiratory support, this failed to identify stability with a particular form of support, e.g. a patient may be ventilated but still have unstable blood gases or inadequate oxygenation when moved, or even at rest. Often it is impossible to turn a patient frequently as 'those who are critically ill have little oxygen reserve to tolerate position changes'. (Wheeler 1997). This is obviously a relevant fact in pressure area care.

170 Intensive and Critical Care Nursing (1999) 15, 169-175 © 1999 Harcourt Publishers Ltd

The revised JacksonlCubbin Pressure Area Risk Calculator

Table 2 Modifications of the original Cubbin and Jackson (1991) Pressure Area Risk Calculator

General skin condition General skin condition Mental Condition Mental condition,

Intact 4 Intact 4 Awake and alert 4 Awake and alert 4

Red skin 3 Red skin 3 Agitated/restless Agitated/restless/ (potential breakdown) confused 3 confused 3

Grazed/excoriated/skin 2 Grazed/excoriated/skin 2 Apathetic/sedated but Apathetic/sedated but (superficial) responsive 2 responsive 2

Necrosis/exuding Necrosis/exuding 1 Coma/unresponsive/ Coma/unresponsive/ (deep) unpurposeful paralysed and sedated 1

movements 1

Respiration Respiration Nutrition Nutrition

Spontaneous 4 Spontaneous 4 Full diet + fluids 4 Full diet + fluids 4

CPAPfF-piece 3 CPAPFF-piece 3 Light diet/oral fluids/ Light diet/oral fluids enteral feeding 3 enteral feeding 9

Mechanical ventilation 2 Mechanical ventilation 2 Parenteral feeding 2 Parental feeding 2

Breathless at rest/on exertion 1 Breathless at rest 1 Clear i.v. fluids only 1 Clear i.v, fluids only !

Incontinence Incontinence Hygiene Hygiene

None/anuric/ None/anuric/ Competent in Independent 4 catheterized 4 catheterized 4 maintaining

own hygiene 4 Requires assistance 3 Urine 3 Urine/profuse sweating 3

Maintaining own Requires much Faeces 2 Faeces/occasional hygiene assistance 2

diarrhoea 2 with slight help 3 Urine + faeces 1 Fully dependent 1

Urine + faeces Requires much Prolonged diarrhoea 1 assistance 2

Fully dependent 1

Table ,~1 Guidelines for past medical history (PMH)

4 None 3 Skin disorders affecting areas prone to pressure 2 Steroid therapy Rheumatoid arthritis Congestive cardiac failure

Non-insulin-dependent Auto immune disease Chronic obstructive airways diabetes myelitis Disease - limited mobility

1 Peripheral vascular disease Person found lying at home on f loor prior to admission Insulin-Dependent diabetes Mellitus Compartment syndrome

Score

None 4 Mild 3 Severe 2 Very severe 1

Past medical history - affecting tissue viability

© 1999 Harcourt Publishers Ltd Intensive and Critical Care Nursing (1999) 15, 169-175 17t


Table 4 Modified scoring criteria for mobility

Mobility Mobility

Fully ambulant 4

Walks with slight help 3

Very limited/chairbound 2

Immobile/bedrest 1

'1'['111 I'1 IPII I I

Table 5 Modified scoring criteria for haemodynamic status III I I i i l l ' lr ' i i i I

Haemodynamic status

Walks with help

Very limited Chairbound

Immobile but tolerates change of position

Unable to tolerate movement/ nursed prone

III1[1111111Pl IIII I III I '1 ' IIIil111

'11'11'1 ' "1 I I

Haemodynamics

Stable without inotropic support 4

Stable with inotropic support 3

Unstable with inotropic support 2

Critical with inotropic support 1 I I I I 1 ' . . . .

Stable without inotropes 4

Stable with inotropes 3

Unstable without inotropes 2

Unstable with inotropes 1 '1

This category has been worded as follows:-

0 2 requ i rements

Moves in bed <40% 0 2 required 4

Requires>40% 0 2 Stable on movement 3

2 Requires 40-60% stable ABGS Desaturates on movement

Requires 60% 0 2 and above Inability to maintain ABGS Desaturates at rest 1

It has been noted that the time patients spend in surgery or transported on trolleys for scans and other investigations is also relevant to tissue breakdown. Therefore a 1-point deduction is suggested for surgery/scan during the last 48 hours. Placing a time limit on this section is reasonable, as any damage incurred would become apparent during this time and then be recorded using the skin condition section. If no damage has occurred, it will not be recorded after 48 hours, therefore avoiding any falsely low recordings.

It is also suggested that a patient is at risk when anaemic or when clotting is impaired. Therefore, we suggest the deduction of 1 point if blood transfusion or clotting factors are required. Once transfused and blood results return to normal further deduction is unnecessary.

Likewise, for a patient who is hypothermic, 1 point is deducted until the patient is warm, the peripheral circulation is restored, and the risk factor is no longer present.

The complete revised Jackson/Cubbin Pressure Area Risk Calculator is shown in Table 6.

Use of specialized beds It has always been a wish or perhaps an ambition, for want of a better word, to be able to identify accurately which bed would be most suitable at which score rating. However, trials of this nature could prove unethical. Our only guide would be a recommendation along with the use of the clinical judgement of a multi-disciplinary team.

The unit on which I work has 13 beds and is extremely fortunate to have adequate funding to provide all our patients with a Nimbus Dynamic Flotation mattress on admission. The need for this is determined by the condition of the majority of the patients admitted. Generally they are elderly, often with chronic disease, predominantly respiratory disorders, in addition to their current acute condition. Therefore, a specialized bed is appropriate from the moment they are admitted. The funding, incidently, was made possible due to work with the pressure area risk calculator in thefirst place.

Although the Pressure Area Risk Calculator is used to identify patients at risk of developing a pressure sore, almost all patients are at risk of


The revised JacksonlCubbin Pressure Area Risk Calculator

Table 6

Age

The Revised Jackson/Cubbin Pressure Area Risk Calculator

Weight PMH-Affecting Tissue Viability Condition

General skin Mental Condition

Mobility

<40 4 Average weight 4 None 4

40-55 3 Obese 3 Mild 3

55-70 2 Cachectic 2 Severe 2

>70 ! Any of the above Very Severe 1 + oedema 1

Intact 4

Red skin/areas (potential breakdown) 3

Grazes/excoriated skin (superficial) 2

Awake & alert 4 Walks with help 4

Agitated/restless/ Very limited confused 3 chairbound 3

Apathetic/sedated Immobile but but responsive 2 tolerates change of

position 2 Coma/

Necrosis/exuding unresponsive/ Unable to sore (deep) 1 paralysed and tolerate movement/"

sedated 1 nursed prone 1

Haemodynamics Respiration Oxygen requirements Nutrition Incontinence Hygiene

Stable without Spontaneous 4 Requires <40%0 2 4 Full diet and None/anuric/ Independent 4 inotropes 4 Stable on move fluids 4 catheterized 4

CPAP/T-piece 3 ment Needs assistance 3 Stable with Light diet, oral Urine/profuse lnotropes 3 Mechanical Requires 40% fluids, enteral sweating 3 Needs much

ventilation 2 60%02 feeding 3 assistance 2 Unstable Stable on movement 3 Faeces/ without Breathless at Parental feeding 2 occasional Fully dependent 1 inotropes 2 rest 1 Requires 40%-60%02 diarrhoea 2

Stable ABGs but Clear i.v. fluids Unstable with desaturates on only 1 Urine and faeces/ inotropes 1 movement 2 prolonged

diarrhoea 1 Requires 60% or above. Inability to maintain ABGs/ desaturates at rest 1

m

Deduct 1 point -÷ time spent in surgery/scan in last 48 hours Deduct 1 point -~ if requires blood products Deduct 1 point -÷ for hypothermia until warm Possible score 48148 - high-risk level 29148 or below. Key:. CPAP; continuous positive airway pressure; ABGs, arterial blood gases.

pressure sore formation from the moment of admission. However, some are more at risk than others and some in time deteriorate. This was the reason for attempting to design a checklist related to bed use, as it is recommended that a patient who is at high risk should be transferred to a more specialized bed.

Clinical judgement must be used in conjunction with the assessment tool in identifying which bed is to be used and many factors are taken into account. For example, a patient who is expected to have a long-term problem with being weaned from respiratory support , taking into account h i s /her present and past medical history, but who is otherwise cardiovascularly stable, may be recommended to be nursed on a Nimbus Dynamic Flotation mattress for a number of reasons.

The reasons include:

1. Cost - in the present economic climate this is foremost; also, why waste hinds on a more expensive bed if unnecessary?

2. Comfort - often difficult to achieve when a patient is used to his own double bed but careful positioning and pain relief may help.

3. Manoeuvrabili ty - the patient is able to achieve upright sitting position, recline, move from bed to chair.

It is recommended that patients have a frequent change of position for many other reasons as well as for pressure relieL for example: to ensure comfort, relaxation and rest; to inflate both lungs and shift secretions; to orientate the patients to surroundings and a change of view now and again;

© 1999 Harcourt Publishers Ltd Intensive and Critical Care Nursing (1999) 15, 169-175 173


Table 7 Recommendations for change of bed i

Score 29 and above --~ recommend Dynamic Flotation Mattress and 4-hourly change of position

On admission- able to tolerate 4-hourly position changes; no severe existing pressure sores; SaO 2 and cardiovascular system stable when moved or returns to stability immediately. *When sitting in chair, stand frequently and use pressure relieving aid as available.

Score 29 and below -~ recommend low-air-loss bed

Severe existing pressure sore Unable to tolerate regular position change due to - CV instability

O2dependency

Score 29 and below

Air fluidized bed only recommended where there are large fluid volumes lost through exuding wounds/pressure sores.

to improve circulation to limbs through movement.

Because, as Dugas (1998) and others have indicated, 'Nursing has looked at positioning as a treatment to improve patient comfort, prevent contractures and skin breakdown, promote drainage and facilitate breathing.

Use of a specialized more 'expensive' bed becomes appropriate for a patient who has become unstable with greater dependence on inotropes and oxygen, and when stability is compromised when the patient is moved. Often, movement is contra-indicated. (It is, of course, arguable that such beds are not expensive when compared with the costs entailed if a pressure sore develops). A more specialized bed allows a greater timespan in the same position without increasing the detrimental effect on the viability of the patient's skin, and allows the patient time to rest.

The score of 29/48 and below as the high-risk level has been determined through numerous trials scoring patients using the calculator. Evidence has shown that at this point the patients have become either too unstable/poorly to relieve pressure areas as frequently as needed, or their skin integrity has begun to deteriorate following a short period (2 hours) in the same position. If this situation is predicted to remain unchanged or deteriorate further in the near future, i.e. 12 hours, it is recommended that a specialized bed should be made available. Alternatively, if the patient's score improves and the patient is seen to be making progress, they may be transferred from the specialized bed to a

dynamic flotation mattress, so avoiding the unnecessary use of more expensive beds.

Therefore, a basic checklist has been devised to use as a guideline combined with the clinical judgement of a multidisciplinary team, when making decisions about the appropriate bed for a particular patient (Table 7).

Conclusion The use of the Pressure Area Risk Calculator has enabled the staff on the intensive care unit at the Royal Liverpool Hospital to strengthen requests for appropriate specialist beds to suit the individuals assessed. The two authors of the original Calculator have attempted to identify the major risk factors contributing to tissue breakdown in a critically ill patient, aiming to highlight the worst possible scenario giving the lowest scores and the best scoring highest. The purpose was to provide an accurate and detailed assessment tool suitable for intensive care patients, with a method for monitoring progress and evaluating pressure area care. It provides an awareness that many factors need to be considered and monitored prior to and during procedures for pressure area care, in accord with Doering's (1993) view that 'Haemodynamic and cardiopulmonary responses to positioning should be evaluated in conjunction with other therapeutic modalities such as those designed to preserve skin integrity and improve Comfort'.

Admittedly, the risk-assessment tool is only as good as the person using it and needs to be used


The revised Jackson/Cubbin Pressure Area Risk Calculator

in conjunction with the nurses' clinical judgement and observational skills. But as Flanagan (1997) stresses, 'clinical judgement is important in risk assessment but pressure sore risk assessment tools also have a useful place in clinical practice'. They are even more useful if constantly reviewed and revised when necessary as indicated by experience and testing, preferably by research.

Acknowledgements

Beverly Cubb in and I w o u l d like to thank all those nurses na t ionwide for their interest and

feedback which m a d e these changes possible. They are too n u m e r o u s to men t i o n as we are still

receiving enquir ies 10 years after the original

article was publ ished. We wou ld also wish to thank all the staff and

Consultant , R. Wenstone, on the Royal Liverpool Hospital Intensive Care Unit, who gave their encouragement , suppor t and feedback to the trials.

References Dealy C 1997 Managing Pressure Sore Prevention. Dinton:

Quay Books Doering L 1993 The effect of positioning on

haemodynamics and gas exchange in the critically iii: a review. American Journal of Critical Care 2(3):208-216

Dugas B 1983 Introduction to Patient Care, 4th edn. Philadelphia: W.B. Saunders

Flanagan M 1997 Choosing pressure sore risk assessment tools. Professional Nurse 12(6)[Suppl]: 307

Cubbin B, Jackson C 1991 Trial of a Pressure Sore Risk Calculator for ITU patients. Intensive Care Nursing 7(1): 40-44

Lowery M 1995 A Pressure Sore Risk Calculator for intensive care patients: 'The Sunderland Experience'. Intensive and Critical Care Nursing 11(6): 344-353

Norton D, Exton Smith AN, McLaren R 1975 An Investigation into Geriatric Nursing Problems in Hospital. Edinburgh: Churchill Livingstone

Tortora G, Grabowski S 1993 Principles of Anatomy and Physiology, 7th edn. New York: Harper Collins

Wheeler H 1997 Positioning: one good turn after another? Nursing in Critical Care 2(3): 129-131

© 1999 Harcourl~o Publishers Ltd IntensiveandCriticalCareNursing(t999) 15, 169-175 175

the revised jackson/cubbin pressure area risk calculator

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