Who Is at Risk for Bedsores?
In making the assessment, your admitting nurse must determine whether anyone or more of the following risk factors exist:
age over 60
spinal cord paralysis
nervous system disease
confined to bed
altered level of consciousness
reduced mobility (traction or body cast)
The usual procedure is to assign a value of 1 to each risk factor and add up those that exist. The totals then translate to one of the three levels of risk as follows: 0 to 6 indicates low risk, 7 to 13 indicates moderate risk, 14 to 18 indicates high risk. The parts of the body that are susceptible to pressure ulcers are the heels, ankles, knees, buttocks, tailbone, lower spine, shoulder blades, ears, and back of the head.