Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

InterRAI Pressure Ulcer Risk Scale

 

For more information about this tool, please refer to:
 
Source: Poss, J., Murphy, K., Woodbury, M, Orsted, H., Stevenson, K., Williams, G. et al. (2010). Development of interRAI Pressure Ulcer Risk Scale (PURS) for use in long-term care and home care setting. BioMed Central Geriatrics, 10, 67
 
Reprinted with permission from BioMed Central
 
InteRai PURS Assessment
 
Score
 Bed mobility: Ability to move from to and from lying position, turn and position body in bed
 
0-Self performance
1-Support required
Walk in room: How resident walks between locations in own room
 
0-Self performance
1-Support required
 
Bowel Continence: Control of bowel movement, with appliance, or bowel program
 
0-Yes
1-No
Weight Change : weight loss -5% or more in last 30 days or 10% or more in last 180 days
0-No
1-Yes
 
Hx of resolved pressure ulcers: Resident has a PU that was resolved in last 90 days
0-No
2- Yes
 
Pain Symptoms: Frequency that resident complains or shows evidence of pain
0-No pain
1-Pain daily
 
Shortness of Breath
0-No
1-Yes
 
        Add numbers to obtain Total Score
(higher score = ↑ risk for developing a pressure ulcer)