Autar DVT Risk Assessment Scale - University of Missouri



Autar DVT Risk Assessment Scale

|ADDRESSOGRAPH | |SPECIAL RISK CATEGORY | |TRAUMA RISK CATEGORY |

| | | | | |

|Name: | |Oral contraceptive: Score | |Score items(s) ONLY pre-operative Score |

| | |20-35 yrs | | |

| | |1 | |Head 1 |

|Unit No: | |35+ yrs | |Chest 1 |

| | |2 | |Spinal 2 |

|Ward: | | | |Pelvic 3 |

| | |Pregnancy/Puerperium | |Lower limb 4 |

| | | | | |

|AGE SPECIFIC GROUP | |ASSESSMENT PROTOCOL | |SURGICAL INTERVENTIONS |

| | | | | |

| | | | |Score only ONE appropriate item Score |

| | | | | |

| | | | |Minor Surgery (41%) | | |

|1 | | | | |

|41-50 | | | | |

|2 | | | | |

|51-60 | | | | |

|3 | | | | |

|61+ | | | | |

|4 | | | | |

| | |THROMBOPROPHYLAXIS | | |

| | |Please tick the appropriate prescribed DVT prophylaxis | | |

| | |Leg Elevation | | |

| | |( | | |

| | |Graduated Elastic Compression stockings (GECS) ( | | |

| | |Pneumatic Compression (PC) ( | | |

| | |Intermittent or | | |

| | |( | | |

| | |Continuous ( | | |

| | |Heparin | | |

| | |( | | |

| | |Heparin Sodium ( standard/unfractionated) | | |

| | |Calciparine (heparin calcium) | | |

| | |Minihep (heparin sodium) | | |

| | |Minehep calcium (heparin calcium) | | |

| | |Monoparin (heparin sodium) | | |

| | |Monoparin calcium (heparin calcium | | |

| | |Multiparin (heparin sodium) | | |

| | |Pump-hep (heparin sodium | | |

| | |Unihep (heparin sodium) | | |

| | |Uniparin (heparin sodium) | | |

| | |Low molecular Weight Heparin ( | | |

| | |Fragmin (dalteparin sodium | | |

| | |Clexane (enoxaparin Heparin) | | |

| | |Innohep (tinzaparin) | | |

| | |Logiparin (tinzaparin) | | |

| | |Warfarin | | |

| | |( | | |

| | |Others, please specify: | | |

| | |( | | |

| | |No Prophylaxis | | |

| | |( | | |

|BUILD BODY MASS INDEX(BMI) | | | |HIGH RISK DESEASES |

| | | | | |

|Build BMI Score | | | |Score |

|Under weight 16-19 0 | | | |Ulcerative Colitis 1 |

|Average 20-25 1 | | | |Anaemia: Sickle Cell 2 |

|Overweight 26-30 2 | | | |Polycythaemia 2 |

| | | | |Haemolytic 2 |

| | | | |Chronic Heart Disease 3 |

| | | | |Myocardial Infraction 4 |

| | | | |Malignancy 5 |

| | | | |Varicose Viens 6 |

| | | | |Previous DVT or CVA 7 |

|MOBILITY | | | | |

| Score | | | | |

| | | | | |

|Ambulant 0 | | | | |

|Limited (users aids self) 1 | | | | |

|Very limited (needs help) 2 | | | | |

|Chair bound 3 | | | | |

|Complete bed rest 4 | | | | |

| | | | |SCORING (within 24 hours of admission) |

| | | | |Identify appropriate items, add record score below |

| | | | | |

| | | | | |

| | | | | |

| | | | |Assesor Date Score |

San Antonio Association of Operating Room Nurses. Autar DVT Risk Assessment Scale.

Retrieved 10-25-2009.

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