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Overview :
The Trial Pressure Sore Risk Assessment Scale is a scale for
evaluating the risk of a patient developing a pressure sore. It was developed by
Watkinson at City Hospital in Nottingham, England.
Parameters used in score:
(1) body mass index
(2) dietary intake
(3) skin state
(4) continence in urine and feces
(5) activity
(6) pain
(7) special risk factors
Each parameter is scored for different levels of risk, from 0 (most favorable) to 4 or 5 (least
favorable). It is recommended that the assessment be done only by:
• staff involved with patient care on the day of testing,
and
• staff who are familiar with its use.
|
Parameter |
Finding |
Score |
|
body mass index |
20 - 25 (acceptable) |
0 |
|
|
26 - 30 (overweight) |
1 |
|
|
>= 31 (obese) |
2 |
|
|
<= 19 (underweight) |
3 |
|
dietary intake |
able to eat full hospital diet |
0 |
|
|
enteral, parenteral feeding (nasogastric tube, PEG
tube, TPN) |
1 |
|
|
eats and drinks some hospital diet and takes dietary
supplements |
2 |
|
|
eats and drinks some hospital diet and fluids
only |
3 |
|
|
anorexic or IV fluids only |
4 |
|
skin state |
healthy |
0 |
|
|
thin, dry and/or edematous |
1 |
|
|
discolored and/or persistent redness |
2 |
|
|
superficial break and/or macerated skin |
3 |
|
|
full thickness tissue break and/or or cavity |
4 |
|
continence (revised) |
continent
catheter/sheath in situ |
0 |
|
|
catheter/sheath in situ and incontinent of feces 1-3
times in 24 hours |
1 |
|
|
catheter/sheath in situ and incontinent of feces > 3
times in 24 hours |
2 |
|
|
incontinent of urine and/or feces 1-3 times in 24
hours |
3 |
|
|
incontinent of urine and/or feces > 3 times in 24
hours |
4 |
|
activity |
fully mobile |
0 |
|
|
restless, fidgety |
1 |
|
|
walks with difficulty |
2 |
|
|
bed-bound and inert |
3 |
|
|
chair-bound and inert |
4 |
|
pain |
none |
0 |
|
|
fear of pain |
1 |
|
|
periodic pain |
2 |
|
|
pain on movement |
3 |
|
|
continual discomfort |
4 |
|
special risk factors |
none |
0 |
|
|
smoking |
1 |
|
|
anemic
chest infection |
2 |
|
|
steroid therapy
dyspnea |
3 |
|
|
neurologic deficit (paraplegia, multiple sclerosis,
etc.) |
4 |
|
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cardiac failure
peripheral vascular disease
diabetes mellitus |
5 |
where:
• The body
mass index = (weight in kilograms) / ((height in meters) ^2).
• The
original continence scale was scored (0) continent or catheter/sheath in situ;
(1) incontinent of urine and feces 1-3 times in 24 hours; (2) incontinent in
urine and feces > 3 times in 24 hours; (3) catheterization but incontinent in
feces; (4) doubly incontinent
risk assessment score =
= (points for BMI) + (points for dietary intake) + (points
for skin state) + (points for continence) + (points for activity) + (points for
pain) + (points for special risk factors)
where:
• "A
patient can obtain a score at each level and can also be awarded a score more
than once at each level."
• The first
6 parameters appear to be scored just once.
• Scoring
the special risk factors is a little unclear to me. Either every one of the
special risk factors is scored, or only one at each level.
Interpretation:
• minimum score: 0
• maximum
score: > 36 (according to Watkinson)
• If only
score first 6 parameters once and all 5 in the special risk group, then the
maximum score could be either 23+15=38 (only 1 in each of special risk items
scored) or 23+30=55 (all possible special risk items scored).
• The
higher the score, the greater the risk of developing a pressure ulcer.
Limitations:
• While
Watkinson found that the score was popular with the nursing staff who used it,
it was not found to have a greater inter-rater reliability than other risk
scores for pressure sores.
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