AT RISK (15-18)*

TURN, TURN, TURN
MAXIMAL REMOBILIZATION
PROTECT HEELS
MANAGE MOISTURE, NUTRITION
AND 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
AND 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
AND FRICTION AND SHEAR

LOW AIR-LOSS BEDS AND PREVENTION

HIGH RISK
+
UNCONTROLLED PAIN
OR
SEVERE PAIN EXACERBATED BY TURNING
OR
BRADEN SCALE SCORE <9 (SEVERE RISK)
+
ADDITIONAL RISK FACTORS

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