Clinical judgement should be used when assessing poor nutritional intake as some patients may receive nutritional support but not tolerate it well and so would be considered to have poor nutritional intake. There may have also been delays in starting the additional nutritional support which should be considered in the assessment

Nurses should use their clinical judgement to assess whether the device is causing a problem, incorporating consideration of skin vulnerability, whether the device is in continuous use and whether the patient is self-caring and can attend to their own device.

The systematic review that was undertaken in the development of PURPOSE-T indicated there is strong evidence that diabetes increases the probability of pressure ulcer development and was therefore considered important to be included. It does link in with the other risk factors mentioned though

The screening stage was developed so that if a yellow items is ticked then you move down immediately to the full assessment (rather than continuing horizontally across all items). For ICU patients it is likely that this will occur at the mobility items and so will practically take a matter of seconds to assess before moving down to full assessment. Having an overview of the patients risk profile is useful for care planning purposes; while most patients will be ‘at risk’ the profile of that risk may vary e.g. some patients may have a moisture problem while others may not, some may have issues with medical devices while others may not. Having an understanding of the risk profile will facilitate appropriate care planning and implementation at an individual patient level. In addition, ongoing and regular monitoring of the patients skin is particularly important in the ICU population.

The clinical judgement item at screening prompts the nurse to use his/her clinical judgement and wider knowledge of the patient to assess whether there are any other significant factors that may impact the patients pressure ulcer risk (requiring the more detailed second step assessment or whether they can be screened out at step 1). This could include factors such as perfusion problems, oedema, epidurals, steroids but this is not an exhaustive list. Other wider factors such as increasing or fluctuating dependency should also be taken into consideration. Confidence in making this decision may grow with experience. If at the screening stage the nurse is uncertain or under confident about their clinical judgement they can always take the patients through the full assessment to allow more detailed consideration. This may make them more confident to indicate the patient as not currently ‘at risk’. Following the full detailed assessment if only yellow or blue boxes are ticked the risk profile of the patient must be considered and clinical judgement should be used to determine whether the patient is ‘at risk’ or ‘not currently at risk’. This should be influenced by number of yellow boxes ticked (i.e. patients with a number of yellow boxes ticked are more likely to be considered ‘at risk’) and consideration of the patient’s individual circumstances. For example a patient may only have the presence of unplanned weight loss but may be terminally ill and nearing the end of life. Here the general trajectory of dependence will increase and the patient may therefore be considered to be ‘at risk’. In another example a young diabetic patient may have undergone acute surgery but be recovering well. Here the general trajectory is increasing independence so the patient may therefore be considered to be ‘not currently at risk’, (this would need to be reviewed if the patient’s condition changed). This may make them more confident to indicate the patient as not currently ‘at risk’.