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Risk and Related Interventions

Risk Category

• At Risk
• Moderate risk
• At risk

Interventions

• Low air-loss beds and prevention
• Manage Moisture
• Manage Nutrition
• Manage Friction and Shear
• Other General Care Issues

AT RISK (15-18)* 

• Turn, turn, turn
• Maximal remobilization
• Protect heels
• Manage moisture, nutrition, friction and shear
• Pressure reduction support surface if bed – or chair-bound

*If other major risk factors are present (advanced age, fever, poor dietary intake of protein, diastolic pressure below 60, hemodynamic instability) advance to next level of risk.

MODERATE RISK (13-14)* 

• Turning schedule with 30° rule
• Pressure reduction support surface
• Maximal remobilization
• Protect heels
• Manage moisture, nutrition, friction and shear

* If other major risk factors present, advance to next level of risk.

HIGH RISK (10-12) 

• Pressure reduction support surface
• Increase frequency of turning, 30° with foam wedges, supplement with small shifts
• Maximal remobilization
• Protect heels
• Manage moisture, nutrition, friction and shear

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LOW AIR-LOSS BEDS AND PREVENTION 

Please Note: low air loss beds do not substitute for turning schedules

MANAGE MOISTURE 

• Use commercial moisture barrier
• Use absorbent pads or diapers that wick and hold moisture

MANAGE NUTRITION 

• Increase protein intake
• Increase calorie intake to spare proteins
• Supplement with multi-vitamin (should have Vitamin A, C and E)
• Act quickly to alleviate deficits
• Consult dietitian

MANAGE FRICTION AND SHEAR 

• Elevate head of bed no more than 30°
• Use trapeze when indicated
• Use lift sheet to move patient
• Protect elbows and heels if being exposed to friction

OTHER GENERAL CARE ISSUES 

• No massage of reddened bony prominences
• No "donut" type devices
• Maintain good hydration
• Avoid drying the skin

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