RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Nursing Best Practice GuidelineSample i) RESPONSE TO PATIENT PRESSURE ULCER RISK ASSESSMENTSource: Leamington District Memorial Hospital, (2006). Reprinted with permission.Risk FactorDATESensory PerceptionMoistureActivityMobilityNutritionFriction & shearTotal ScoreIntialsClient is Automatically At Risk if answering yes to any one of the following questions:❏ Is the Braden Scale Score 18/23? Or Less?❏ Is the client non-compliant with changing position?❏ Does the client present with an existing pressure ulcer?If client presents with a pressure ulcer – circle ulcer severity: Stage I, Stage II, Stage III or Stage IV❏ Does the client present with uncontrolled pain? (Pain 4/5 or 5/5 – c/o 3 times in 12 hrs)❏ Does the client present with Paraplegia, Hemiplegia or Quadriplegia?❏ Does the client present with extreme lethargy or weakness?Clients Most Likely At Risk if answers yes to any one of the following questions:❏ Does the client have a history of previous pressure ulcers?If client history includes pressure ulcer – circle ulcer severity: Full Thickness (with scar) or Partial Thickness?❏ Does the client have a diagnosis of Diabetes with peripheral neuropathy?❏ Is the client Morbidly Obese or Cachexia plus have strength, mobility or activity?❏ Does the client require the HOB to be elevated plus have strength, mobility or activity?Review nursing interventions & determine ifappropriate for patient. Consider Co-morbidities.Intervention PlannedDateInterventionPlannedInitialsDateInterventionInitiatedInitialsNO INTERVENTION NECESSARYWritten q2h repositioning schedule – see KardexHead of Bed (HOB) Default Flat or < 30 (Unless Contraindicated)Where Client Controlled HOB – Encourage HOB flat, use pillowsfor head elevation & assist to chair PRN for reading, meals etc.Pain ManagementSeizure ManagementIncontinence ManagementPrevent ContracturesMaintain Maximum ROM – see KardexPhysician Referral: Occupational Tx – Bed/Seating AssessmentPhysician Referral: Physiotherapy – ROM/MobilityReferral: Enterostomal Tx – Bed/Wound AssessmentReferral: DietitianSpecialty Mattress Replacement per MD, OT or ETReport 1) CCAC For Home Equipment Needs2) LTC/Rest Home For Equipment NeedsReference: Bauer, Bushey & Amaro, 2002; RNAO, 2002105