Registed Nurses' Association of Ontario

Assessment and Management of Stage I to IV Pressure Ulcers

Project / Initiative: 
Long-Term Care Best Practices Program
Type of Guideline: 
Publish Date: 
About this Guideline:

The purpose of this guideline is to identify nursing care related to assessment, management of tissue load, ulcer care and the management of bacterial colonization and infection of pressure ulcers. The guideline has relevance to all areas of clinical practice including acute care, chronic care, rehabilitation, community care and long-term care.

The guideline focuses on three areas of pressure ulcer care:

  • practice recommendations, including assessment, planning and interventions;
  • education recommendations; and
  • organization & policy recommendations.

This guideline contains recommendations for Registered Nurses (RNs) and Registered Practical Nurses (RPNs). Although the guideline is written for the nurse, wound healing is an interdisciplinary endeavour. Many settings have formalized interdisciplinary teams and the guideline development panel strongly supports this structure. Collaborative assessment and treatment planning with the client is essential. The recommendations made are not binding for nurses and should accommodate patient/family wishes and local circumstances.

Revised: 2007

Related File(s):
Pressure Ulcers I - IV Summary67.15 KB