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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.