Pressure Ulcer Prevention
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HOW TO CONDUCT OUR PERFORMANCE ASSESSMENT
To conduct our performance test, a licensed nurse should ask residents lying in bed to turn to one side, and then the other side. For each turn, be prepared to offer the resident the minimum level of human assistance possible, according to a standardized graduated assistance protocol:
- Level 0: Request only, no physical assistance required
- Level 1: No physical assistance but encouragement, verbal cues, prompting, or instructions on how to perform the activity (e.g., "Reach for the siderail, pull yourself over")
- Level 2: Verbal cues required plus minimal manual guidance to start the movement (e.g., "Please move your hand towards the siderail")
- Level 3: Partial physical assistance (e.g., move arm to siderail and pull the shoulder and upper body over to help in the turning movement)
- Level 4: Unable to turn to the side without complete physical assistance
Residents are rated "able to move" if their performance falls within Level 0 or 1 on both sides.
Please note: Some of these residents, especially those rated Level 1, will need verbal cuing or reminders to turn (though they don't need time-consuming physical help). Remember also to provide verbal reminders as needed when residents are in their wheelchairs. Be sure to share performance assessment results with fellow staff workers so they, too, can provide appropriate care.
If residents are rated at higher levels (2-4) on either or both sides, they are considered "unable to move independently" and thus, require physical help from staff with repositioning every two hours.
Use our Performance Assessment Form to document resident results.
This assessment takes about five minutes per resident to conduct (about three minutes per side). Inter-rater reliability is excellent and stability of results is good (4).
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