National best practice and evidence based guidelines for wound ...

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N at i o N a l b e s t p r ac t i c e a N d e v i d e N c e b a s e d g u i d e l i N e s f o r w o u N d m a N ag e m e N t 68 Appendix 3: Examples of Pressure Ulcer Risk Assessment tools - Waterlow Name: Date of Birth: Room No / Unit: Waterlow Pressure Ulcer Prevention/Treatment Policy Ring Scores in Table, Add Total, more than 1 Score/Category Can Be Used Sex Malnutrition Screening Tool (MST) Age Nutrition Vol. 15, No.6 1999-Australia Date Score Signature Skin type Visual Risk Areas Build/Weight for Height B – Weight Loss Score 0.5 - 5 kg = 1 5 - 10kg = 2 10 - 15kg = 3 >15kg = 4 unsure = 2 Nutrition Score If > 2 refer for Nutrition assessment / intervention A – Has Patient Lost Weight Recently Yes - go to B No - go to C Unsure - go to C And score 2 C – Patient Eating Poorly Or Lack of Appetite ‘No’ = 0; ‘Yes’ Score = 1 1 2 1 2 3 4 5 Male Female 14-49 50-64 65-74 75-80 81+ 0 1 1 1 1 Healthy Tissue Paper Dry 0 Oedematous Clammy, Pyrexia Discoloured Grade 1 Broken/Spots Grade 2-4 1 2 2 3 3 Average BMI – 20 – 24.9 Above Average BMI – 25 – 29.9 Obese BMI > 30 Below Average BMI < 20 BMI= Wt(kg)/Ht(m)2 Continence Mobility Special Risks Tissue Malnutrition Neurological Deficit 0 Fully 4-6 4-6 4-6 Diabetes, MS, CVA Motor/Sensory Paraplegia (Max of 6) 0 Complete/ Catherised 8 Restless/Fidgety Terminal Cachexia 1 2 Apathetic 1 Urine incont. Major Surgery or Trauma 8 Multiple Organ Failure 3 Restricted 2 Faecel incon. 5 Orthopaedic / Spinal Single Organ Failure (Resp, Renal, Cardiac,) 5 4 Bedbound e.g. Traction 3 Urinary + Faecel Incontinence 5 On Table > 2 hr# 5 Peripheral Vascular Disease 5 Chairbound e.g. Wheelchair 8 On Table > 6 hr# 2 Anaemia (Hb
BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Appendix 3: Examples of Pressure Ulcer Risk Assessment tools - Braden Scale Patient••s Name _____________________________________ Evaluator••s Name________________________________ Date of Assessment 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.. 3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over • • of body. 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of con-sciousness or sedation. OR limited ability to feel pain over most of body SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort 4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals. 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. 2. Very Moist Skin is often, but not always moist. Linen must be changed at least once a shift. 1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. MOISTURE degree to which skin is exposed to moisture 4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours 3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair 2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 1. Bedfast Confined to bed. ACTIVITY degree of physical activity 4. No Limitation Makes major and frequent changes in position without assistance. 3. Slightly Limited Makes frequent though slight changes in body or extremity position independently. 2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 1. Completely Immobile Does not make even slight changes in body or extremity position without assistance MOBILITY ability to change and control body position 4. Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. 3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs 2. Probably Inadequate Rarely eats a complete meal and generally eats only about • • of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding 1. Very Poor Never eats a complete meal. Rarely eats more than • • of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IV••s for more than 5 days. NUTRITION usual food intake pattern 3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. 2. Potential Problem Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. FRICTION & SHEAR 1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction 0205-52 (Page 1 of 3) • • Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved Obtain permission for use at www.bradenscale.com/copyright.asp Total Score 69
Page 1 and 2:
National best practice and evidence
Page 3 and 4:
Foreword The development of HSE nat
Page 5 and 6:
The management of diabetic foot dis
Page 7 and 8:
These guidelines have been endorsed
Page 9 and 10:
Section 3 - Clinical Guidelines 25-
Page 11 and 12:
Section 4 References and Appendices
Page 13 and 14:
SECTION 1: Background and Justifica
Page 15 and 16:
anked operations of the skin and su
Page 17 and 18:
The number of adults diagnosed with
Page 19 and 20: On Society The loss to society due
Page 21 and 22: 1.3 Terms of Reference ● To ensur
Page 23 and 24: SECTION 2: Methodology 21
Page 25 and 26: 2.2 Outline of the grading method u
Page 27 and 28: SECTION 3: Clinical Guidelines 25
Page 29 and 30: 3.2 Principles of Wound Management
Page 31 and 32: Wound Dressings ● The integrity o
Page 33 and 34: ● Removal of devitalised tissue c
Page 35 and 36: 3.4 Guidelines for management of ar
Page 37 and 38: 3.5 Guidelines for the prevention a
Page 39 and 40: Table 10: Patient Education Inspect
Page 41 and 42: Evaluation ● If one or more pedal
Page 43 and 44: ● Alteration in skin condition in
Page 45 and 46: 3.7 Repositioning for the Preventio
Page 47 and 48: 3.8 Support Surfaces General Statem
Page 49 and 50: SECTION 4: References and Appendice
Page 51 and 52: Graham, I.D., Harrison, M.B., Nelso
Page 53 and 54: Appendices 1. Glossary of Terms 2.
Page 55 and 56: ● Bulla/Bullae: Another term for
Page 57 and 58: ● Granulation: During the prolife
Page 59 and 60: ● Periwound: The area immediately
Page 61 and 62: Appendix 2: Examples of Wound Asses
Page 63 and 64: date odour None on dressing change
Page 65 and 66: Anatomical chart Please mark the ar
Page 67 and 68: Date WOUND DIMENSIONS Max. length m
Page 69: Date Time THE ADELAIDE & MEATH HOSP
Page 73 and 74: I need permission for: Name: Title:
Page 75 and 76: BAPEN 'Malnutrition Universal Scree
Page 77 and 78: BAPEN Weight before weight loss (kg
Page 79 and 80: BAPEN Advancing Clinical Nutrition
Page 81 and 82: AUDIT TOOL for NATIONAL WOUND MANAG
Page 83 and 84: Objective Statement 4 identify shor
Page 85 and 86: Objective Statement 10 identify sho
Page 87 and 88: Treatment Statement 16 in persons a
Page 89 and 90: Objectives Statement 23 the use of
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