The plan should focus on the actions needed to help prevent a pressure ulcer from developing, taking into account: The results of the risk and skin assessment. The need for any extra pressure relief, for example a high-specification foam mattress or cushion.

Any other conditions. If not, use of the Mental Capacity Act may be necessary. Repositioning advice Changing position to reduce or remove the pressure on a particular area can be key to preventing pressure ulcers.

Explain to anyone who has been assessed as being at risk of pressure ulcers: The importance of changing their position regularly and how it can help. How frequently to move, depending on the level of risk.

Repositioning help Difficulty mobilising and a loss of feeling in part of the body are risk factors for developing pressure ulcers, and may make it difficult or impossible for the person to change position unaided. How often? Providing information Anyone who is assessed as being at high risk of developing pressure ulcers should be given information on how to prevent them by a healthcare professional.

The information should be given in a way that the person can understand and should cover: What causes pressure ulcers. Early signs to look out for. How to prevent them. The effect of having a pressure ulcer on the person's health. How to use any equipment needed to change position.

Useful links More information about pressure ulcers and resources to support prevention and management, including a skin inspection guide, can be found at Stop the Pressure - national wound care strategy programme.

Pressure ulcers: prevention and management NICE guideline Pressure ulcers NICE quality standard Decision-making and mental capacity NICE guideline Safeguarding adults protocol: pressure ulcers and the interface with a safeguarding enquiry Department of Health and Social Care.

If not feasible, reason s must be documented, the heels must be monitored, and other prevention strategies implemented. heel boots, wedges, etc. Determine the rationale for bed rest and focus on getting the client up into an appropriate wheelchair for part of the day, as appropriate.

Consult with an occupational therapist or physical therapist as appropriate. Recommendation 4. Recommendation 5.

Program evaluation is a critical component of the program planning process. Information on the following areas should be include:. Recommendation 6. surfaces is needed. Organizations may wish to develop a plan for implementation that includes:. 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.

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. 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. 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 This new edition will replace RNAO's BPGs Assessment and Management of Pressure Injuries for the Interprofessional Team and Risk Assessment and Prevention of Pressure Ulcers Best practice guidelines.

Risk Assessment and Prevention of Pressure Ulcers Published: September Clinical, Older adults. Guideline Revision status.

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. European Pressure Ulcer Advisory Panel EPUAP , National Pressure Injury Advisory Panel NPIAP , and Pan Pacific Pressure Injury Alliance PPPIA.

The International Guideline. National Pressure Injury Advisory Panel NPIAP. NPIAP Pressure Injury Stages. Lyder CH and Ayello EA. Chapter 12; Pressure Ulcers: A Patient Safety Issue. National Center for Biotechnology Information, U. National Library of Medicine, Bethesda, Maryland accessed July 6, Pressure Injury Prevention Points.

Bedsores pressure sores. Mayo Clinic. The Joint Commission. Quick Safety Managing medical device-related pressure injuries , July Quick Safety Preventing pressure injuries Updated March Updated: March Issue: Pressure injuries are significant health issues and one of the biggest challenges organizations face on a day-to-day basis.

Provides recommendations on approaches to measuring and reporting pressure injury rates. Applies to all clinical settings, including acute care, rehabilitation care, long term care, and assistive living at home, and can be used by health professionals, patient consumers and informal caregivers.

Includes guidance for population groups with additional needs, including those in palliative care, critical care, community, or operating room settings, individuals with obesity, individuals with spinal cord injury, and neonates and children.

Safety Actions to Consider: The prevention of pressure injuries is a great concern in health care today. Use a structured risk assessment tool to identify patients at risk as early as possible.

Refine the assessment by identifying other risk factors, including existing pressure injuries and other diseases, such as diabetes and vascular problems. Repeat the assessment on a regular basis and address changes as needed. Develop a plan of care based on the risk assessment.

Prioritize and address identified issues. Assess pressure points, temperature, and the skin beneath medical devices. Clean the skin promptly after episodes of incontinence, use skin cleansers that are pH balanced for the skin, and use skin moisturizers. Avoid positioning the patient on an area of pressure injury.

Refer at-risk patients to a registered dietitian or nutritionist. Provide supplemental nutrition as indicated. Turn and reposition at-risk patients, if not contraindicated.

Plan a scheduled frequency of turning and repositioning the patient. Consider using pressure-relieving devices when placing patients on any support surface.

Monitor the prevalence and incidence of pressure injuries.

The risk assessment tools are not meant to replace clinical assessments and judgment but are to be used in conjunction with clinical assessments. Many other factors might be considered as part of clinical judgment. However, many of these factors, such as having had a stroke, are captured by existing tools through the resulting immobility.

Several additional specific factors should be considered as part of the risk assessment process. However, also remember that patients who are just "not doing well" always seem to be at high risk for pressure ulcers.

Comprehensive risk assessment includes both the use of a standardized scale and an assessment of other factors that may increase risk of pressure ulcer development. Remember that risk assessment scales are only one part of a pressure ulcer risk assessment. These scales or tools serve as a standardized way to review some factors that may put a person at risk for developing a pressure ulcer.

Research has suggested that these tools are especially helpful in identifying people at mild to moderate risk as nurses can identify people at high risk or no risk.

All risk assessment scales are meant to be used in conjunction with a review of a person's other risk factors and good clinical judgment. While some institutions have created their own tools, two risk assessment scales are widely used in the general adult population: the Norton Scale and the Braden Scale.

Both the Norton and Braden scales have established reliability and validity. When used correctly, they provide valuable data to help plan care. The Norton Scale is made up of five subscales physical condition, mental condition, activity, mobility, incontinence scored from 1 for low level of functioning and 4 for highest level of functioning.

The subscales are added together for a total score that ranges from 5 to A lower Norton Scale score indicates higher levels of risk for pressure ulcer development. Scores of 14 or less generally indicate at-risk status.

Total scores range from 6 to A lower Braden Scale score indicates higher levels of risk for pressure ulcer development. Scores of 18 or less generally indicate at-risk status. This threshold may need to be adjusted for the specific patient population on your unit or according to your hospital guidelines.

Other scales may be used instead of the Norton or Braden scales. What is critical is not which scale is used but just that some validated scale is used in conjunction with a consideration of other risk factors not captured by the risk assessment tool.

By validated, we mean that they have been shown in research studies to identify patients at increased risk for pressure ulcer development.

Copies of the Braden and Norton scales are included in Tools and Resources Tool 3D, Braden Scale , and Tool 3E, Norton Scale. The risk assessment tools described above are appropriate for the general adult population. However, these tools may not work as well in terms of differentiating the level of risk in special populations.

These include pediatric patients, patients with spinal cord injury, palliative care patients, and patients in the OR. Risk assessment tools exist for these special settings but they may not have been as extensively validated as the Norton and Braden scales. Overall scale scores provide data on general pressure ulcer risk and help clinicians plan care according to the amount of risk high, moderate, low, etc.

Subscale scores provide information on specific deficits such as moisture, activity, and mobility. These deficits should be specifically addressed in care plans. Remember, even a score that indicates no risk does not guarantee that a person will not develop a pressure ulcer, especially as their condition changes.

Consider performing a risk assessment in general acute care settings on admission and then daily or with a significant change in condition. However, pressure ulcer risk may change rapidly, especially in acute care settings. Therefore, recommendations for frequency of risk assessment will vary.

In settings where patients' status may change quickly, such as in critical care, risk assessment should be performed more frequently, such as every shift. In the OR, recommendations exist to assess on admission, at discharge to the recovery room, and periodically for operations lasting longer than 4 hours.

Consider the time in the holding and recovery rooms when assessing the time. For patients with more stable conditions, such as acute rehabilitation, pressure ulcer risk assessment may be less frequent.

What is important is that the frequency of pressure ulcer risk assessment be individualized to the person's unique setting and circumstances.

Documenting pressure ulcer risk is essential to ensure that all staff are aware of patients' pressure ulcer risk status. While documenting in the medical record is necessary, documentation alone may not be sufficient to ensure that all staff know the level of risk.

Among the options to consider for complete documentation are:. Remember that in documenting pressure ulcer risk, you want to incorporate not only the score and subscale scores of the standardized risk assessment tool, but also other factors placing the individual at risk. This information is often included in narrative text.

Risk status should be communicated orally at shift change or by review of the written material in the medical record or patient care worksheet. Consider innovative approaches to conveying level of risk.

For example, some facilities have color-coded the patient wristband, placed stickers on the patient chart or worksheet, or used picture magnets on the doors to indicate risk status.

The accuracy of a risk assessment scale depends on the person completing it. Experience has shown tremendous variability among staff even when evaluating the same patient.

Therefore, training in how to use the scale is needed to ensure consistency. Refer to Issue 5 under the General Assessment Series. Lindgren M, Unosson M, Krantz AM, et al. A risk assessment scale for the prediction of pressure sore development: reliability and validity. J Adv Nurs ;38 2 Internet Citation: 3.

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Careers Contact Us Español FAQs. Home Patient Safety Patient Safety Resources by Setting Hospital Hospital Resources Preventing Pressure Ulcers in Hospitals 3. What are the best practices in pressure ulcer prevention that we want to use? Preventing Pressure Ulcers in Hospitals 3.

Previous Page. Next Page. Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? How will we manage change? How do we implement best practices in our organization? How do we measure our pressure ulcer rates and practices? How do we sustain the redesigned prevention practices?

Tools and Resources. Consensus should be reached on the following questions: What "bundle" of best practices do we use? How should a comprehensive skin assessment be conducted?

How should a standardized pressure ulcer risk assessment be conducted? How frequently? How should pressure ulcer care planning based on identified risk be used?

What items should be in our bundle? What additional resources are available to identify best practices for pressure ulcer prevention? Some of the factors that make pressure ulcer prevention so difficult include: It is multidisciplinary: Nurses, physicians, dieticians, physical therapists, and patients and families are among those who need to be invested.

It is multidimensional: Many different discrete areas must be mastered. It needs to be customized: Each patient is different, so care must address their unique needs.

It is also highly routinized: The same tasks need to be performed over and over, often many times in a single day without failure. It is not perceived to be glamorous: The skin as an organ, and patient need for assessment and care, does not enjoy the high status and importance of other clinical areas.

The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment. Standardized pressure ulcer risk assessment. Care planning and implementation to address areas of risk. The challenge to improving care is how to get these key practices completed on a regular basis.

Resources The bundle concept was developed by the Institute for Healthcare Improvement IHI. Additional Information The following article describes successful efforts to improve pressure ulcer prevention that relied on the use of the components in the IHI bundle: Walsh NS, Blanck AW, Barrett KL. Some of the advantages of these clinical pathways are to: Reduce variation and standardize care.

Provide efficient, evidence-based care. Improve outcomes. Educate staff as to best practices. Improve care planning. Facilitate discussion among staff. Tools An example of a clinical pathway detailing the different components of the bundle is found in Tools and Resources Tool 3A, Pressure Ulcer Prevention Pathway.

This color-coded tool can be used by the hospital unit team in designing the new system, as a training tool for frontline staff, and as an ongoing clinical reference tool on the units. This tool can be modified, or a new one created, to meet the needs of your particular setting.

If you prepared a process map describing your current practices described in section 2 , you can compare that to desired practices outlined on the clinical pathway. Practice Insights Given the complexity of pressure ulcer preventive care, develop a clinical pathway that describes your bundle of best practices and how they are to be performed.

Return to Contents 3. This leads to cell obliteration and eventually tissue death. In the prevention of PIs, it is essential that patients at risk are identified so an individualised prevention plan can be implemented to mitigate the risks.

A risk factor is any element that either diminishes the skins tolerance to pressure or contributes to increased exposure of the skin to excess pressure.

Prevention requires an on-going risk assessment, consideration of casual factors, implementation of prevention strategies and the selection of an appropriate use of support surfaces.

When an assessment identifies a patient at risk of pressure injury, interventions should be implemented immediately. PI risk assessment tools are the key to determining if a patient is susceptible to PIs. Validated risk assessment tools for children are effective for identifying those at risk and increasing awareness of potential pressure related injuries, however they cannot embody every possible circumstance.

Therefore, clinicians need to use their experience, clinical judgment and knowledge to prevent tissue damage and protect the skin in conjunction with the risk screening tool. The pressure injury risk assessment tool used at RCH is a modified Glamorgan Pressure Injury Risk Assessment Tool.

Once completed, the risk assessment should be documented on the Primary Assessment flowsheet within the EMR. This plan should be reviewed for appropriateness following every pressure injury risk assessment completion. Complete a general visual check of the skin including analysis of the entire skin surface to assess its integrity and identify any characteristics indicative of pressure damage.

Monitor and check the skin beneath dressings, prosthesis and devices when clinically appropriate. Check for areas of localised heat, skin breakdown, oedema, areas of redness that do not blanch and induration of the wound.

Particular attention should be paid to areas of bony prominence, which are at an increased risk for pressure injury due to pressure, friction and shearing forces. High risk areas include; sacrum, heels, elbows, wrists, temporal region of skill, ears, shoulders, back of head especially in children less than 36 months of age , knees, and toes.

Document skin assessment findings in the Focused Assessment Flowsheet within the EMR. Parents and carers play a vital role in the care of their child; and therefore, their engagement is vital in helping to prevent the formation of pressure injuries.

Carers and parents should be educated around the risk of their child developing pressure injuries whilst in hospital and be provided with effective and age-appropriate strategies to mitigate these risks. The PI prevention factsheet should be provided to all carers and parents of patients that have been identified to be at risk of developing a pressure injury.

Malnourished children are at increased risk of pressure injury development due to their compromised ability to maintain healthy skin and mucosa. Hydration and nutritional support should be aimed at preventing and correcting these deficits.

Maintenance of a positive nitrogen balance and serum albumin levels are vital in maintaining adequate skin integrity and hydration. Monitoring patient weight loss as well as protein and micronutrient intake have been identified as key factors in nutrition to support immunity and skin integrity.

Increased moisture on the skin or excessive dryness can exacerbate pressure injury development due to the risk of skin breakdown and altered skin integrity. Barrier wipes e. These wipes create a transparent barrier preventing incontinence associated skin irritation and nappy rash without impacting the absorbency of incontinence products.

When used in nappy cares, barrier wipes have been shown to decrease redness and pain by preventing breakdown and can be used in a similar way to traditional barrier creams. Barrier wipes also allow for ongoing integumentary assessments and do not require removal.

This is exacerbated in the paediatric inpatient population with device related pressure injuries causing the majority of all paediatric pressure injuries due to the immature skin barrier and decreased tissue tolerance.

Prior to the application of medical devices and associated preventative dressings, barrier products e. These products repel moisture and provide protection from fluids and friction, which can prevent skin breakdown in areas with frequent dressing changes or repositioning.

Dressings should be changed as appropriate or when soiled, however removal within the first 24 hours of application should be avoided due to the increased risk of sheering force that can cause trauma to patient skin.

Where appropriate adhesive removal products e. Convacare® removal wipes should be used to promote comfort and reduce skin trauma when dressings are difficult to remove.

Pressure injuries that originate in the operating room may not appear until one to four days post-operatively, highlighting the importance of thorough skin assessment and prevention interventions as the child continues their journey through the pre-operative, surgery and post-operative phase at the RCH.

Assessment taken should be documented on the pre-operative assessment through EMR. Factors that should be assessed include:. Research suggests surgery that lasts longer than two hours has been associated with an increased risk of PIs.

Anaesthetised patients that are positioned on specialised frames in the prone position, may be at an even higher risk of developing PIs in uncommon areas such as the: chest, iliac crest, face tip of the nose, chin and forehead and heels.

The RCH operating tables are all fitted with high density pressure-redistributing foam to reduce the risk of pressure injury development. Other methods of managing a patient to reduce the risk of pressure injuries include:.

In the postoperative phase, a full integumentary assessment is required. Any altered skin integrity must be documented on the EMR flowsheet and communicated to the multidisciplinary team.

Pressure injury prevention in this specialised population should be managed carefully, considering the effect of various dressing and barrier products on underdeveloped skin.

Consultation with neonatal specialists is suggested before application of new products. Please refer to the Neonatal and infant skin care Clinical guideline for further information on the management of neonatal skin and prevention of pressure injuries. If the patient is identified as too clinically unstable to attend to major pressure area care and repositioning, an alternative pressure injury prevention plan needs to be discussed with the multidisciplinary team.

Orthopaedic patients are considered to be at high risk of pressure injuries due to the prolonged presence of fixed devices such as external fixation, traction, plasters casts and braces. These devices can cause sheering force and friction, so should be regularly monitored and assessed.

These patients are also at higher risk of immobilisation due to painful procedures and extended periods of bed rest or reduced weight bearing capacity.

Support surfaces are devices e. air mattresses, cushions that are used to assist with pressure redistribution to manage the pressure load on the integumentary system. Support surfaces typically support pressure redistribution through either immersion to increase the body surface area in contact with the surface, or by alternating and offloading the area of the body in contact with the support surface.

Decisions about an appropriate support surface to use for pressure injury prevention should be based on an overall assessment of the patient, including their weight, and their Glamorgan screening tool score.

The LINK Bariatric Procedure should be referred to for guidance regarding suitable support surfaces for patients above kg. For support surfaces to be effective, there must be minimal layering in between the device and the person.

The use of additional sheets, kylie pads, dry-flows and towels can alter the pressure relieving qualities of pressure redistribution equipment and should be avoided where possible.

A single sheet that can be kept dry and crease free is optimal. Please note: support surfaces facilitate the redistribution of body weight but do not negate the need for regular repositioning of patients or pressure area care.

For patients that are very high risk, these surfaces may allow a decrease in turning frequency overnight to hourly to encourage rest patterns, however, this should be considered carefully on a case-by-case basis.

Please consider the sudden infant death syndrome SIDS risk reduction recommendations when using support surfaces for infants. Monitoring is required for infants nursed outside of these recommendations. Consider Occupational Therapy referral for assistance with assessment of causal factors and advice on pressure injury prevention or management plans, including selection of most appropriate support surfaces.

Assessment of the occiput and surrounding tissue should take place before and after doughnut shaped gel ring use. Please see the table below for further information regarding the pressure mattresses available for use at RCH. At RCH, all pressure mattresses available for patient use are on consignment externally managed Keystone Healthcare Supplies and are available through bed pool.

Skin assessment. Development and implementation of an individualized skin care program. Instruction on accurate documentation of pertinent data. Roles and responsibilities of team members in relation to pressure ulcer risk assessment and prevention. Ongoing evaluation of the education and program goals.

Evaluation results are to be integrated into the program on a continuous basis i. 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. Methodology documents Risk Assessment and Prevention of Pressure Ulcers search strings.

pdf 38k. Revision status Current edition published: March with September 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.

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