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A direct comparison of the Hartford Institute for Geriatric Nursing (HIGN) and the Registered Nurses Association of Ontario (RNAO) recommendations for prevention of pressure ulcers is provided in the tables below.
Following the content comparison tables, the areas of agreement and areas of differences among the guidelines are identified.
Abbreviations
TABLE 3: COMPARISON OF RECOMMENDATIONS FOR THE ASSESSMENT AND PREVENTION OF PRESSURE ULCERS | |
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Assessment | |
HIGN (2008) |
Parameters of Assessment
Nursing Care Strategies and Interventions Risk Assessment Documentation
General Care Issues and Interventions
|
RNAO (2005) |
Assessment 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. (Level of Evidence = IV) 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. (Level of Evidence = IV) 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. (Level of Evidence = IV) All pressure ulcers are identified and staged using the NPUAP criteria. (Level of Evidence = IV) If pressure ulcers are identified, utilization of the RNAO best practice guideline Assessment and Management of Stage I to IV Pressure Ulcers is recommended. (Level of Evidence = IV) All data should be documented at the time of assessment and reassessment. (Level of Evidence = IV) |
PREVENTION | |
Skin Care and Protection | |
HIGN (2008) |
Agency for Health Care Policy and Research (now known as the Agency for Healthcare Research and Quality, AHRQ) (AHCPR, 1992) prevention recommendations:
Other care issues and interventions
|
RNAO (2005) |
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. (Level of Evidence = IV) Avoid massage over bony prominences. (Level of Evidence = IIb) Protect and promote skin integrity:
(Level of Evidence = IV) Protect skin from excessive moisture and incontinence:
(Level of Evidence = IV) |
Positioning and Pressure-Relieving Devices | |
HIGN (2008) |
Agency for Health Care Policy and Research (now known as the Agency for Healthcare Research and Quality, AHRQ) (AHCPR, 1992) prevention recommendations:
Other care issues and interventions
Interventions Linked to Braden Risk Scores (Adapted from Ayello & Braden, 2001) Prevention protocols linked to Braden Risk are as follows: At risk: score of 15 to 18
Moderate risk: score of 13 to 14
High risk: score of 10 to 12
Very high risk: score of 9 or below
|
RNAO (2005) |
For clients with an identified risk for pressure ulcer development, minimize pressure through the immediate use of a positioning schedule. (Level of Evidence = IV) 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. (Level of Evidence = IV) 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. (Level of Evidence = Ia) For high risk clients experiencing surgical intervention, the use of pressure-relieving surfaces intraoperatively should be considered. (Level of Evidence = Ia) For individuals restricted to bed:
(Level of Evidence = IV) For individuals restricted to chair:
(Level of Evidence = IV) |
Nutrition | |
HIGN (2008) |
Manage nutrition:
|
RNAO (2005) |
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:
|
Patient, Caregiver and Professional Education | |
HIGN (2008) |
Other Care Issues and Interventions Teach patient, caregivers, and staff the prevention protocols |
RNAO (2005) |
Education Recommendations Educational programs for the prevention of pressure ulcers should be structured, organized, and comprehensive and should be updated on a regular basis to incorporate new evidence and technologies. Programs should be directed at all levels of health care providers including clients, family or caregivers. (Level of Evidence = III) The educational program for prevention of pressure ulcers should be based on the principles of adult learning, the level of information provided and the mode of delivery. Programs must be evaluated for their effectiveness in preventing pressure ulcers through such mechanisms as quality assurance standards and audits. Information on the following should be included:
(Level of Evidence = III) |
Other Prevention Interventions | |
HIGN (2008) |
Follow-up Monitoring of Condition
|
RNAO (2005) |
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. (Level of Evidence = IV) The nurse uses clinical judgment to interpret risk in the context of the entire client profile, including the client's goals. (Level of Evidence = IV) 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. (Level of Evidence = IV) 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.) (Level of Evidence = IV) Consider the impact of pain on local tissue perfusion (Level of Evidence = IV) 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. (Level of Evidence = IV) Advance notice should be given when transferring a client between setting (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. (Level of Evidence = IV) Clients moving between care settings should have the following information provided:
(Level of Evidence = IV) |
TABLE 5: EVIDENCE RATING SCHEMES AND REFERENCES | |
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HIGN (2008) |
Levels of Evidence Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews) Level II: Single experimental study (randomized controlled trials [RCTs]) Level III: Quasi-experimental studies Level IV: Non-experimental studies Level V: Care report/program evaluation/narrative literature reviews Level VI: Opinions of respected authorities/Consensus panels REFERENCES SUPPORTING THE RECOMMENDATIONS Agency for Health Care Policy and Research (AHCPR). Pressure ulcers in adults: prediction and prevention. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, AHCPR; 1992 May. 63 p. (Clinical practice guideline; no. 3). [127 references] Ayello EA, Braden B. Why is pressure ulcer risk assessment so important? Nursing 2001 Nov;31(11):74-9. Bank D. Decreasing the incidence of skin tears in a nursing and rehabilitation center. Adv Skin Wound Care 2005;18:74-5. Baranoski S, Ayello EA. Wound care essentials: practice principles. Springhouse (PA): Lippincott, Williams, & Wilkins; 2004. 54-8 p. Baranoski S. Skin tears: the enemy of frail skin. Adv Skin Wound Care 2000;13(3):123-6. Birch S, Coggins T. No-rinse, one-step bed bath: the effects on the occurrence of skin tears in a long-term care setting. Ostomy Wound Manage 2003 Jan;49(1):64-7. PubMed Centers for Medicare & Medicaid Services (CMS). Guidance for surveyors in long term care: Tag F 314: pressure ulcers. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2004. Gilcreast DM, Warren JB, Yoder LH, Clark JJ, Wilson JA, Mays MZ. Research comparing three heel ulcer-prevention devices. J Wound Ostomy Continence Nurs 2005 Mar-Apr;32(2):112-20. PubMed Hampton S, Collins F. Reducing pressure ulcer incidence in a long-term setting. Br J Nurs 2005 Aug 11-Sep 7;14(15):S6-12. PubMed Hanson DH, Anderson J, Thompson P, Langemo D. Skin tears in long-term care: effectiveness on skin care protocols on prevalence. Adv Skin Wound Care 2005;18:74. Houwing RH, Rozendaal M, Wouters-Wesseling W, Beulens JW, Buskens E, Haalboom JR. A randomised, double-blind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip-fracture patients. Clin Nutr 2003 Aug;22(4):401-5. PubMed Hunter S, Anderson J, Hanson D, Thompson P, Langemo D, Klug MG. Clinical trial of a prevention and treatment protocol for skin breakdown in two nursing homes. J Wound Ostomy Continence Nurs 2003 Sep;30(5):250-8. PubMed Iglesias C, Nixon J, Cranny G, Nelson EA, Hawkins K, Phillips A, Torgerson D, Mason S, Cullum N, PRESSURE Trial Group. Pressure relieving support surfaces (PRESSURE) trial: cost effectiveness analysis. BMJ 2006 Jun 17;332(7555):1416. PubMed Mason SR. Type of soap and the incidence of skin tears among residents of a long-term care facility. Ostomy Wound Manage 1997 Sep;43(8):26-30. PubMed Payne RL, Martin ML. Defining and classifying skin tears: need for a common language. Ostomy Wound Manage 1993 Jun;39(5):16-20, 22-4, 26. PubMed White MW, Karam S, Cowell B. Skin tears in frail elders: a practical approach to prevention. Geriatr Nurs 1994 Mar-Apr;15(2):95-9. PubMed |
RNAO (2005) |
Levels of Evidence Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials Ib Evidence obtained from at least one randomized controlled trial IIa Evidence obtained from at least one well-designed controlled study without randomization IIb Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities |
The Hartford Institute for Geriatric Nursing (HIGN) and the Registered Nurses Association of Ontario (RNAO) present recommendations for the prevention of pressure ulcers. Both groups rank the level of evidence for each major recommendation, and HIGN offers literature citations to support its major recommendations.
The guidelines differ somewhat in scope. In addition to addressing pressure ulcer prevention, HIGN provides recommendations for skin tear risk assessment and prevention; RNAO addresses management of Stage I pressure ulcers. These topics, however, are beyond the scope of this synthesis.
Both guidelines either reviewed or explicitly adapted recommendations from a guideline developed by the U.S. Agency for Healthcare Policy and Research (now the U.S. Agency for Healthcare Research and Quality [AHRQ]), Pressure Ulcers in Adults: Prediction and Prevention (1992). (NGC note: The AHCPR guideline does not meet criteria for inclusion in the National Guidelines Clearinghouse because it is more than five years old).
Both guidelines agree on the need for timely assessment of pressure ulcer risk and most explicitly recommend a combination of informal (i.e., clinical judgment) and formal (i.e., use of a risk assessment tool) methods. As a formal risk assessment method, use of a standardized tool is recommended by both guidelines. The Braden Scale and the Norton Scale are mentioned as appropriate instruments by both groups. Both guidelines also agree on the need for reassessment when a patient's clinical condition changes, or on a regular basis for high-risk patients.
Both guidelines address skin care as a prevention intervention and recommend daily assessment of skin. There is overall agreement that keeping the skin dry and moisturized is an important prevention step. Both guidelines stress the need to avoid vigorous massage, especially over bony prominences. They also address the need to protect the skin from friction and shear, particularly during transfer and repositioning, as well as the need to manage moisture from incontinence. RNAO specifically recommends establishing a bowel and bladder program for incontinent patients.
Recommendations concerning positioning and pressure-relieving devices are similar between guidelines, with both noting the need for frequent repositioning of bed-bound and chair-bound patients and the need to use pressure-reducing mattresses and positioning devices such as wedges and pillows. Both groups recommend use of a written repositioning schedule and caution against the use of doughnut-type devices. RNAO specifically cites the need for use of a pressure-relieving mattress during surgery for at-risk patients.
Both groups stress the importance of adequate nutrition as a part of pressure ulcer prevention. HIGN cites the need for adequate hydration, protein, calories, and vitamins A, C, and E. Both guidelines recommend consultation with a dietitian to assess nutritional needs and develop a nutritional support plan.
The need for education aimed at patients, carers, and professional staff is recommended by both groups. The groups are in agreement that educational programs should be structured, organized, comprehensive, and directed at all levels of healthcare providers, patients, and families or caregivers. RNAO stresses the importance of incorporating updated information and new technologies into educational programs.
RNAO notes that pain has an impact on the risk for developing pressure ulcer by limiting a patient's mobility and, therefore, needs to be assessed and managed. They also include recommendations for creating a plan of care for transferring patients to another location and for implementing a rehabilitation program, when feasible, to improve patient mobility. HIGN urges the importance of monitoring the effectiveness of prevention interventions as well as the healing of any existing pressure ulcers.
There are no significant areas of difference between the guidelines.
This Synthesis was prepared by ECRI on October 31, 2006. The information was verified by UIGN on November 21, 2006, by AMDA and WOCN on December 5, 2006, and by RNAO on December 11, 2006. This summary was updated by ECRI Institute on July 30, 2007 following the withdrawal of the Singapore Ministry of Health guideline from the NGC Web site. This synthesis was updated on December 12, 2007 to remove UIGN recommendations, and on September 12, 2008 to update HIGN recommendations and to remove NCCNSC/NICE and WOCN recommendations.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Pressure Ulcer Prevention. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 2006 Dec (revised 2008 Sep). [cited YYYY Mon DD]. Available: http://www.guideline.gov.