Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Risk and Related Interventions

Risk Category

Interventions


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 

  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

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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