INFORMATION ON TISSUE VIABILITY (This information is required only if you are requesting a pressure distributing cushion) Does the client have an existing pressure ulcer? Yes: No: If yes, please give details of severity/grade and site of pressure ulcer(s): Is the client at risk of developing a pressure ulcer? Yes: No: If yes, please give details of potential problems: PRESSURE ULCER RISK ASSESSMENT BRADEN SCALE – Patients with existing or previous pressure damage are immediately high risk Sensory perception Mobility – ability to respond meaningfully to pressure related – ability to change and control body position discomfort 1. Completely immobile 1. Completely Limited 2. Very Limited 2. Very Limited 3. Slightly Limited 3. Slightly Limited 4. No limitations 4. No impairment Moisture Nutrition degree to which skin is exposed to moisture Usual food intake – – 1. Constantly moist 1. Very poor 2. Very moist 2. Probably inadequate 3. Occasionally moist 3. Adequate 4. Rarely moist 4. Excellent Activity Friction and Shear – degree of physical activity 1. Problem 1. Bedfast 2. Potential problem 2. Chair fast 3. No apparent problem 3. Walks Occasionally 4. Walks frequently Total Score 16+ = Low risk 13 15 = Medium risk – Less than 12 = High risk To be used in conjunction with clinical judgement. Please note lower scores indicate a higher risk of pressure ulcer development. Information on other Risk Factors (E.g. sitting posture, transfer technique etc): FURTHER ASSESSMENT Yes No *Further assessment required? If Yes, please tick one or more boxes: Non-powered wheelchair Powered wheelchair
INFORMATION ON TISSUE VIABILITY (This information is required only if you are requesting a pressure distributing cushion) Does the client have an existing pressure ulcer? Yes: No: If yes, please give details of severity/grade and site of pressure ulcer(s): Is the client at risk of developing a pressure ulcer? Yes: No: If yes, please give details of potential problems: PRESSURE ULCER RISK ASSESSMENT – BRADEN SCALE Patients with existing or previous pressure damage are immediately high risk Sensory perception – ability to respond meaningfully to pressure related discomfort 1. Completely Limited 2. Very Limited 3. Slightly Limited 4. No impairment Mobility – ability to change and control body position 1. Completely immobile 2. Very Limited 3. Slightly Limited 4. No limitations Moisture – degree to which skin is exposed to moisture 1. Constantly moist 2. Very moist 3. Occasionally moist 4. Rarely moist Nutrition – Usual food intake 1. Very poor 2. Probably inadequate 3. Adequate 4. Excellent Activity – degree of physical activity 1. Bedfast 2. Chair fast 3. Walks Occasionally 4. Walks frequently Friction and Shear 1. Problem 2. Potential problem 3. No apparent problem Total Score 16+ = Low risk 13 – 15 = Medium risk Less than 12 = High risk To be used in conjunction with clinical judgement. Please note lower scores indicate a higher risk of pressure ulcer development. Information on other Risk Factors (E.g. sitting posture, transfer technique etc): FURTHER ASSESSMENT *Further assessment required? Yes No If Yes, please tick one or more boxes: Non-powered wheelchair Powered wheelchair
538OWSreferralformv23.docx