When should you be screening? When to use clinical your judgement? These and many more of your questions answered
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’.