AT RISK (15-18)* FREQUENT TURNING 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	MANAGE MOISTURE USE COMMERCIAL MOISTURE BARRIER USE ABSORBANT PADS OR DIAPERS THAT WICK & HOLD MOISTURE ADDRESS CAUSE IF POSIBLE OFFER BEDPAN/URINAL AND GLASS OF WATER IN CONJUNCTION WITH TURNING SCHEDULES
MODERATE RISK (13-14)* TURNING SCHEDULE USE FOAM WEDGES FOR 30E LATERAL POSITIONING 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	MANAGE NUTRITION INCREASE PROTEIN INTAKE INCREASE CALORIE INTAKE TO SPARE PROTEINS. SUPPLEMENT WITH MULTI-VITAMIN (SHOULD HAVE VIT A, C & E) ACT QUICKLY TO ALLEVIATE DEFICITS CONSULT DIETITIAN
HIGH RISK (10-12) INCREASE FREQUENCY OF TURNING SUPPLEMENT WITH SMALL SHIFTS PRESSURE REDUCTION SUPPORT SURFACE USE FOAM WEDGES FOR 30E LATERAL POSITIONIING MAXIMAL REMOBILIZATION PROTECT HEELS MANAGE MOISTURE, NUTRITION AND FRICTION AND SHEAR	MANAGE FRICTION & SHEAR ELEVATE HOB NO MORE THAN 30E USE TRAPEZE WHEN INDICATED USE LIFT SHEET TO MOVE PATIENT PROTECT ELBOWS & HEELS IF BEING EXPOSED TO FRICTION
VERY HIGH RISK (9 or below) ALL OF THE ABOVE + USE PRESSURE-RELIEVING SURFACE IF PATIENT HAS INTRACTABLE PAIN OR SEVERE PAIN EXACERBATED BY TURNING OR ADDITIONAL RISK FACTORS *low air loss beds do not substitute for turning schedules	OTHER GENERAL CARE ISSUES NO MASSAGE OF REDDENED BONY PROMINENCES NO DO-NUT TYPE DEVICES MAINTAIN GOOD HYDRATION AVOID DRYING THE SKIN

© Barbara Braden, 2001