Evaluate the patient's daily living ability to reflect the degree of care the patient needs for next step identification and decision-making

barthel index rating scale

Admission, postoperative, condition change, discharge

Total score ≤40: severe dependence 41～60: Moderate dependence 61～99: Mild dependence 100: No dependencies required

No need for dependence: tertiary care Mild dependence: secondary care or tertiary care Moderate dependence: secondary care Severe dependence: first level care

Braden rating

Factors such as moisture, mobility, nutrition, friction and shear

Completed within 2 hours after patient admission

Low-risk patients are evaluated weekly, those at intermediate- and high-risk twice weekly, and those at very high risk every 48 hours.

15～18: Low risk

13～14: Moderate risk

10～12: Highly dangerous

9 points and below: very dangerous

Keep the bed unit flat and dry

Keep skin clean and dry

Strict shift handover, check skin condition every shift

Turn over and change positions every 2 hours to reduce pressure and avoid friction.

Provide health education and provide relevant knowledge and skills to family members

Use air cushions, protective films and other tools

VTE-Padua Score and VTE-Caprini Assessment Scale

Immobility, known thrombophilia

Within 24 hours after admission, within 6 hours after surgery, before discharge, and when the patient's VTE risk factors change

0~3 points: low risk

4 points and above: high risk

Replenish fluids and drink water appropriately to avoid dehydration

Raise the affected limb 20 to 30 degrees

Control blood sugar and blood lipids

Get out of bed as early as possible

Use compression stockings, inflatable compression devices, etc. for patients as directed by the doctor

Pain severity visual analog scale and related content assessment sheet

Pain location, pain nature, pain frequency and impact on life, etc.

When patients are admitted and when pain levels change

VAS visual simulation method: 0 points (no pain) to 10 points (most painful)

facial expression scale

Observe and record the nature, extent and duration of pain, etc.

Administer analgesics as directed by the doctor, and observe and record the effects of the medication.

Adjust to a comfortable position

Instruct patients and family members to use analgesics correctly, protect painful areas, and master methods to relieve pain.

Spiritual comfort and psychological counseling

Instruct patients on the application of relaxation therapy

Nutritional risk assessment form for inpatients

Nutritional status impairment score, disease severity score, etc.

When the patient is admitted to the hospital

Total score ≥3 points: the patient is at risk of malnutrition

Encourage patients to take in adequate nutrition and eat a diet high in protein, vitamins, and calories that is easy to digest.

For those with poor appetite and difficulty eating, it is advisable to eat small amounts frequently and eat a diet with less residue.

Provide intravenous high nutritional support when necessary

Catheter slippage risk scoring scale

Patient age, state of consciousness, emotional state, catheter risk level, and number of catheters, etc.

Patients are evaluated upon admission and postoperatively, with high-risk catheters assessed once per shift, intermediate-risk catheters daily, and low-risk catheters twice weekly.

≤8 points: mild risk

9 to 12 points: moderate risk

≥13 points: high risk

All pipes must be properly secured and marked by the installer

Strictly abide by the operating procedures, be gentle during treatment and care, and pay attention to protecting the catheter to prevent it from slipping

Strengthen the observation of high-risk patients and make detailed handovers as key handover content

Provide health guidance to patients and their families

Morse Fall Risk Assessment Form

Patient's history of falls, assistance with activities, medical diagnosis, gait and cognitive status, etc.

When the patient is admitted to hospital, when the condition changes, before discharge, when medications with high fall risk are used

<25 points: low risk

25-45 points: medium risk

>45 points: high risk

Regularly inspect ward facilities to keep them in good condition and eliminate potential safety hazards

The ward environment is well-lit, the floor is flat and dry, and anti-slip warning signs are installed in special circumstances.

Carry out health education and enhance prevention awareness among patients and their families

Patients taking sedatives and sleeping pills should not get out of bed and move around when they are not fully awake; patients taking antihypertensive drugs and other drugs should pay attention to their reactions after taking the drugs.

For patients who have been bedridden for a long time or have fractures, someone should accompany them when they get out of bed and walk for the first time.

CORN Intraoperative Acquired Pressure Injury Risk Assessment Scale

Body weight, operation time, intraoperative pressure and shear force changes, etc.

Before, during and after surgery

Preoperative pressure injury risk factor assessment

Assessment of risk factors for intraoperative pressure injury

Postoperative skin assessment of pressure areas

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