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:
(1) staff involved with patient care on the day of testing, and
(2) 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 |
|
|
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.
Specialty: Dermatology, Surgery, general
ICD-10: ,
