Purpose and scope
The purpose of this best practice guideline (BPG) is to assist nurses who work in diverse practice settings to identify adults who are at risk of pressure ulcers. This guideline further provides direction to nurses in defining early interventions for pressure ulcer prevention, and to manage Stage I pressure ulcers.
Main guideline (including 2011 supplement):
Registered Nurses’ Association of Ontario (2005). Risk assessment and prevention of pressure ulcers. (Revised). Toronto, Canada: 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), Risk Assessment and Prevention of Pressure Ulcers.
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: A comprehensive 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 and skin adjacent to external devices.
Recommendation 1.2a: The client’s risk for pressure ulcer development is determined by the combination of clinical judgment and the use of a valid reliable risk assessment tool. The use of a structured tool that has been tested for validity and reliability, such as the Braden Scale for Predicting Pressure Sore Risk, the Norton Pressure Sore Risk Assessment Scale and the Waterlow Pressure Ulcer Risk Assessment Tool are recommended.
Recommendation 1.2b: Assess for intrinsic/extrinsic risk factors that are associated with the development of pressure ulcers.
Recommendation 1.3: Assessment scales to assess and re-assess risk for skin breakdown and overall skin condition specific to vulnerable populations such as the elderly, palliative patients, the neonate/the child, spinal cord injured patients, and bariatric patients should be considered.
Recommendation 1.4: Assessment and documentation of skin changes amongst palliative patients at the end of life should be conducted as recommended by the consensus statement Skin Changes At Life’s End (SCALE).
Recommendation 1.5: All sectors of the health care system, programs, and services should conduct risk assessments and re-assessments to plan prevention strategies that will minimize the risk of pressure ulcer development.
Recommendation 1.6a: All pressure ulcers should be identified and described using standardized systems and language (e.g. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel pressure ulcer classification system).
Recommendation 1.6b: If pressure ulcers are identified, utilization of the RNAO best practice guideline Assessment and Management of Pressure Injuries for the Interprofessional Team along with other related guidelines is recommended.
Recommendation 1.7: All data should be documented at the time of assessment and reassessment.
Recommendation 2.1: An individualized plan of care should be developed in collaboration with the client, significant others and an interdisciplinary team, including consulting health care providers as appropriate. The team uses assessment and reassessment data in combination with clinical judgment to identify risk factors and to recommend the plan of care. Client centered care aligns with the recommendations and the client’s choice of goals.
Recommendation 3.1a: Clients identified to be at risk for developing a pressure ulcer should be resting on a pressure management surface such as a high-specification foam pressure redistribution mattress.
Recommendation 3.1b: A re-positioning schedule of at least every two hours should be promptly implemented when using a standardized mattress, emergency stretcher or operating table surface. When using a pressure management surface (re-distribution mattress or cushion) use a re-positioning schedule of at least every four hours or as required by the patient’s condition. Consider other patient factors such as the development of redness to increase the frequency of repositioning.
Recommendation 3.2: Heels must be completely off loaded in all positions. If not feasible, reason(s) must be documented, the heels must be monitored, and other prevention strategies implemented.
Recommendation 3.3: Use proper positioning, transferring and turning techniques. Consult an Occupational or Physical Therapist (OT/PT) regarding transfer and positioning techniques and strategies, as well as devices to reduce pressure friction and shear in all positions, and how to optimize client independence.
Recommendation 3.4: Assess, document and effectively manage pain to enable implementation of the most appropriate plan of care for pressure ulcer prevention without compromising comfort and quality of life.
Recommendation 3.5: Massaging over bony prominences and reddened areas should be avoided.
Recommendation 3.6: Implementation of intraoperative pressure management devices is recommended for surgical procedures lasting more than 90 minutes.
Recommendation 3.7a: Before implementing localized pressure management devices (e.g. heel boots, wedges, etc.) consider:
- Potential for increased pressure over surrounding areas of the skin by the device;
- Caregiver training and education to ensure correct use of the device; and/or
- Factors that enable client adherence.
Recommendation 3.7b: Complete bed rest is not recommended for the prevention and healing of pressure ulcers. Determine the rationale for bed rest and focus on getting the client up into an appropriate wheelchair for part of the day, as appropriate.
Recommendation 3.8: Protect skin from excessive moisture and incontinence to maintain skin integrity:
- Monitor fluid intake to ensure adequate hydration;
- Use a pH balanced, non-sensitizing skin cleanser with warm water for cleansing;
- Minimizing force and friction during care (e.g. use a soft wipe or spray cleanser);
- Maintain skin hydration by applying moisturizing agents that are non-sensitizing, pH balanced, fragrance free and/or alcohol free;
- Use topical protective barriers to protect skin from moisture. Avoid ingredients and excess application of products that may compromise the absorptive capacity of the incontinent brief;
- Use protective barriers (e.g. liquid barrier films, transparent films, hydrocolloids) or protective padding to reduce friction injuries;
- If skin irritation persists due to moisture, consult with advanced practice nurses and/or with the appropriate interdisciplinary team for evaluation and topical treatment; and/or
- Establish a bowel and bladder program.
Recommendation 3.9: A nutrition and hydration assessment with appropriate interventions should be implemented on entry to any health-care setting and when the client’s condition changes. If nutritional deficit and/or dehydration is suspected:
- Consult with a registered dietitian;
- Investigate factors that compromise an apparently well nourished individual’s dietary intake (especially protein or calories) and/or fluid intake and offer the individual support with eating/drinking;
- Plan and implement a nutritional support and/or supplementation program for nutritionally compromised/ dehydrated individuals; and
- If dietary/fluid intake remains inadequate, consider alternative nutritional interventions.
Recommendation 3.10: Institute a rehabilitation/restorative/activity program with the interprofessional team to maximize client’s functional status that is consistent with the overall goals of care. Consult with an occupational therapist or physical therapist as appropriate.
Recommendation 4.1: Provide the following information for clients moving between care settings:
- Risk factors identified;
- Details of pressure points and skin condition prior to discharge;
- Current plan to minimize pressure, friction and shear:
- Type of bed/mattress
- Type of seating
- Current transfer techniques used by the client (bed-chair-commode);
- History of ulcers, previous treatments, products used and products not effective:
- Stage/Category, site and size of existing ulcers
- Type of dressing currently used and frequency of dressing change
- Allergies and adverse reactions to wound care products
- Summary of relevant laboratory results
- Client and family response/ adherence to prevention and treatment plan
- Requirement for pain management;
- Details of ulcers that are closed; and
- Need for on-going interprofessional support.
Recommendation 5.1a: 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.
Recommendation 5.1b: Programs should be directed at all levels of health care providers including clients, family or caregivers.
Recommendation 5.2: An educational program for prevention of pressure ulcers should incorporate the principles of adult learning and the level of information provided, and the mode of delivery must be flexible to accommodate the needs of the adult learner. Program evaluation is a critical component of the program planning process. Information on the following areas should be include:
- 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 to ensure effective care planning, Appendix C.
- Skin assessment.
- Categorization/Grading of pressure ulcers.
- Selection and/or use of pressure management devices.
- 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.
- Client/family education and/or client/ family involvement in the plan of care.
- Ongoing evaluation of the education and program goals.
- Evaluation results are to be integrated into the program on a continuous basis (i.e. yearly).
Recommendation 6.1: Organizations require a policy to provide and request advance notice when transferring or admitting clients at risk of pressure ulcers between practice settings when special equipment (e.g. surfaces) is needed.
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.
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.
Recommendation 6.4: Organizations need to ensure that financial and human resources are available to clients and staff. These resources include, but are not limited to, appropriate moisturizers, skin barriers, access to equipment (therapeutic surfaces), relevant consultants and interprofessional wound care team (e.g. OT; PT; enterostomal therapist; wound, ostomy and continence nurses; dietitian; physicians; nurse practitioners; chiropodist; wound specialists, etc.) as well as time and support for front line nursing staff.
Recommendation 6.5: Interventions and outcomes should be monitored and documented using prevalence and incidence studies, surveys and focused audits.
Recommendation 6.6: Create and support the development of skin and wound care champions to assist with local implementation of pressure ulcer prevention programs specific to the client population.
Recommendation 6.7: Embed annual prevalence of pressure ulcer studies into assessment of risk/quality and professional practice.
Recommendation 6.8: Prevalence studies funded by the setting should be conducted annually for quality monitoring, client safety and program improvement. Funding should be provided to involve point of care staff in data collection and analysis. All participants of this process need to participate in a rigorous standardized education program prior to conducting the study.
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: March 2005 with September 2011 supplement.
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 RNAO's BPGs Assessment and Management of Pressure Injuries for the Interprofessional Team (2016) and Risk Assessment and Prevention of Pressure Ulcers (2011).