Assessment and Management of Pressure Injuries for the Interprofessional Team
Purpose and scope
The purpose of this guideline is to present evidence-based recommendations that apply to the decisions and best practices of interprofessional teams working to assess and manage existing pressure injuries in people 18 years of age and above.
The guideline focuses on the core competencies and the evidence-based strategies that members of interprofessional teams require to assess and treat people with existing pressure injuries.
We’ve designed this guideline to help nurses and their interprofessional teams become more comfortable, confident and competent when caring for people with existing pressure injuries. It is intended for use in all domains of health care and public health, including clinical work, administration, and education.
Registered Nurses’ Association of Ontario (2016). Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition. Toronto, ON: Registered Nurses’ Association of Ontario.
Do you want to learn about and implement the most- up-to-date evidence-based recommendations on this topic with your colleagues? Download and share the full best practice guideline (BPG), Assessment and Management of Pressure Injuries for the Interprofessional Team.
See below for a snapshot of the recommendations from this BPG. We strongly suggest you review the full BPG before implementing the recommendations and good practice statements. The BPG also includes further resources to support implementation and evaluation.
Recommendation 1.1: Conduct a health history, a psychosocial history, and a physical exam on initial examination and whenever there is a significant change in the person’s medical status.
Recommendation 1.2: Assess the risk for developing additional pressure injuries on initial examination and if there is a significant change in the person’s medical status using a valid and reliable pressure injury risk assessment tool.
Recommendation 1.3: Assess the person’s pressure injury using the same valid and reliable wound assessment tool on initial examination and whenever there is a significant change in the pressure injury.
Recommendation 1.4: Assess the person’s pressure injury for signs and symptoms of infection (superficial critical colonization/localized infection and/or deep and surrounding infection/systemic infection) using a standardized approach on initial examination and at every dressing change.
a) Screen all persons with pressure injuries for risk of malnutrition using a valid and reliable screening tool on first examination and if there is a delay in pressure injury healing.
b) Determine the nutritional status of all persons at risk for malnutrition using a valid and reliable assessment tool within 72 hours of initial examination, and whenever there is a change in health status and/or the pressure injury.
c) Perform a comprehensive nutrition assessment of all persons with poor nutritional status within 72 hours of initial examination, and if there is a change in health status or delayed healing.
Recommendation 1.6: Assess for pressure injury pain on initial examination and continue to monitor pain at subsequent visits, including prior to and after every wound care intervention, using the same valid and reliable tool consistent with the person’s cognitive ability.
Recommendation 1.7: Perform a vascular assessment (i.e., medical history, physical exam) of all persons with pressure injuries in the lower extremities on initial examination.
Recommendation 1.8: Conduct a mobility and support surface assessment on initial examination and whenever there is a significant change in the person’s medical condition, weight, equipment, mobility, and/ or pressure injury healing.
Recommendation 2.1: Obtain the referral or consultations required to plan and coordinate a pressure injury plan of care.
Recommendation 2.2: Develop a pressure injury plan of care that incorporates goals mutually agreed upon by the person, the person’s circle of care, and the interprofessional team.
Recommendation 3.1: Reposition the person at regular intervals (i.e., every two to four hours) based on person-centred concerns. While sitting, weight-shift the person every 15 minutes.
Recommendation 3.2: Position all persons with a pressure injury on a pressure redistribution support surface at all times.
Recommendation 3.3: Implement an individualized nutritional plan of care in collaboration with the person and his/her circle of care that addresses nutritional requirements and provides adequate protein, calories, fluid, and appropriate vitamin and mineral supplementation to promote pressure injury healing.
Recommendation 3.4: Provide local pressure injury care consisting of the following, as appropriate:
- moisture balance (healable) or moisture reduction (nonhealable, maintenance);
- infection control (i.e., superficial critical colonization/ localized infection and/or deep and surrounding infection/systemic infection); and
Recommendation 3.5: Provide electrical stimulation (when available) as an adjunct to best practice wound care in order to speed healing and promote wound closure in stalled but healable stage 2, 3, and 4 pressure injuries.
Recommendation 3.6: Implement, as an alternative, the following treatments in order to speed closure of stalled but healable pressure injuries, as appropriate and if available:
- electromagnetic therapy,
- ultrasound, and
- ultraviolet light.
Do not consider the following treatment in order to speed closure of stalled but healable pressure injuries:
- laser therapy (not recommended )
Recommendation 3.7: Provide negative pressure wound therapy to people with stage 3 and 4 pressure injuries in exceptional circumstances, including enhancement of quality of life and in accordance with other person-/family-centred preferences.
Recommendation 3.8: Collaborate with the person and his/her circle of care to implement a pressure injury self-management plan.
Recommendation 3.9: Implement a person-centred pain management plan using pharmacological and non-pharmacological interventions.
Recommendation 4.1: Use the initial risk assessment tool to reassess the person’s risk for developing additional pressure injuries on a regular basis and whenever a change in the person’s health status occurs.
Recommendation 4.2: Use the initial wound assessment tool to monitor the person’s pressure injuries for progress toward person-centred goals on a regular basis and at dressing changes.
Recommendation 5.1: Develop and implement comprehensive and sustainable interprofessional pressure injury education programs for clinicians and students entering health-care professions.
Recommendation 5.2: Assess health-care professionals’ knowledge, attitudes, and skills related to the assessment and management of existing pressure injuries before and following educational interventions using an appropriate, reliable, and validated assessment tool.
Recommendation 6.1: Organizations must lead and provide the resources to integrate pressure injury management best practices into standard and interprofessional clinical practice, with continuous evaluation of outcomes.
Recommendation 6.2: Lobby and advocate for investment in pressure injury management as a strategic quality and safety priority in jurisdictions in order to improve health outcomes for people with pressure injuries.
Disclaimer: These guidelines are not binding for nurses, other health providers or the organizations that employ them. The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.
Current edition published 2016.
About the next edition
The Registered Nurses' Association of Ontario (RNAO) is developing a fourth edition of this best practice guideline (BPG), with the working title Risk Assessment, Prevention and Treatment of Pressure Injuries. The anticipated publication date is 2024.
This new edition will replace Assessment and Management of Pressure Injuries for the Interprofessional Team (2016) and Risk Assessment and Prevention of Pressure Ulcers (2011).