Patient at risk of Pressure Damage
OR
Blanching erythema/Grade 1-2/WATERLOW <20
Carry out positional changes on electric profiling bed/30 degree tilt
Nurse on pressure reducing foam mattress (Pentaflex)
Deteriorating skin integrity/ Established pressure damage/DTI/Unable to carry out regular positional changes/Up to Grade 4/Ungradable
WATERLOW > 20
HIGH-VERY HIGH RISK
AURALIS (incorporates Heelguard)
Max weight 39 stones/250kg
If patient cannot tolerate an alternating support surface contact TVN or Arjo clinical nurse advisor for clinical advice
Specialist products
Bariatric equipment
Arjo Clinical Nurse Advisor: Jo Robertson (07815 660628 Joanna.Robertson@arjo.com)
or
Bariatric equipment specialist Christina Boyle (07812766981 Christina.Boyle@arjo.com)
Seating cushions: AURA (Indicated for all Grades of Pressure Ulcers Max Weight 18 Stones/120kg)
Consider the following:
- Continual reassessment of patient utilising the flow chart is essential to ensure all patients receive optimum benefit of equipment
- Waterlow Risk Assessment score must be used in conjunction with Clinical Judgement
- If the patient has a spinal injury or unstable fracture consent from a clinician must be obtained before using a therapeutic mattress
- Ensure positional changes are carried out as per Care Rounding Tool.
Stepping down: Ask yourself: -
- Are the patients pressure areas improving?
- Is their mobility improving and they are now able to move themselves independently?
- Can they turn in bed with minimal assistance? Is the patient to be discharged within 72 hours? Will they be discharged with an Alternating/Specialised Support Surface?
- If the patients mobility and/or skin is now improving and/or they are not being discharged with a specialised mattress then step down to Pentaflex.