Case Study
72 Y.O. Female. No sensory deficit, skin is dry, linens only require changing at routine intervals, walks frequently around the unit with no assist, eats most of every meal, and moves from bed to chair with ease.
23- low risk
What is activity described as?
The degree of physical activity.
How would you score a patient that eats most of every meal and doesn't require supplements?
4- Excellent!
Friction and Shear is in reference to what?
How much assistance the patient needs moving in bed. Patients sliding down in bed increase friction and shearing when scooting down or being pulled up.
If linens (chux pads) have to be changed on a patient every time the patient is moved due to incontinence, what score would be used?
1- constantly moist
36 Y.O. Male. Unresponsive, arms and legs constantly weeping, on bedrest, completely immobile, NPO for over 5 days, requires 2 nurses turn him and has contractures
6- severe risk
1- bedfast
If a patient eats over half of their meals OR is on a tube feeding or TPN regimen which probably meets most of their nutritional needs, what score would you give them?
3- Adequate
If a patient is able to move themselves up in bed, what score would you give them?
3- no apparent problem
If skin is dry and there is no dampness on linens, what score is given?
4- rarely moist
82 Y.O. male. Responds to verbal commands but needs assistance turning. Skin is moist often, requiring chux pads to be changed at least once a shift. Unable to walk, and can reach for the side of the bed, but unable to maintain position. On continuous tube feeds and occasionally needs boosted in bed.
13- moderate risk
A patient needs the maxi move to sit in the chair, what is their activity?
2- Chairfast
If a patient receives less than optimum amount of liquid diet or tube feeding, they will receive a nutrition score of?
2- probably inadequate
If a patient requires minimal assistance, but still has help from nurses boosting them in the bed, what score would they get?
2- potential problem
If a patient's linens (chux pads) require changing once a day due to moisture, what score is given?
3- occasionally moist
58 Y.O. female. Responds to painful stimuli only, skin is dry, no need to change linens frequently. Able to walk, however severely limited, needs assistance to chair. Can shift herself in bed but not make significant changes. She only drinks 1 ensure a day and will pick at her food. She scoots down in the bed frequently, requiring boosts at least 4 times a shift.
13- moderate risk
If a patient spends the majority of their time in bed, but can walk to the chair, what is their mobility?
A patient is NPO and/or maintained on clear liquids for more than 5 days, they would score a?
1- very poor :(
If a patient doesn't slide down in the bed, but has contractures, what score would they receive?
1- problem
Skin is often moist, but not always. Linens (chux pads) need changed at least each shift. What score you thinking?
2- very moist
17 Y.O. male. Sedated and paralyzed. Skin is dry, on bedrest. On bolus tube feeds. Requires q 2 hours.
11- high risk
At least once every two hours (during waking hours)
A patient is NPO, but on IVMF for more than 5 days, they would score a?
1- very poor
If a patient needs complete lifting assistance from nurses, what score would they get?
1- problem
Patient is weeping on just the arms. Chux need changed for their arms every hour. Their legs are dry and clean. What score do they get?
1- constantly moist