Clinical judgement must override any score you get when using a numerical pressure ulcer risk assessment tool.
So how do you assess a patient using clinical judgement?
Ask the patient if they can:
1. lift their arms up / off the bed
2. lift their legs up / off the bed
3. roll from side to side
If the patient cannot perform these movements they are at risk of pressure injury / ulcer.
Simple…
You can use this very quick and very simple 15 second assessment when you don’t have time to fill in a complicated, time-consuming, assessment tool that contains parameters that are irrelevant to pressure injury development e.g. incontinence and poor nutrition.
