A client is assessed as: having no sensory deficits; skin is dry and not exposed to moisture; confined to bed; is completely immobile; requires moderate assistance in moving; and nutritional status is adequate. Which pressure ulcer risk score is the most appropriate based on the assessment data?
1. 14, indicating moderate risk
2. 15, indicating high risk
3. 12, indicating risk
4. 14, indicating high risk
1
Rationale 1: The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15–18 indicates some risk, 13–14 indicates moderate risk, 10–12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.
Rationale 2: The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15–18 indicates some risk, 13–14 indicates moderate risk, 10–12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.
Rationale 3: The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15–18 indicates some risk, 13–14 indicates moderate risk, 10–12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.
Rationale 4: The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15–18 indicates some risk, 13–14 indicates moderate risk, 10–12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.
Global Rationale: The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15–18 indicates some risk, 13–14 indicates moderate risk, 10–12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.
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