Skin Assessment  Check skin when giving personal care  If patient is complaining of discomfort or pain  Check areas at risk of pressure damage (see body chart )  If area is red, check for blanching  Document if skin is at risk such as very dry or over moist Assess for problem skin Assess any breaks/wounds to skin What skin regime are they presently using ? Can patient check and maintain their own skin health? Have they got carers to help them with personal care

Surface  Check what mattress and cushions they are using  Is it the correct surface level of risk ?  Check that mattresses and cushions are correctly installed and working –plugged in,pumped up,foams integrity (fist test) What is the patient laying on –pads,kylies (do they need to?) Sheets- are they wrinkle free? Baggy clothing Do they need their surface upgrading or replacing?

Incontinence  Have they been incontinent ?  Urine or faeces  Are they wearing pads – how often are they changed ?  Do they need a continence assessment?  What is their skin regime?  Do they need emollients ?  Skin barriers  What are they washing with?  Any problems with moisture –moisture lesions  Function - can they get to the toilet?  What is their toilet regime?

Keep moving  Can they move  Are they motivated to move  Do they need prompting  Do they need assistance to move  Is there anything we can do to make they more independent  Do they need referring-OT /PHYSIO   Do they have/need a turning regime ?  Do they a positioning plan ?  Has the patient been educated to move every 1-2 hours stand / change position,rest on the bed  Do they need passive exercises to prevent contractures

Nutrition  MUST has it been done,when was it, done is it current?  Is the patient at risk ?  What is the action plan /care plan  Has the plan been followed? if not why not ?  What are they eating and drinking? Does the patient know what a good diet is?  Do they need a food chart ?  Do they need a fluid chart ?  Can they fill their own chart in? Can a carer help?  Do they need a high calorie diet ?  Do they need a high protein diet (do they have any renal problems )  Do they need referring ?