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.

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.

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.

Recommendation 1.4a

All pressure ulcers are identified and staged using the National Pressure Ulcer Advisory Panel (NPUAP) criteria.

Recommendation 1.4b

If pressure ulcers are identified, utilization of the RNAO best practice guideline Assessment and Management of Stage I to IV Pressure Ulcers is recommended.

Recommendation 1.5

All data should be documented at the time of assessment and reassessment.

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.

Recommendation 2.2

The nurse uses clinical judgment to interpret risk in the context of the entire client profile, including the client’s goals.

Recommendation 3.1

For clients with an identified risk for pressure ulcer development, minimize pressure through the immediate use of a positioning schedule.

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.

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.

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.).

Recommendation 3.3c

Consider the impact of pain on local tissue perfusion.

Recommendation 3.4

Avoid massage over bony prominences.

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.

Recommendation 3.6

For high risk clients experiencing surgical intervention, the use of pressure-relieving surfaces intraoperatively should be considered.

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 30º 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 30º 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

Recommendation 3.8

• For individuals restricted to chair:
• Utilize 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 Occupational Therapy/Physiotherapy (OT/PT) for seating assessment and adaptations for special needs

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

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 exudate, saliva, etc.)
• Gently cleanse skin at time of soiling
• Avoid friction during care with the use of a spray perineal cleanser 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

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
• Investigate factors that compromise an apparently well nourished individual’s dietary intake (especially protein or calories) and offer him or her support with eating
• Plan and implement a nutritional support and/or supplementation program for nutritionally compromised individuals
• If dietary intake remains inadequate, consider alternative nutritional interventions
• Nutritional supplementation for critically ill older clients should be considered

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.

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

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; and Need for on-going nutritional support.