Download Pressure Area Risk Assessment Tool

MRN:...........................................................................
Morgan Bay Health Services
Name:..........................................................................
Pressure Area Risk
Assessment Tool
Address:......................................................................
D.O.B. . ..................................VMO ............................
(Attach Identification Label)
(Based on Waterlow Pressure Score Prevention / Treatment Guideline). Circle appropriate score: 10+ at
risk, 15+ high risks, and 20+ very high risks. Utilise Risk Management Assessment Tool Nursing Care Plan
if score = 10 or >10 Re-assess on any change in patient’s condition.
Gender
Build / weight for height
Male
Female
1
2
BINDING MARGIN – DO NOT WRITE
Age
Average
Above average
Obese
Below average
0
1
2
3
Cardiovascular
14-49
50-64
65-74
75-80
81+
1
2
3
4
5
Appetite
Terminal cachexia etc
Cardiac failure
Peripheral Vascular Disease
anaemia
Smoker
9
5
5
2
1
Neurological and Diabetes
Average
Poor
Tube feed / fluids only
Anorexia
0
1
2
3
Continence
Diabetes / CVA / MS / Paraplegic / Motor Sensory
4-6
(Depending on severity)
Medications
Complete / catheterized
Occasional incontinence
Catheter / incontinent of faeces
Dual incontinent
0
1
2
3
Skin
Steroids / cytotoxic / anti-inflammatory
4
Surgery / Trauma
Healthy
Tissue paper / dry
Clammy / oedematous
Discoloured
Broken area
0
1
2
3
4
Mobility: possible to use more than one score
Fully mobile
Restless / fidgety
Apathetic
Restricted mobility (inc, IV, IDC, drain insitu)
Inert or in traction
Chair bound
0
1
2
3
4
5
Orthopaedic - below waist
Spinal anaesthetic
On table > 2 hours
5
5
5
N.B. The category ‘on table’ 2 hrs is only
relevant for 48 / 24 post OT.
Total score
On admission:
Total
score
Assessed by (name):
Signature:
Date:
On review:
Total
score
Assessed by (name):
Signature:
Date:
On review:
Total
score
Assessed by (name):
Signature:
Date:
On review:
Total
score
Assessed by (name):
Signature:
Date:
Pressure Area Risk Assessment Tool
Utilizing the pressure risk score, the next step is to link the risk assessment to preventive protocols. Due to different
staffing patterns of preventative products the following should be used as a guide
Place a tick () in appropriate box/s).
At risk 10-14
Consider frequency of turning utilizing lifting and manual handling techniques.
Facilitate maximal remobilization.
Protect the patient’s heels (elevate off the mattress using 2 pillows).
Provide pressure reducing support surfaces if the patient is bed rest or chair fast (eg. spenko)
Provide wedge or pillows for 30 degree lateral positioning.
Manage moisture (using Kylies’ instead of draw sheets, use of incontinence pads).
Ensure nutrition (involves dietitian) and (involves speech pathologist for swallowing problems).
Reduce friction and shear force by:
• Avoiding direct contact between bony prominences with pillows or foam wedges.
• Keeping the head of the bed at the lowest elevation suitable for the patient’s condition.
• Relieve heel pressure in bed bound patients or those with immobilized lower extremities.
At risk 15-19
Increase the frequency of turning, supplement turning with small shifts in position. Utilize proper lifting and manual
handling techniques.
Facilitate maximal removilization.
Protect the patient’s heels with Opsite / comfeel plus, flexi grid prophylaxis (plus elevate as above) if there is
persistent redness.
Provide foam wedges or pillows for 30 degree lateral positioning.
Manage moisture (as above).
Enhance nutrition (as above).
Reduce friction and shear forces (as above).
At risk 20+
As above, plus use an alternating mattress if the patient has intractable pain, severe pain exacerbated by turning,
or additional risk factors such as immobility and malnutrition.
Additional Information
The following suggestions can assist with management if the patient has intractable pain, severe pain exacerbated by
turning, or additional risk factors such as immobility and malnutrition.
Manage Moisture
Use moisturizing barrier creams and use incontinence pads that wick and hold moisture. Address the cause of
moisture if possible bedpan or urinal and a glass of water in conjunction with turning schedule.
Manage Nutrition
Consult with a Dietitian and act quickly to alleviate nutritional deficits. Increase the patient’s protein intake and
increase his/her calorie intake if needed. Supplement with a multivitamin containing vitamin A, C and E.
Manage friction and shear
Elevate the head of the bed no more than 30 degrees and have the patient use a ‘monkey bar’ when indicated.
Use a slide to move the patient. Protect the patient’s elbow, heels, sacrum and back of head if he/she is exposed
to friction.
General
Do not massage reddened boney prominences. Do not use doughnuts / 0-type devices (These can cause
shearing and friction to fragile skin). Maintain good hygiene and avoid drying out patient’s skin.
NB: Document on the Nursing Care Plan daily if same strategies are being implemented. If not re-score Waterlow and strategies to be used.