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It was attached to the original message from Mike. I am
copying it into this email from Word, and I will attach a copy as well, just in
case you can't get attachments.
Resident�s Name: _________________________________ UNAVOIDABLE PRESSURE ULCER RISK ASSESSMENT CRITERIA Clinical conditions that are PRIMARY RISK FACTORS for developing pressure sores include, but are not limited to immobility and: The resident has two or more of the following diagnoses: ____ Continuous Urinary Incontinence or Chronic Voiding Dysfunction ____ Severe Peripheral Vascular Disease ____ Diabetes ____ Severe Chronic Bowel Incontinence ____ Paraplegia ____ Quadriplegia ____ Sepsis ____ Terminal Cancer ____ Chronic or End Stage Renal, Liver and/or Heart Disease ____ Disease or Drug related Immunosuppression ____ Full Body Cast ____ Semi-comatose or Comatose The resident receives 2 or more of the following treatments: ____ Steroid Therapy ____ Radiation Therapy ____ Chemotherapy ____ Renal Dialysis ____ Head of Bed elevated the majority of the day due to medical necessity. Malnutrition/dehydration whether secondary to poor appetite or another disease Process, places resident at risk for poor healing and may be indicated by the Following lab values: ____ Serum Albumin below 3.4 g/dl ____ Weight Loss of more than 10% during the last 30 days ____ Serum Transferrin level below 180 mg/dl ____ Hgb less than 12 mg/dl Use these values in conjunction with an evaluation of the resident�s clinical condition. If lab data are not available, clinical signs and symptoms of Malnutrition, dehydration may be: ____ pale skin ____ red, swollen lips ____ swollen and/or dry tongue with scarlet or magenta base ____ cachexia ____ bilateral edema ____ muscle wasting Cont�d ____ calf tenderness ____ Sunken eyes and/or cracked lips ____ reduced urinary output PREVENTIVE MEASURE IMPLEMENTED Pressure relief surface: ___________________________________________________ Additional protective equipment: ____________________________________________ Nutritional Supplements: __________________________________________________ Vitamin/mineral supplements: _______________________________________________ History of healed pressure ulcer(s): __________________________________________ Mental Status: ________________________ Mobility: _________________________ Resident�s compliance with treatment plan: ____________________________________ Resident�s Name: _____________________________________ Braden Scale: ______ Date: __________________ Physician�s Signature: ________________________________ Date: ______________
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unavoidable pressure ulce assessment.doc
Description: MS-Word document
