This a new guideline from NICE about assessing a patient’s risk of pressure ulcers and then for their management. I always feel a bit out of my depth when it comes to this kind of thing and in reality most of this is done by the district nurses, but I think it is important for us to know who is at increased risk, so that we can refer on for a proper assessment.
NICE lists 3 different risk assessment tools that you can use. These are the Braden Risk Assessment, the Waterlow Scale and the Norton Pressure Scale. These all seem rather complex and really if people have any of the following risk factors listed by NICE, it may be worth considering whether they need further assessment:
- Significantly impaired mobility
- Significant loss of sensation
- A previous or current pressure ulcer
- A nutritional deficiency
- An inability to reposition themselves
- Significant cognitive impairment
If you are asked to assess a patent’s pressure areas, consider:
- Skin integrity in areas of pressure
- Colour changes or discolouration
- Changes in heat, firmness or moisture (eg due to incontinence, oedema or dry skin)