Mobility Completely Immobile Very Limited Slightly Limited No Limitations Skin assessment and inspection q shift. Skin assessment and inspection q shift. Check skin daily. Check skin daily. Turn/reposition q 1-2 hours. Turn/reposition 1-2 hours. Turn/reposition frequently. Encourage ambulating outside Post turning schedule. Post turning schedule. Teach frequent small shifts of body the room at least bid. weigh. Teach or do frequent small shifts of Teach or do frequent small shifts of No interventions body weight. body weight. PT consult for required. strengthening/conditioning. Elevate heels. Elevate heels. Gait belt for assistance. Consider specialty bed. Consider specialty bed. Nutrition Very Poor Probably Inadequate Adequate Excellent Nutrition consult. Nutrition consult. Monitor nutritional intake. Out of bed for all meals. Skin assessment and inspection q shift. Offer nutrition supplements and water. If NPO for > 24 hours, discuss plan with MD. Provide food choices. Offer nutrition supplements and water. Encourage family to bring favorite foods. Record dietary intake and I&O if Offer nutrition Encourage family to bring favorite appropriate. supplements. If NPO foods. Monitor nutritional intake. for > 24 hours, Monitor nutritional intake. Small frequent meals. discuss plan with If NPO for > 24 hours, discuss plan with If NPO for > 24 hours, discuss plan MD. MD. with MD. Record dietary intake. Record dietary intake and I & O if Record dietary intake and I & O if appropriate. appropriate. Friction Problem Potential Problem No apparent problem and Shear Skin assessment and inspection q shift. Keep bed linens clean, dry, and wrinkle Keep bed linens clean, dry, and free. wrinkle free. Minimum of 2 people + draw sheet to pull patient up in bed. Avoid massaging pressure points. Keep bed linens clean, dry, and wrinkle Apply transparent dressing or free. elbow/heel protectors to intact skin over elbows and heels. Apply elbow/heel protectors to intact skin over elbows and heels. Elevate head of bed 30 degrees or less.
Mobility Completely Immobile Skin assessment and inspection q shift. Turn/reposition q 1-2 hours. Post turning schedule. Teach or do frequent small shifts of body weight. Elevate heels. Consider specialty bed. Very Limited Skin assessment and inspection q shift. Turn/reposition 1-2 hours. Post turning schedule. Teach or do frequent small shifts of body weight. Elevate heels. Consider specialty bed. Slightly Limited Check skin daily. Turn/reposition frequently. Teach frequent small shifts of body weigh. PT consult for strengthening/conditioning. Gait belt for assistance. No Limitations Check skin daily. Encourage ambulating outside the room at least bid. No interventions required. Nutrition Very Poor Nutrition consult. Skin assessment and inspection q shift. Offer nutrition supplements and water. Encourage family to bring favorite foods. Monitor nutritional intake. If NPO for > 24 hours, discuss plan with MD. Record dietary intake and I & O if appropriate. Probably Inadequate Nutrition consult. Offer nutrition supplements and water. Encourage family to bring favorite foods. Monitor nutritional intake. Small frequent meals. If NPO for > 24 hours, discuss plan with MD. Record dietary intake and I & O if appropriate. Adequate Monitor nutritional intake. If NPO for > 24 hours, discuss plan with MD. Record dietary intake and I&O if appropriate. Excellent Out of bed for all meals. Provide food choices. Offer nutrition supplements. If NPO for > 24 hours, discuss plan with MD. Record dietary intake. Friction and Shear Problem Skin assessment and inspection q shift. Minimum of 2 people + draw sheet to pull patient up in bed. Keep bed linens clean, dry, and wrinkle free. Apply elbow/heel protectors to intact skin over elbows and heels. Elevate head of bed 30 degrees or less. Potential Problem Keep bed linens clean, dry, and wrinkle free. Avoid massaging pressure points. Apply transparent dressing or elbow/heel protectors to intact skin over elbows and heels. No apparent problem Keep bed linens clean, dry, and wrinkle free.
putoolkit_module3_tools.docx