The guideline provides recommendations for interprofessional teams working to assess and manage existing pressure injuries in people 18 years of age and above.
The guideline provides recommendations for interprofessional teams working to assess and manage existing pressure injuries in people 18 years of age and above.
As an introduction, we’ve provided summaries of the practice recommendations from the BPG document — but we strongly encourage downloading RNAO’s official PDF.
Conduct a health history, a psychosocial history, and a physical exam on initial examination and whenever there is a significant change in the person’s medical status.
Assess the risk for developing additional pressure injuries on initial examination and if there is a significant change in the person’s medical status using a valid and reliable pressure injury risk assessment tool.
Assess the person’s pressure injury using the same valid and reliable wound assessment tool on initial examination and whenever there is a significant change in the pressure injury.
Assess the person’s pressure injury for signs and symptoms of infection (superficial critical colonization/localized infection and/or deep and surrounding infection/systemic infection) using a standardized approach on initial examination and at every dressing change.
Assess for pressure injury pain on initial examination and continue to monitor pain at subsequent visits, including prior to and after every wound care intervention, using the same valid and reliable tool consistent with the person’s cognitive ability.
Perform a vascular assessment (i.e., medical history, physical exam) of all persons with pressure injuries in the lower extremities on initial examination.
Conduct a mobility and support surface assessment on initial examination and whenever there is a significant change in the person’s medical condition, weight, equipment, mobility, and/or pressure injury healing.
Obtain the referral or consultations required to plan and coordinate a pressure injury plan of care.
Develop a pressure injury plan of care that incorporates goals mutually agreed upon by the person, the person’s circle of care and the interprofessional team.
Reposition the person at regular intervals (i.e., every two to four hours) based on personcentred concerns. While sitting, weight-shift the person every 15 minutes.
Position all persons with a pressure injury on a pressure redistribution support surface at all times.
Implement an individualized nutritional plan of care in collaboration with the person and his/her circle of care that addresses nutritional requirements and provides adequate protein, calories, fluid, and appropriate vitamin and mineral supplementation to promote pressure injury healing.
Provide local pressure injury care consisting of the following, as appropriate:
Provide electrical stimulation (when available) as an adjunct to best practice wound care in order to speed healing and promote wound closure in stalled but healable stage 2, 3, and 4 pressure injuries.
Implement, as an alternative, the following treatments in order to speed closure of stalled but healable pressure injuries, as appropriate and if available:
Provide negative pressure wound therapy to people with stage 3 and 4 pressure injuries in exceptional circumstances, including enhancement of quality of life and in accordance with other person-/family-centred preferences.
Collaborate with the person and his/her circle of care to implement a pressure injury self-management plan.
Implement a person-centred pain management plan using pharmacological and non-pharmacological interventions.
Use the initial risk assessment tool to reassess the person’s risk for developing additional pressure injuries on a regular basis and whenever a change in the person’s health status occurs.
Use the initial wound assessment tool to monitor the person’s pressure injuries for progress toward person-centred goals on a regular basis and at dressing changes.
This website was developed by a team of researchers at the Daphne Cockwell School of Nursing at Toronto Metropolitan University (Formerly Ryerson University). The purpose of the site is to provide supplementary resources for implementing RNAO’s Best Practice Guidelines. Some information about the best practice guidelines has been collected directly from the RNAO BPG website. We have done our best to ensure accuracy, however some discrepancies may occur. For official, up-to-date information about the best practice guidelines, please refer to the RNAO website.
