The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.
Practice Recommendations
Assessment
Recommendation 1.1
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)
Recommendation 1.2
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)
Recommendation 1.3
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)
Recommendation 1.4a
All pressure ulcers are identified and staged using the National Pressure Ulcer Advisory Panel (NPUAP) criteria.
(Level of Evidence = IV)
Recommendation 1.4b
If pressure ulcers are identified, utilization of the Registered Nurses Association of Ontario (RNAO) best practice guideline Assessment and Management of Stage I to IV Pressure Ulcers is recommended.
(Level of Evidence = IV)
Recommendation 1.5
All data should be documented at the time of assessment and reassessment.
(Level of Evidence = IV)
Planning
Recommendation 2.1
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)
Recommendation 2.2
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)
Interventions
Recommendation 3.1
For clients with an identified risk for pressure ulcer development, minimize pressure through the immediate use of a positioning schedule.
(Level of Evidence = IV)
Recommendation 3.2
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)
Recommendation 3.3a
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)
Recommendation 3.3b
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)
Recommendation 3.3c
Consider the impact of pain on local tissue perfusion
(Level of Evidence = IV)
Recommendation 3.4
Avoid massage over bony prominences
(Level of Evidence = IIb)
Recommendation 3.5
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)
Recommendation 3.6
For high risk clients experiencing surgical intervention, the use of pressure-relieving surfaces intraoperatively should be considered.
(Level of Evidence = Ia)
Recommendation 3.7
For individuals restricted to bed:
- Utilize an interdisciplinary approach to plan care.
- Use devices to enable independent positioning, lifting, and transfers (e.g., trapeze, transfer board, bed rails).
- Reposition at least every 2 hours or sooner if at high risk.
- Use pillows or foam wedges to avoid contact between bony prominences.
- Use devices to totally relieve pressure on the heels and bony prominences of the feet.
- A 30 degree turn to either side is recommended to avoid positioning directly on the trochanter.
- Reduce shearing forces by maintaining the head of the bed at the lowest elevation consistent with medical conditions and restrictions. A 30 degree elevation or lower is recommended.
- Use lifting devices to avoid dragging clients during transfer and position changes.
- Do not use donut type devices or products that localize pressure to other areas.
(Level of Evidence = IV)
Recommendation 3.8
For individuals restricted to chair:
- Use an interdisciplinary approach to plan care.
- Have the client shift weight every 15 minutes, if able.
- Reposition at least every hour if unable to shift weight.
- Use pressure-reducing devices for seating surfaces.
- Do not use donut type devices or products that localize pressure to other areas.
- Consider postural alignment, distribution of weight, balance, stability, support of feet, and pressure reduction when positioning individuals in chairs or wheelchairs.
- Refer to OT/PT for seating assessment and adaptations for special needs.
(Level of Evidence = IV)
Recommendation 3.9
Protect and promote skin integrity:
- Ensure hydration through adequate fluid intake.
- Individualize the bathing schedule.
- Avoid hot water and use a pH balanced, non-sensitizing skin cleanser.
- Minimize force and friction on the skin during cleansing.
- Maintain skin hydration by applying non-sensitizing, pH balanced, lubricating moisturizers and creams with minimal alcohol content.
- Use protective barriers (e.g., liquid barrier films, transparent films, hydrocolloids) or protective padding to reduce friction injuries.
(Level of Evidence = IV)
Recommendation 3.10
Protect skin from excessive moisture and incontinence:
- Assess and manage excessive moisture related to body fluids (e.g., urine, feces, perspiration, wound exudates, saliva)
- Gently cleanse skin at time of soiling. Avoid friction during care with the use of a spray perineal cleaner or soft wipe.
- Minimize skin exposure to excess moisture. When moisture cannot be controlled, use absorbent pads, dressings, or briefs that wick moisture away from the skin. Replace pads and linens when damp.
- Use topical agents that provide protective barriers to moisture.
- If unresolved skin irritation exists in a moist area, consult with the physician for evaluation and topical treatment.
- Establish a bowel and bladder program.
(Level of Evidence = IV)
Recommendation 3.11
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:
- Consult with a registered dietitian. (Level of Evidence = IV)
- Investigate factors that compromise an apparently well nourished individual's dietary intake (especially protein or calories) and offer him or her support with eating. (Level of Evidence = IV)
- Plan and implement a nutritional support and/or supplementation program for nutritionally compromised individuals. (Level of Evidence = IV)
- If dietary intake remains inadequate, consider alternative nutritional interventions. (Level of Evidence = IV)
- Nutritional supplementation for critically ill older clients should be considered. (Level of Evidence = Ib)
Recommendation 3.12
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)
Discharge/Transfer of Care Arrangements
Recommendation 4.1
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.
(Level of Evidence = IV)
Recommendation 4.2
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
- Need for on-going nutritional support
(Level of Evidence = IV)
Education Recommendations
Recommendation 5.1
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)
Recommendation 5.2
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 areas should be included:
- The etiology and risk factors predisposing to pressure ulcer development
- Use of risk assessment tools, such as the Braden Scale for Predicting Pressure Sore Risk. Categories of the risk assessment should also be utilized to identify specific risks and ensure effective care planning
- Skin assessment
- Staging of pressure ulcers
- Selection and/or use of support surfaces
- Development and implementation of an individualized skin care program
- Demonstration of positioning/transferring techniques to decrease risk of tissue breakdown
- Instruction on accurate documentation of pertinent data
- Roles and responsibilities of team members in relation to pressure ulcer risk assessment and prevention
(Level of Evidence = III)
Organization & Policy Recommendations
Recommendation 6.1
Organizations need a policy with respect to providing and requesting advance notice when transferring or admitting clients between practice settings when special needs (e.g., surfaces) are required.
(Level of Evidence = IV)
Recommendation 6.2
Guidelines are more likely to be effective if they take into account local circumstances and are disseminated by ongoing educational and training programs.
(Level of Evidence = IV)
Recommendation 6.3
Nursing best practice guidelines can be successfully implemented only when there is adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to education
- Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process
- Dedication of a qualified individual to provide the support needed for the education and implementation process
- Ongoing opportunities for discussion and education to reinforce the importance of best practices
- Opportunities for reflection on personal and organizational experience in implementing guidelines
In this regard, RNAO (through a panel of nurses, researchers, and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of the RNAO guideline Risk Assessment and Prevention of Pressure Ulcers.
(Level of Evidence = IV)
Recommendation 6.4
Organizations need to ensure that resources are available to clients and staff. These resources include, but are not limited to, appropriate moisturizers, skin barriers, access to equipment (therapeutic surfaces), and relevant consultants (Occupational Therapy [OT], Physical Therapy [PT], Enterostomal Therapy [ET], wound specialists, etc.)
(Level of Evidence = IV)
Recommendation 6.5
Interventions and outcomes should be monitored and documented using prevalence and incidence studies, surveys, and focused audits.
(Level of Evidence = IV)
Definitions:
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
