Purpose : Assessment of risk for the development of pressure sore or ulcer

 

Admin time :  5-10 min

User Friendly :  High

Administered by : Nurses, healthcare professionals and carers at the patient/client interface

 

Content : Seven known risk factors that contribute towards the development of pressure ulcers.

These risk factors include the patient's:

• age and gender

• body mass index (BMI)

• level of continence

• skin condition (healthy or broken)

• appetite

• level of mobility (fully mobile to bed-bound)

• individual risk factors, e.g. medication, surgery and trauma

The patient is then allocated a score for each of the above criteria. The total score, in conjunction with the nursing staff's clinical expertise, places the patient into one of three pressure sore risk categories:

• a score of 10-14 indicates "at-risk"

• a score of 15-19 indicates "high risk"

• a score of 20 and above indicates "very high risk"

 

Author :  Judy Waterlow, 1985

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Copyright : Judy Waterlow

Free to download and use from copyright holder's website