your patients from moving pressure and...
TRANSCRIPT
Protecting your patients from
pressure ulcers
Nutrition and
hydration
Moving and
handling
Top tips for staff
Activities of daily living – holistic needs assessment
Needs assessments for nutrition, hydration, mobility, skin integrity, continence.
Waterlow Assessment Tool (Adults)/Glamorgan Assessment Tool (Children and Young People)
Malnutrition Universal Screening Tool (MUST)
Moving and handling
Falls assessment
Remember to hand out the patient pressure ulcer prevention leaflet.
Essential assessments
Causes Pressure/shear Moisture present (incontinence, perspiration)
Location Bony prominences Skin folds, anal cleft, perianal area, sacrum
Shape Regular, defined shape Diffuse superficial spots, kissing lesion, linear wound
Depth Grade 3 or 4 deeper Superficial wounds (infection)Necrosis Black necrosis No necrosisEdges Distinct edges Diffuse edges, irregular lesions
Colour Non blanchable erythema, necrosis and slough
Red but not uniformly distributed, pink or white surrounding skin
Pressure ulcer or moisture lesion?
Pressure ulcer Moisture lesion
Don’t forget you need to report as an incident:• any patients who come onto your caseload/ward with a pressure ulcer • any patients who have pressure ulcers that deteriorate, e.g. from a category 2 to 3.●●
Category 1
Category 2
Category 3
Category 4
Ungradeable
Deep tissue injury
S is for surface Make sure the correct support surface is in use at all times, in bed, in a chair/wheelchair or any other surface the patient is in contact with. Check all equipment is working. Also consider foot wear.
S is for skin Early inspection means early detection. Teach patients and carers how to inspect the skin. Always check the whole body not just the sacrum.
K is for keep moving Keep active and keep moving. Make sure patients continue to move or be moved regularly regardless of the pressure reliving equipment put in to use.
I is for incontinence/moisture Patients need to be kept clean and dry. Incontinence products reduce the efficiency of the pressure reducing/redistributing equipment.
N is for nutrition and hydration Help patients to eat and drink well.
SSKIN
The prevention pathway
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Glamorgan Assessment Tool
• This tool should be used to support but not replace your clinical judgment deciding whether the child/young person is at risk of pressure ulcer development
• Best practice suggests the Glamorgan Assessment Tool should be completed with the child/young person and their parent/carer where appropriate and applicable
• All sections of the tool should be completed, however if data such as serum albumin or haemoglobin is not available, write NK – not known and score 0.
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• de-saturates with position changes • becomes hypotensive in a certain position• has contracture deformities and only
comfortable in limited positions• unable to consciously change their own
position without help e.g. a child may be unable to move independently, but carers can move the child
Special risksMobility: For example a child/young person who cannot be moved without great difficulty or deterioration in condition:
Remember: Decreased mobility will increase risk and patients may score in several areas.
• can make movements but these may not be purposeful (repetitive dyskinetic movements)
• has some mobility but reduced for age e.g. a child with developmental delay
• in traction who is able to make limited movements
• on bed rest.
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Make sure you have:• documented total Glamorgan score• acted upon individual risk factors identified e.g. optimise nutrition and mobility. • documented any actions taken following your assessment• used the diagram of the child to indicate the position of any skin lesions, and if
lesions are near to, or associated with any equipment such as BIPAP mask, nasogastric tube or splint, these should also be indicated.
Glamorgan Assessment Tool continued
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Equipment/objects/hard surface pressing or rubbing on the skin: Any object pressing or rubbing on the skin for long enough or with enough force can cause pressure damage e.g. pulse oximeter probes, ET tubes, masks, tubing/wires, tight clothing (anti-embolic stockings), plaster casts/splints.Significant anaemia: (Hb <9g/dl)Persistent pyrexia: (temperature >38.0ºC for more than 4 hours)Poor peripheral perfusion: (cold extremities/capillary refill > 2 seconds/cool mottled skin)Inadequate nutrition/PYMS: score >2 (discuss with a dietician if in doubt)Low serum albumin: (<35g/l)Incontinence: Inappropriate for age e.g. A seven-year-old child who needs to wear nappies during the day and night. Moisture lesions should not be confused with pressure ulcers.
Special risks Terminal Cachexia: Loss of body mass not treatable with nutrition.
Peripheral Vascular Disease: Anything to do with the circulation not including the brain and the heart.
Diabetes, Stroke, Multiple Sclerosis, Cerebro Vascular Accident: Assess degree of damage that patient has suffered. Score between 4-6 based on clinical knowledge and medical evidence.
Paraplegia: Anybody with major nerve disruption will be at very high risk of developing pressure ulcers. They will not have normal sense of pain/discomfort which warns patient to change position. Score between 4-6 depending on ability to lift themselves or change position every 15mins.
Dementia: Mild dementia score 4, severe dementia score 6.
Make sure have documented the action taken following your assessment.
Waterlow Assessment Tool
●●●
• Always complete Waterlow Assessment Tool with the patient and or carer.• Complete all seven sections of the tool.• Remember the skin type visual risk areas. You can score more than once in this
section. Only score discoloured/broken spots in areas vulnerable to pressure.
Surface
Vital considerations when prescribing a cushion: • Is the cushion the correct size
for the seat?
• Does the patient have any physical limitations that impact on their sitting ability, such as poor balance, joint contractures, spinal deformity?
• If any of the above points cannot be resolved you should consider a referral to an occupational therapist (OT).
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Seating – quick checks:• Is the patient sliding forward in
the seat? • Is the seat depth too deep? • Is the patient sitting uneven?
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• Is the seat too wide or narrow? • Is there support from the armrests? • Is the seat is too high; are the
patient’s feet unsupported?
●●●
Remember – appropriate seating can support posture and prevent shear and friction.
Think about: • seat height • armrest height • seat depth
Quick tips for chairs and beds
Cushions should not be used on rise recliner chairs.
Encourage patient to change their own position
where possible.
Remember – appropriate positioning will support posture and prevent shear and friction.
Think about: • sliding down the bed • falling/leaning to one side • ability to reposition self or
to correct position.
• seat angle • seat width • lumbar support.
Cha
irsB
eds
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Quick tips for chairs and beds continued
A knee break can be used on a profiling bed to help prevent the patient slipping/sliding when the back rest is elevated. Is it appropriate to use pillows to aid postural support where a patient tends to fall/lean to one side?
Encourage patient to change position where possible.
Sitting in bed with back rest at 90 degrees will impact on the effectiveness of any support surface. Is this necessary? Can activities be carried out in an alternative position or in a chair?
Can the time be limited in the position?
For patients with complex postural needs/contractures consider an OT referral.
It is the clinician’s responsibility to ensure the correct pressure setting is selected according to weight comfort tolerance and activity.
Remember turning – 30 degree tilt.
At risk of falling out of bed? Complete a bed rail assessment.
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Consider:
Beds
• Use slide sheets under the full length of the patient when moving patients in the bed. Do not use bed sheets without slide sheets.
• Take care when positioning and removing slide sheets.
• The use of slide sheets under heavy legs to assist with movement in bed to avoid dragging.
• A roller slide sheet or folded flat sheet under the heels when hoisting into or out of bed will prevent heels being dragged and may reduce the need for staff to support the legs.
• Positioning a slide sheet behind the patient’s upper body when profiling into
Keep moving
Keeping patients mobile plays a big part in the prevention of pressure ulcers.
sitting can reduce friction on the scapula, etc.
• Regular repositioning can reduce the risk of pressure ulcer this may include the use of equipment e.g. standing hoist to reduce sitting time, etc.
• Ensure hoist sling is fitted correctly and the correct sling for the task.
• Consider more specialist slings if the risk assessment indicates the need to leave the sling in place.
• Consider using slide sheets to help position hoist slings.
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Tips of how your patients can increase their dietary intake• Eat little and often.
• Keep nutritious snacks readily available.
• Add extra calories to meals e.g. adding butter, cream, grated cheese, extra sauces and gravy.
• Eat puddings twice a day and have nourishing drinks.
• Allow time to eat slowly and encourage chewing food well.
• Keep some cupboard essentials on standby for meals and snacks such as tins of soup, beans, crackers, UHT milk.
• Drink at least six to eight mugs/glasses of fluid per day.
Nutrition and hydration
Complete the Malnutrition Universal Screening Tool (MUST) on initial assessment and at regular intervals as specified in the tool, or sooner if patients condition indicates reassessment. Take action as indicated in Trust nutrition policies such as monitor food intake, food fortification, referral to dietitian.
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Information sheets to support patients with these changes are available on StaffZone.
Remember, consent needs to be gained every time you see your patient. Valid consent must be obtained before starting assessments, treatment or physical investigation.
For the consent to be valid, the patient must be competent to make the particular decision; have received sufficient information to take it; and not be acting under duress.
• discuss options and alternatives – there is always another way to minimise risk.
• If a patient refuses care, find out why.
• Concerns that your patient may lack capacity to consent to the proposed care? Complete a mental capacity assessment.
To support patients to make their own decisions and give valid consent:• give small amounts of information• use simple language• be clear and avoid jargon• use pictures and graphics e.g. for an
adult with communication problems or dementia
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Has your patient given consent?
Remember, we are all accountable to our patients, the public, our employer and our professional body. We all have a duty to make sure our actions cause no harm.
We have a duty to identify, report and escalate concerns to managers.
Accountability
Before you do anything, remember, it’s your responsibility to make sure you have: • had all the necessary training, development,
supervision and competence assessments• been given or take responsibility for the care
and/or treatment you are providing• your job description and/or professional registration
give you authority to act.
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Clinical Nutrition and Dietetics
Queen Victoria Memorial Hospital Phone: 01227 594739 Fax: 01227 594862
Email: [email protected]
For appointment enquiries please contact theCentral Appointment TeamPhone: 0300 1230861 Email: [email protected]
Useful contacts
Tissue Viability
Central Referral Unit Email: [email protected]
Medway TVN office Phone: 01634 810919Email: [email protected]
Unit 2, Whitfield CourtPhone: 01304 828755Fax: 01304 828702
Wheelchair Service
Phone: 0300 7900128 Email: [email protected]
www.nhs.stopthepressure.co.uk
www.epuap.org
www.pathways.nice.org.uk/pathways/pressure-ulcers
www.rcn.org.uk/development/practice/clinicalguidelines/pressure_ulcers
www.nice.org.uk
www.institute.nhs.uk
www.nhshealthquality.org
www.activahealthcare.co.uk/e-learning-zone/
www.woundsinternational.com
Need more help or advice?
Safety thermometer guidance Pressure ulcers
Doe
s yo
ur p
atie
nt
have
a p
ress
ure
ulce
r?
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
NO
It is
a n
ew
pres
sure
ulc
er
ente
r the
gra
de
(2, 3
or 4
)
Did
it d
evel
op
befo
re o
r with
in 3
da
ys o
f adm
issi
on
to y
our c
asel
oad?
It is
an
old
pres
sure
ulc
er
Are
you
cer
tain
? M
ake
sure
it is
a p
ress
ure
ulce
r and
no
t a m
oist
ure
lesi
on, w
hich
are
not
re
porte
d on
saf
ety
ther
mom
eter
. If
you
are
unsu
re, p
leas
e re
fer t
o yo
ur
patie
nt s
afet
y to
p tip
s fli
p ca
rds
or
spea
k to
you
r tea
m le
ader
.
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
pre
ssur
e ul
cer
in th
e ‘T
ag’ c
olum
n an
d tic
k th
e ‘F
lag’
box
if it
has
be
en re
porte
d on
a p
revi
ous
safe
ty th
erm
omet
er
YES
YES
NO
NO
Has
you
r pat
ient
ha
d a
fall?
Leav
e th
e
pre-
set a
nsw
er
of ‘N
o Fa
ll’.
NO
Did
it o
ccur
with
in
the
past
3 d
ays?
Ent
er th
e se
verit
y of
har
m
Low
for f
irst a
id
Mod
erat
e fo
r A&
E/A
cute
Adm
issi
on
Seve
re fo
r per
man
ent i
njur
y
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
fall
in th
e ‘T
ag’ c
olum
n
YES
YES
NO
NO
Was
the
patie
nt
on y
our c
asel
oad
whe
n it
occu
rred
?
Was
the
patie
nt
harm
ed?
Sel
ect
‘No
Har
m’
NO
YES
Doe
s yo
ur p
atie
nt
have
a U
TI?
NO
It is
a n
ew U
TI
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
UTI
in
the
‘Tag
’ col
umn
YES
NO
Was
it d
iagn
osed
be
fore
or w
ithin
3
days
of a
dmis
sion
to
you
r cas
eloa
d?
Doe
s yo
ur p
atie
nt
have
an
indw
ellin
g ca
thet
er?
*
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
NO
YES
Hav
e th
ey h
ad
one
with
in th
e la
st
3 da
ys? N
O
Ent
er h
ow m
any
days
the
cath
eter
has
bee
n/w
as in
pla
ce
(1-2
8, 2
8+ o
r unk
now
n)
YES
It is
an
old
UTI
.
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
Doe
s yo
ur p
atie
nt
have
a V
TE?
NO
It is
a n
ew V
TE
ente
r the
type
of V
TE
(DV
T, P
E, O
ther
).
YES
Was
it d
iagn
osed
be
fore
or w
ithin
3
days
of a
dmis
sion
to
you
r cas
eloa
d?
It is
an
old
VTE
ente
r the
type
of V
TE
(DV
T, P
E, O
ther
).
Are
you
cer
tain
? If
your
pat
ient
is o
n pr
ophy
laxi
s be
caus
e th
ey
are
’at r
isk’
of d
evel
opin
g a
VTE
, you
do
not
repo
rt a
VTE
on
safe
ty th
erm
omet
er.
P
rovi
de c
omm
ents
/reas
on fo
r the
V
TE in
the
‘Tag
’ col
umn
‘VTE
Ass
ess’
col
umn
Has
you
r pat
ient
had
a V
TE ri
sk A
sses
smen
t?
Ans
wer
Yes
, No
or N
/A
‘VTE
Pro
ph’ c
olum
n Is
you
r pat
ient
kno
wn
to b
e at
incr
ease
d ris
k of
a
VTE
and
on
prev
enta
tive
(pro
phyl
axis
) tre
atm
ent e
.g. p
re/p
ost-o
pera
tive
clex
ane?
A
nsw
er Y
es, N
o or
N/A
an
d pr
ovid
e co
mm
ents
in th
e ta
g co
lum
n
NO
NO
YES
YES
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
Safety thermometer guidance Falls
Doe
s yo
ur p
atie
nt
have
a p
ress
ure
ulce
r?
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
NO
It is
a n
ew
pres
sure
ulc
er
ente
r the
gra
de
(2, 3
or 4
)
Did
it d
evel
op
befo
re o
r with
in 3
da
ys o
f adm
issi
on
to y
our c
asel
oad?
It is
an
old
pres
sure
ulc
er
Are
you
cer
tain
? M
ake
sure
it is
a p
ress
ure
ulce
r and
no
t a m
oist
ure
lesi
on, w
hich
are
not
re
porte
d on
saf
ety
ther
mom
eter
. If
you
are
unsu
re, p
leas
e re
fer t
o yo
ur
patie
nt s
afet
y to
p tip
s fli
p ca
rds
or
spea
k to
you
r tea
m le
ader
.
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
pre
ssur
e ul
cer
in th
e ‘T
ag’ c
olum
n an
d tic
k th
e ‘F
lag’
box
if it
has
be
en re
porte
d on
a p
revi
ous
safe
ty th
erm
omet
er
YES
YES
NO
NO
Has
you
r pat
ient
ha
d a
fall?
Leav
e th
e
pre-
set a
nsw
er
of ‘N
o Fa
ll’.
NO
Did
it o
ccur
with
in
the
past
3 d
ays?
Ent
er th
e se
verit
y of
har
m
Low
for f
irst a
id
Mod
erat
e fo
r A&
E/A
cute
Adm
issi
on
Seve
re fo
r per
man
ent i
njur
y
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
fall
in th
e ‘T
ag’ c
olum
n
YES
YES
NO
NO
Was
the
patie
nt
on y
our c
asel
oad
whe
n it
occu
rred
?
Was
the
patie
nt
harm
ed?
Sel
ect
‘No
Har
m’
NO
YES
Doe
s yo
ur p
atie
nt
have
a U
TI?
NO
It is
a n
ew U
TI
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
UTI
in
the
‘Tag
’ col
umn
YES
NO
Was
it d
iagn
osed
be
fore
or w
ithin
3
days
of a
dmis
sion
to
you
r cas
eloa
d?
Doe
s yo
ur p
atie
nt
have
an
indw
ellin
g ca
thet
er?
*
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
NO
YES
Hav
e th
ey h
ad
one
with
in th
e la
st
3 da
ys? N
O
Ent
er h
ow m
any
days
the
cath
eter
has
bee
n/w
as in
pla
ce
(1-2
8, 2
8+ o
r unk
now
n)
YES
It is
an
old
UTI
.
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
Doe
s yo
ur p
atie
nt
have
a V
TE?
NO
It is
a n
ew V
TE
ente
r the
type
of V
TE
(DV
T, P
E, O
ther
).
YES
Was
it d
iagn
osed
be
fore
or w
ithin
3
days
of a
dmis
sion
to
you
r cas
eloa
d?
It is
an
old
VTE
ente
r the
type
of V
TE
(DV
T, P
E, O
ther
).
Are
you
cer
tain
? If
your
pat
ient
is o
n pr
ophy
laxi
s be
caus
e th
ey
are
’at r
isk’
of d
evel
opin
g a
VTE
, you
do
not
repo
rt a
VTE
on
safe
ty th
erm
omet
er.
P
rovi
de c
omm
ents
/reas
on fo
r the
V
TE in
the
‘Tag
’ col
umn
‘VTE
Ass
ess’
col
umn
Has
you
r pat
ient
had
a V
TE ri
sk A
sses
smen
t?
Ans
wer
Yes
, No
or N
/A
‘VTE
Pro
ph’ c
olum
n Is
you
r pat
ient
kno
wn
to b
e at
incr
ease
d ris
k of
a
VTE
and
on
prev
enta
tive
(pro
phyl
axis
) tre
atm
ent e
.g. p
re/p
ost-o
pera
tive
clex
ane?
A
nsw
er Y
es, N
o or
N/A
an
d pr
ovid
e co
mm
ents
in th
e ta
g co
lum
n
NO
NO
YES
YES
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
Safety thermometer guidance Catheters and UTIs
Doe
s yo
ur p
atie
nt
have
a p
ress
ure
ulce
r?
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
NO
It is
a n
ew
pres
sure
ulc
er
ente
r the
gra
de
(2, 3
or 4
)
Did
it d
evel
op
befo
re o
r with
in 3
da
ys o
f adm
issi
on
to y
our c
asel
oad?
It is
an
old
pres
sure
ulc
er
Are
you
cer
tain
? M
ake
sure
it is
a p
ress
ure
ulce
r and
no
t a m
oist
ure
lesi
on, w
hich
are
not
re
porte
d on
saf
ety
ther
mom
eter
. If
you
are
unsu
re, p
leas
e re
fer t
o yo
ur
patie
nt s
afet
y to
p tip
s fli
p ca
rds
or
spea
k to
you
r tea
m le
ader
.
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
pre
ssur
e ul
cer
in th
e ‘T
ag’ c
olum
n an
d tic
k th
e ‘F
lag’
box
if it
has
be
en re
porte
d on
a p
revi
ous
safe
ty th
erm
omet
er
YES
YES
NO
NO
Has
you
r pat
ient
ha
d a
fall?
Leav
e th
e
pre-
set a
nsw
er
of ‘N
o Fa
ll’.
NO
Did
it o
ccur
with
in
the
past
3 d
ays?
Ent
er th
e se
verit
y of
har
m
Low
for f
irst a
id
Mod
erat
e fo
r A&
E/A
cute
Adm
issi
on
Seve
re fo
r per
man
ent i
njur
y
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
fall
in th
e ‘T
ag’ c
olum
n
YES
YES
NO
NO
Was
the
patie
nt
on y
our c
asel
oad
whe
n it
occu
rred
?
Was
the
patie
nt
harm
ed?
Sel
ect
‘No
Har
m’
NO
YES
Doe
s yo
ur p
atie
nt
have
a U
TI?
NO
It is
a n
ew U
TI
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
UTI
in
the
‘Tag
’ col
umn
YES
NO
Was
it d
iagn
osed
be
fore
or w
ithin
3
days
of a
dmis
sion
to
you
r cas
eloa
d?
Doe
s yo
ur p
atie
nt
have
an
indw
ellin
g ca
thet
er?
*
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
NO
YES
Hav
e th
ey h
ad
one
with
in th
e la
st
3 da
ys? N
O
Ent
er h
ow m
any
days
the
cath
eter
has
bee
n/w
as in
pla
ce
(1-2
8, 2
8+ o
r unk
now
n)
YES
It is
an
old
UTI
.
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
Doe
s yo
ur p
atie
nt
have
a V
TE?
NO
It is
a n
ew V
TE
ente
r the
type
of V
TE
(DV
T, P
E, O
ther
).
YES
Was
it d
iagn
osed
be
fore
or w
ithin
3
days
of a
dmis
sion
to
you
r cas
eloa
d?
It is
an
old
VTE
ente
r the
type
of V
TE
(DV
T, P
E, O
ther
).
Are
you
cer
tain
? If
your
pat
ient
is o
n pr
ophy
laxi
s be
caus
e th
ey
are
’at r
isk’
of d
evel
opin
g a
VTE
, you
do
not
repo
rt a
VTE
on
safe
ty th
erm
omet
er.
P
rovi
de c
omm
ents
/reas
on fo
r the
V
TE in
the
‘Tag
’ col
umn
‘VTE
Ass
ess’
col
umn
Has
you
r pat
ient
had
a V
TE ri
sk A
sses
smen
t?
Ans
wer
Yes
, No
or N
/A
‘VTE
Pro
ph’ c
olum
n Is
you
r pat
ient
kno
wn
to b
e at
incr
ease
d ris
k of
a
VTE
and
on
prev
enta
tive
(pro
phyl
axis
) tre
atm
ent e
.g. p
re/p
ost-o
pera
tive
clex
ane?
A
nsw
er Y
es, N
o or
N/A
an
d pr
ovid
e co
mm
ents
in th
e ta
g co
lum
n
NO
NO
YES
YES
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
Safety thermometer guidance VTE
Doe
s yo
ur p
atie
nt
have
a p
ress
ure
ulce
r?
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
NO
It is
a n
ew
pres
sure
ulc
er
ente
r the
gra
de
(2, 3
or 4
)
Did
it d
evel
op
befo
re o
r with
in 3
da
ys o
f adm
issi
on
to y
our c
asel
oad?
It is
an
old
pres
sure
ulc
er
Are
you
cer
tain
? M
ake
sure
it is
a p
ress
ure
ulce
r and
no
t a m
oist
ure
lesi
on, w
hich
are
not
re
porte
d on
saf
ety
ther
mom
eter
. If
you
are
unsu
re, p
leas
e re
fer t
o yo
ur
patie
nt s
afet
y to
p tip
s fli
p ca
rds
or
spea
k to
you
r tea
m le
ader
.
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
pre
ssur
e ul
cer
in th
e ‘T
ag’ c
olum
n an
d tic
k th
e ‘F
lag’
box
if it
has
be
en re
porte
d on
a p
revi
ous
safe
ty th
erm
omet
er
YES
YES
NO
NO
Has
you
r pat
ient
ha
d a
fall?
Leav
e th
e
pre-
set a
nsw
er
of ‘N
o Fa
ll’.
NO
Did
it o
ccur
with
in
the
past
3 d
ays?
Ent
er th
e se
verit
y of
har
m
Low
for f
irst a
id
Mod
erat
e fo
r A&
E/A
cute
Adm
issi
on
Seve
re fo
r per
man
ent i
njur
y
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
fall
in th
e ‘T
ag’ c
olum
n
YES
YES
NO
NO
Was
the
patie
nt
on y
our c
asel
oad
whe
n it
occu
rred
?
Was
the
patie
nt
harm
ed?
Sel
ect
‘No
Har
m’
NO
YES
Doe
s yo
ur p
atie
nt
have
a U
TI?
NO
It is
a n
ew U
TI
YES
P
rovi
de c
omm
ents
/reas
on fo
r the
UTI
in
the
‘Tag
’ col
umn
YES
NO
Was
it d
iagn
osed
be
fore
or w
ithin
3
days
of a
dmis
sion
to
you
r cas
eloa
d?
Doe
s yo
ur p
atie
nt
have
an
indw
ellin
g ca
thet
er?
*
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
NO
YES
Hav
e th
ey h
ad
one
with
in th
e la
st
3 da
ys? N
O
Ent
er h
ow m
any
days
the
cath
eter
has
bee
n/w
as in
pla
ce
(1-2
8, 2
8+ o
r unk
now
n)
YES
It is
an
old
UTI
.
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
Doe
s yo
ur p
atie
nt
have
a V
TE?
NO
It is
a n
ew V
TE
ente
r the
type
of V
TE
(DV
T, P
E, O
ther
).
YES
Was
it d
iagn
osed
be
fore
or w
ithin
3
days
of a
dmis
sion
to
you
r cas
eloa
d?
It is
an
old
VTE
ente
r the
type
of V
TE
(DV
T, P
E, O
ther
).
Are
you
cer
tain
? If
your
pat
ient
is o
n pr
ophy
laxi
s be
caus
e th
ey
are
’at r
isk’
of d
evel
opin
g a
VTE
, you
do
not
repo
rt a
VTE
on
safe
ty th
erm
omet
er.
P
rovi
de c
omm
ents
/reas
on fo
r the
V
TE in
the
‘Tag
’ col
umn
‘VTE
Ass
ess’
col
umn
Has
you
r pat
ient
had
a V
TE ri
sk A
sses
smen
t?
Ans
wer
Yes
, No
or N
/A
‘VTE
Pro
ph’ c
olum
n Is
you
r pat
ient
kno
wn
to b
e at
incr
ease
d ris
k of
a
VTE
and
on
prev
enta
tive
(pro
phyl
axis
) tre
atm
ent e
.g. p
re/p
ost-o
pera
tive
clex
ane?
A
nsw
er Y
es, N
o or
N/A
an
d pr
ovid
e co
mm
ents
in th
e ta
g co
lum
n
NO
NO
YES
YES
Leav
e th
e
pre-
set a
nsw
er
of ‘N
one’
.
0037
4