This best practice guideline assists nurses who work in diverse practice settings to identify adults who are at risk of pressure ulcers, define early interventions for pressure ulcer prevention, and manage Stage I pressure ulcers.
This best practice guideline assists nurses who work in diverse practice settings to identify adults who are at risk of pressure ulcers, define early interventions for pressure ulcer prevention, and manage Stage I pressure ulcers.
As an introduction, we’ve provided summaries of the practice recommendations from the BPG document — but we strongly encourage downloading RNAO’s official PDF.
A head-to-toe skin assessment should be carried out with all clients at admission, and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences.
The client’s risk for pressure ulcer development is determined by the combination of clinical judgment and the use of a reliable risk assessment tool. The use of a tool that has been tested for validity and reliability, such as the Braden Scale for Predicting Pressure Sore Risk, is recommended. Interventions should be based on identified intrinsic and extrinsic risk factors and those identified by a risk assessment tool, such as Braden’s categories of sensory perception, mobility, activity, moisture, nutrition, friction and shear. Risk assessment tools are useful as an aid to structure assessment.
Clients who are restricted to bed and/or chair, or those experiencing surgical intervention, should be assessed for pressure, friction and shear in all positions and during lifting, turning and repositioning.
All pressure ulcers are identified and staged using the National Pressure Ulcer Advisory Panel (NPUAP) criteria.
If pressure ulcers are identified, utilization of the RNAO best practice guideline Assessment and Management of Stage I to IV Pressure Ulcers is recommended.
All data should be documented at the time of assessment and reassessment.
An individualized plan of care is based on assessment data, identified risk factors and the client’s goals. The plan is developed in collaboration with the client, significant others and health care professionals.
The nurse uses clinical judgment to interpret risk in the context of the entire client profile, including the client’s goals.
For clients with an identified risk for pressure ulcer development, minimize pressure through the immediate use of a positioning schedule.
Use proper positioning, transferring, and turning techniques. Consult Occupational Therapy/Physiotherapy (OT/PT) regarding transfer and positioning techniques and devices to reduce friction and shear and to optimize client independence.
Consider the impact of pain. Pain may decrease mobility and activity. Pain control measures may include effective medication, therapeutic positioning, support surfaces, and other non-pharmacological interventions. Monitor level of pain on an on-going basis, using a valid pain assessment tool.
Consider the client’s risk for skin breakdown related to the loss of protective sensation or the ability to perceive pain and to respond in an effective manner (e.g., impact of analgesics, sedatives, neuropathy, etc.).
Consider the impact of pain on local tissue perfusion.
Avoid massage over bony prominences.
Clients at risk of developing a pressure ulcer should not remain on a standard mattress. A replacement mattress with low interface pressure, such as high-density foam, should be used.
For high risk clients experiencing surgical intervention, the use of pressure-relieving surfaces intraoperatively should be considered.
For individuals restricted to bed:
Protect and promote skin integrity:
Protect skin from excessive moisture and incontinence:
A nutritional assessment with appropriate interventions should be implemented on entry to any new health care environment and when the client’s condition changes. If a nutritional deficit is suspected:
Institute a rehabilitation program, if consistent with the overall goals of care and the potential exists for improving the individual’s mobility and activity status. Consult the care team regarding a rehabilitation program.
Advance notice should be given when transferring a client between settings (e.g., hospital to home/long-term care facility/hospice/residential care) if pressure reducing/relieving equipment is required to be in place at time of transfer (e.g., pressure relieving mattresses, seating, special transfer equipment). Transfer to another setting may require a site visit, client/family conference, and/or assessment for funding of resources to prevent the development of pressure ulcers
Clients moving between care settings should have the following information provided: Risk factors identified; Details of pressure points and skin condition prior to discharge; Type of bed/mattress the client requires; Type of seating the client requires; Details of healed ulcers; Stage, site and size of existing ulcers; History of ulcers, previous treatments and products used; Type of dressing currently used and frequency of change; Adverse reactions to wound care products; Summary of relevant laboratory results; and Need for on-going nutritional support.
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.
