These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute 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 RNAO give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.First published in 2002 by the Registered Nurses' Association of Ontario. This document was revised in March 2005. With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced and published, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses' Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows: Registered Nurses' Association of Ontario (2005). Risk assessment and prevention of pressure ulcers. (Revised). Toronto, Canada: Registered Nurses' Association of Ontario.# Nursing Best Practice Guideline

# Summary of Recommendations

# RECOMMENDATION LEVEL OF EVIDENCE
Practice Recommendations Assessment 1.1 A head-to-toe skin assessment should be carried out with all clients at admission, IV and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences.
- 2 The client's risk for pressure ulcer development is determined by the combination IV 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.
- 3 Clients who are restricted to bed and/or chair, or those experiencing surgical IV intervention, should be assessed for pressure, friction and shear in all positions and during lifting, turning and repositioning.
- 4a All pressure ulcers are identified and staged using the National Pressure Ulcer IV Advisory Panel (NPUAP) criteria.
- 4b If pressure ulcers are identified, utilization of the RNAO best practice guideline IV Assessment and Management of Stage I to IV Pressure Ulcers is recommended.
- 5 All data should be documented at the time of assessment and reassessment. IV Planning 2.1 An individualized plan of care is based on assessment data, identified risk factors IV and the client's goals. The plan is developed in collaboration with the client, significant others and health care professionals.
The nurse uses clinical judgment to interpret risk in the context of the entire IV client profile, including the client's goals.
- 1 For clients with an identified risk for pressure ulcer development, minimize IV pressure through the immediate use of a positioning schedule.
- 2 Use proper positioning, transferring, and turning techniques. Consult Occupational IV Therapy/Physiotherapy (OT/PT) regarding transfer and positioning techniques and devices to reduce friction and shear and to optimize client independence.
Consider the impact of pain. Pain may decrease mobility and activity. Pain control IV 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.
Consider the client's risk for skin breakdown related to the loss of protective IV sensation or the ability to perceive pain and to respond in an effective manner (e.g., impact of analgesics, sedatives, neuropathy, etc.).
Consider the impact of pain on local tissue perfusion. IV See page 14 for an Interpretation of Evidence.
- 4 Avoid massage over bony prominences.
IIb 3.5 Clients at risk of developing a pressure ulcer should not remain on a standard Ia mattress. A replacement mattress with low interface pressure, such as high-density foam, should be used.
For high risk clients experiencing surgical intervention, the use of pressure-relieving Ia surfaces intraoperatively should be considered.
For individuals restricted to bed: IV  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.

# For individuals restricted to chair:
IV  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.
- 9 Protect and promote skin integrity: IV  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)
-r protective padding to reduce friction injuries.
Nursing Best Practice Guideline RECOMMENDATION LEVEL OF EVIDENCE 3.10 Protect skin from excessive moisture and incontinence: IV  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. -Level Ib 3.12 Institute a rehabilitation program, if consistent with the overall goals of care and IV the potential exists for improving the individual's mobility and activity status. Consult the care team regarding a rehabilitation program.
- 1 Advance notice should be given when transferring a client between settings IV of Care Arrangements (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.
Clients moving between care settings should have the following IV 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.

# Education Recommendations
- 1 Educational programs for the prevention of pressure ulcers should be structured, III organized, and comprehensive and should be updated on a regular basis to incorporate new evidence and technologies. Programs should be directed at all levels of health care providers including clients, family or caregivers.
The educational program for prevention of pressure ulcers should be based on III the principles of adult learning, the level of information provided and the mode of delivery. Programs must be evaluated for their effectiveness in preventing pressure ulcers through such mechanisms as quality assurance standards and audits. Information on the following areas should be included:  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 and ensure effective care planning.  Skin assessment.  Staging of pressure ulcers. Organization & Policy Recommendations 6.1 Organizations need a policy with respect to providing and requesting advance IV notice when transferring or admitting clients between practice settings when special needs (e.g., surfaces) are required.
- 2 Guidelines are more likely to be effective if they take into account local IV circumstances and are disseminated by ongoing educational and training programs.
Nursing Best Practice Guideline RECOMMENDATION LEVEL OF EVIDENCE 6.3 Nursing best practice guidelines can be successfully implemented only when IV 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. In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the RNAO guideline Risk Assessment and Prevention of Pressure Ulcers.
- 4 Organizations need to ensure that resources are available to clients and staff. IV These resources include, but are not limited to, appropriate moisturizers, skin barriers, access to equipment (therapeutic surfaces) and relevant consultants (OT, PT, ET, wound specialists, etc.).
Interventions and outcomes should be monitored and documented using IV prevalence and incidence studies, surveys and focused audits.

# Interpretation of Evidence

# Levels of Evidence
Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials.
Ib Evidence obtained from at least one randomized controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomization.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.

# Responsibility for Development
The Registered Nurses' Association of Ontario (RNAO), with funding from the Government of Ontario, has embarked on a multi-year program of nursing best practice guideline development, pilot implementation, evaluation and dissemination. One of the areas of focus is on risk assessment and prevention of pressure ulcers. This guideline was originally developed, and subsequently revised, by a panel of nurses and researchers convened by the RNAO and conducting its work independent of any bias or influence from the Government of Ontario.

# Purpose & Scope
Best practice guidelines are systematically developed statements to assist practitioners' and clients' decisions about appropriate health care (Field & Lohr, 1990). This best practice guideline assists 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.
This guideline focuses its recommendations on: Practice Recommendations including assessment, planning, intervention and discharge/transfer of care; Educational Recommendations for supporting the skills required for nurses working with adults at risk for pressure ulcers; and Organization & Policy Recommendations addressing the importance of a supportive practice environment as an enabling factor for providing high quality nursing care, which includes ongoing evaluation of guideline implementation.
The RNAO panels strongly acknowledge that successful pressure ulcer prevention requires an interdisciplinary team effort. The purpose of this guideline is to assist nurses with the provision of evidence-based quality care to those adults at risk for developing pressure ulcers. Nurses, working in partnership with the interdisciplinary health care team and individuals at risk for pressure ulcers, have an important role in risk assessment and prevention. The panel recognizes however that prevention and management of pressure ulcers are intertwined in practice, and therefore recommends the use of the RNAO nursing best practice guideline Assessment and Management of Stage I to IV Pressure Ulcers (2002b) in conjunction with this guideline.
The guideline contains recommendations for Registered Nurses (RNs) and Registered Practical Nurses (RPNs) on best nursing practices in the area of pressure ulcer risk identification and prevention. It is acknowledged that the individual competencies of nurses vary between nurses and across categories of nursing professionals (RPNs and RNs) and are based on knowledge, skills, attitudes, critical analysis and decision making which are enhanced over time by experience and education. It is expected that individual nurses will perform only those aspects of risk assessment and prevention interventions for which they have appropriate education and experience.
It is expected that nurses, both RPNs and RNs, will seek appropriate consultation in instances where the client's care needs surpass the professional's ability to act independently. Effective health care depends on a coordinated interdisciplinary approach with ongoing communication between health care professionals and clients, ever mindful of the personal preferences and unique needs of each individual client.

# Nursing Best Practice Guideline

# Original Development Process -2000
In January 2000, a panel of clinicians, educators and researchers with expertise in the practice and research of pressure ulcer prevention from institutional, community and academic settings was convened under the auspices of the RNAO. The panel identified a set of five existing guidelines for the prevention of pressure ulcers. The five guidelines were then evaluated using the Appraisal Instrument for Canadian Clinical Practice Guidelines which is an adapted tool from Cluzeau, Littlejohns, Grimshaw, Feder & Moran (1997). The panel subsequently selected the following two guidelines to adapt and modify:
Agency for Health Care Policy and Research (1992). Pressure ulcers in adults: Prediction and prevention. Clinical practice guideline.. Available: www.ncbi.nlm.nih.gov.
Clinical Resource Efficiency and Support Team (1998). Guidelines for the prevention and management of pressure sores.
. Available: www.n-i.nhs.uk/crest.
An additional review of systematic review articles and pertinent literature was conducted to update the existing guidelines. The scope of this guideline and the focus on risk assessment and prevention of pressure ulcers in adults was established. Through a process of discussion and consensus, recommendations for nursing care were developed. The final draft was submitted to a set of external stakeholders for review and feedback. The completed nursing best practice guideline was further refined after a pilot implementation phase in selected practice settings in Ontario (see Acknowledgement for a listing of stakeholders and implementation sites). Pilot implementation practice settings were identified through a "request for proposal" process conducted by the RNAO. The pilot implementation comprised of an eight month systematic implementation and evaluation of the best practice guideline.

# Revision Process -2005
The Registered Nurses' Association of Ontario (RNAO) has made a commitment to ensure that this best practice guideline is based on the best available knowledge. In order to meet this commitment, a monitoring and revision process has been established for each published guideline.
Guideline development staff have reviewed abstracts published in key databases on the topic of pressure ulcer prevention, focusing on systematic reviews, RCTs and recently published clinical practice guidelines on a quarterly basis since the nursing best practice guideline Risk Assessment and Prevention of Pressure Ulcers was originally published. The purpose of this review was to identify evidence that would impact on the recommendations, either further supporting the published recommendations, or indicating that a recommendation was no longer appropriate. In the latter case, an "action alert" would be issued, or a full review would be conducted prior to the three-year schedule. No evidence of this nature was identified during the ongoing monitoring phase, and this guideline moved into the revision phase as originally scheduled.

# Risk Assessment & Prevention of Pressure Ulcers
In September of 2004, a panel of nurses with expertise in pressure ulcer prevention from a range of practice settings (including institutional, community and academic sectors) was convened by the RNAO. This group was invited to participate as a review panel to revise the Risk Assessment and Prevention of Pressure Ulcers guideline that was originally published in January 2002. This panel was comprised of members of the original development panel, as well as other recommended specialists, including representation from the pilot implementation site.
The panel members were given the mandate to review the guideline, focusing on the currency of the recommendations and evidence, keeping to the original scope of the document. This work was conducted as follows:
 Clinical questions were identified to structure the literature search.  Search terms were generated with input from the panel team leader for each recommendation in the guideline.  Literature search was conducted by a health sciences librarian.

# Quality Appraisal:
 Search results were reviewed by a Research Assistant assigned to the panel. This review included assessing for inclusion/exclusion related to the clinical questions. See Appendix A for a detailed description of the search strategy.
 Studies/guidelines that met the inclusion/exclusion criteria were retrieved. Quality appraisal and data extraction was conducted by the Research Assistant. These results were summarized and circulated to the panel.

# Background Context
Pressure ulcers, also known as pressure sores, bedsores and decubitus ulcers, are areas of localized damage to the skin and underlying tissue. This damage is generally a result of external forces -pressure, shear and/or friction. Pressure ulcer development occurs in institutional and community settings, and is most often seen in elderly, debilitated and immobile (e.g., orthopaedic) clients, those with severe acute illness (e.g., those in intensive care units) and in individuals with neurological deficits (e.g., spinal cord injuries) (NHS Centre for Reviews and Dissemination, 1995).
The high prevalence of pressure ulcers is a significant health care concern. A recent study reported by Woodbury & Houghton (2004) reviewed data that surveyed over 14,000 patients from 45 health care institutions across Canada, and estimated the prevalence of pressure ulcers as follows: Acute Care Hospitals: 25.1% Non-Acute Facilities (Long-term care, Nursing Homes, etc) 29.9% Mixed Health Care Facilities (acute and non-acute)
- 1% Community Care 15.1% Overall, the estimate of the prevalence of pressure ulcers in all health care institutions across Canada was 26.2%. This data suggests that pressure ulcers are a significant concern in all health care settings in Canada (Woodbury & Houghton, 2004).
Estimates have indicated that up to 10% of those admitted to hospital develop a pressure ulcer, the elderly being at the highest risk with approximately 70% of all pressure ulcers occurring in elders (Lyder, 2002). In those individuals who develop pressure ulcers, approximately 60% occur in the acute care setting -usually within the first two weeks of hospitalization (Langemo et al., 1989). With the increased acuity of those admitted to hospital, it is estimated that 15% of elderly patients will develop pressure ulcers within the first week of hospitalization (Lyder, 2002). In the long term care setting, pressure ulcers are most likely to develop within the first four weeks of admission (Bergstrom & Braden, 1992). Malnutrition is a significant problem for the elderly, and is a risk factor for the development of pressure ulcers. Rates of malnutrition in the institutionalized elderly are estimated to affect 23-85% of the population, while the rate for those being admitted to hospital is estimated to range from 20-50%. Pressure ulcer risk increases by 74% with the combination of immobility, stress to the immune system and loss of lean body mass (muscle).
Mortality is associated with pressure ulcers -several studies have reported mortality rates as high as 60% for elders with a pressure ulcer within one year of discharge from hospital. The pressure ulcer is not generally the cause of death, but rather it develops after a decline in the health status of the older person (Lyder, 2002).

# Risk Assessment & Prevention of Pressure Ulcers 20
The burden of pressure ulcers and their treatment impacts on quality of life for the client and family, but also creates significant financial strain for those living with a pressure ulcer, their families, and the health care system. Costs associated with the treatment of pressure ulcers in the United States have been conservatively estimated to be $500 to $50,000 (US) per ulcer, with more severe wounds being significantly more expensive to manage than less severe ulcers (Pompeo, 2001). AHCPR (1992) estimated that the total national cost (United States) for pressure ulcer treatment was at that time $1.3 billion dollars (U.S.) annually and rising. Although there is no comparable Canadian data related to national costs, the Canadian Association of Wound Care ( 2004) reported on a study conducted in the late 1990s that estimated the cost of treating an individual with a pressure ulcer within a long term care facility to be an average of $24,050 for three months of treatment. Similarly, a recent case study (Allen & Houghton, 2004) estimated the total cost for 12 weeks of treatment in the community, including electrical stimulation, to be $27,632. These costs, however, do not address the burden of pain and suffering and the impact on the individual's quality of life.
Early intervention is essential for those at risk of developing pressure ulcers. The principle components of early intervention are (National Pressure Ulcer Advisory Panel, 1992):
 Identification of at-risk individuals who need preventive interventions and of the specific factors that place them at risk;
 Protection and promotion of skin integrity;  Protection against the forces of pressure, friction and shear; and  Reduction of the incidence of pressure ulcers through educational programs for health professionals and clients.
Best Practice Guideline Risk Assessment &

# Discussion of Evidence:
As pressure ulcers usually develop over bony prominences, it is recommended that these areas be the focus for assessment (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000;Royal College of Nursing, 2000;Weir, 2001). Skin inspection should be based on a head-to-toe assessment of those areas known to be vulnerable for each patient. These areas typically include the temporal region and occiput of the skull, ears, scapulae, spinous processes, shoulders, elbows, sacrum, coccyx, ischial tuberosities, trochanters, knees, malleoli, metatarsal areas, heels, and the toes. In addition, areas of the body covered by anti-embolic stockings or restrictive clothing, areas where pressure, friction and shear are exerted during activities of daily living, and parts of the body in contact with equipment are also considered vulnerable. Additional areas should be inspected as determined by the individual's condition (National Institute for Clinical Excellence, 2001;Weir, 2001). Refer to Appendix B for additional details regarding skin inspection and assessment.
The Royal College of Nursing (2000) and the National Institute for Clinical Excellence ( 2001) describe a thorough skin assessment for sites of non-blanchable erythema. This assessment should involve a comprehensive visual and tactile inspection. The first indication of a developing ulcer is usually a change in the colour, texture and sensation of the skin surface, however, it is recognized that it may not be possible to observe redness/erythema associated with tissue damage in people with darkly pigmented skin (Consortium for Spinal Cord Medicine, 2000;RCN, 2000). The following signs may indicate incipient pressure ulcer development in individuals with darkly pigmented skin: persistent erythema; non-blanching hyperemia; blisters and discolouration (purplish/bluish localized areas); localized heat, which if tissue becomes damaged is replaced by coolness; localized edema and localized induration.
Those individuals who are able to participate in the inspection of their own skin should be encouraged to do so, following appropriate education. Wheelchair users should be instructed to use a mirror to visualize areas that they cannot see easily, or alternatively, to get assistance from others (NICE, 2001).

# 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.

# Level of Evidence -IV

# Risk Assessment Tools
In order to determine the client's level of risk, the AHCPR guideline (1992) recommends the use of a standard risk assessment tool. The Braden Scale and the Norton Scale have been tested sufficiently for reliability and validity to be useful adjuncts to nursing assessments and care planning. The Braden Scale has good sensitivity (83-100%) and specificity (64-77%), while the Norton Scale has a sensitivity of 73-92% and specificity of 61-94%. Positive predictive values are documented as: Braden -approximately 40%; Norton -approximately 20% (Lyder, 2002). Refer to Appendix C for a sample of the Braden Scale for Predicting Pressure Sore Risk.

# Frequency of Risk Assessment
Although the optimum frequency of risk assessment has not been substantiated in the literature, there are clinical standards that are widely accepted and reported. It has been noted that the majority of pressure ulcers develop within the first two weeks after admission to a facility (Maklebust & Sieggreen, 1996). One prospective study of new admissions to a nursing home over three months showed that of those who developed pressure ulcers, 80% did so within the first two weeks and 96% did so within three weeks (Bergstrom & Braden, 1992). These results support the need to identify those clients "at risk" for developing pressure ulcers early in their care, preferably on admission. The literature also supports reassessments for "at risk" individuals ranging from daily to weekly, however, many sources agree that whenever a client's condition changes, reassessments should be conducted (Consortium for Spinal Cord Medicine, 2000;Ferguson, Cook, Rimmasch, Bender & Voss, 2000;Maklebust & Sieggreen, 1996;NICE, 2001;RCN, 2000).
The Consortium for Spinal Cord Medicine (2000) supports the view that regular assessment should be incorporated into the overall assessment of all individuals with spinal cord injuries. Documentation may vary from every shift, to daily or weekly, to variable intervals in the community, depending on client need and clinical presentation. The trigger for reassessment should be based on deterioration or improvement in the individual's health status. Braden (2001) suggests that the frequency of risk assessments should be based on the findings of the initial admission assessment and the rapidity of the client's change in health status. Ideally, the client should be assessed for risk on admission, again in 48 hours and as often as the level of morbidity indicates. In addition, Braden (2001) makes recommendations for assessment of specific populations according to the following schedules:

# SITE OF CARE RISK ASSESSMENT SCHEDULE
Long-term care facilities -At admission, then every week for four weeks and quarterly thereafter Intensive Care Units -Daily General medical/surgical units -Every other day Community -Every home visit
Best Practice Guideline Risk Assessment & Prevention of Pressure Ulcers 24
Intrinsic/Extrinsic Risk Factors
The determination of risk for pressure ulcer development is established by the combination of the use of a reliable risk assessment tool and clinical judgment (refer to Recommendation 2.2). There is discussion in the literature regarding the need to look beyond assessment tools in considering risk, as the development of pressure ulcers may be influenced by factors not addressed within these tools. The potential to develop pressure ulcers may be influenced by intrinsic risk factors that relate to aspects of the client's physical, psychosocial or medical condition. These factors should be considered when performing a risk assessment, and include nutritional status (malnutrition and dehydration), reduced mobility or immobility, repetitive stress syndrome (involuntary movements), posture/contractures, neurological/sensory impairment, incontinence (urinary and fecal), extremes of age, level of consciousness, acute illness, history of previous pressure damage, vascular disease, and severe chronic or terminal illness (CREST, 1998;Gould et al., 2000;Lyder, 2002;NICE, 2001;RCN, 2000). In addition, it is the consensus of the review panel that pain as a risk factor should also be assessed. Refer to Recommendation 3.3.
Extrinsic factors derived from the environment can also influence the development of pressure ulcers.
These include factors such as hygiene, living conditions, medication, pressure, shearing, friction, garments, transfer slings, restraint use and the support systems used to relieve pressure (CREST, 1998;Gould et al., 2000;Lyder, 2001;NICE, 2001;RCN, 2000). Clinical assessment of all factors that increase the client's risk for skin breakdown must be considered to facilitate early identification of those at risk.
An additional category of risk factors discussed in the literature is specific to surgical interventions. Recommendation 1.3 reviews surgical risk factors.

# 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.

# Level of Evidence -IV

# Discussion of Evidence
An understanding of mechanical loads (pressure, friction and shear) and the risk of pressure ulcer development is essential in the assessment of clients, particularly those restricted to bed and/or chair (Cuddigan & Frantz, 1998). Fleck (2001) identifies extrinsic mechanical forces and factors that contribute to pressure ulcers. They are pressure, shear, friction and moisture. All contribute to soft tissue damage impacting on blood flow, tissue necrosis and pressure ulcer development, especially in the immobile patient. Physical movements associated with improper turning and transfer techniques and prolonged, unrelieved pressure can result in the development of pressure ulcers (Consortium for Spinal Cord Medicine, 2000).
External pressure over the tissue causes compression and distortion of underlying structures -if the pressure is higher than the capillary closing pressure, occlusion of the blood vessels, decreased tissue perfusion and tissue death may result (CREST, 1998). Deep tissue damage and necrosis can occur when the shearing between two layers of tissue leads to stretching, kinking and tearing of vessels at the subcutaneous level. The resulting disruption of the local blood supply produces ischemia. Prolonged ischemia is the precursor to endothelial damage and cell death (Consortium for Spinal Cord Medicine, 2000;CREST, 1998). Shearing forces should not be considered separately from pressure as they are an integral component of the effect of pressure on the client (RCN, 2000). The majority of shear injuries can be eliminated with proper positioning (AHCPR, 1992), as most shearing occurs when individuals slide down, or are dragged up in bed or chair (RCN, 2000).
Friction (a third mechanical force) occurs when two surfaces move across each other, and often results in the removal of superficial layers of skin. Friction damage often occurs as a result of poor lifting techniques (RCN, 2000). In addition, voluntary and involuntary movements by the client can lead to friction injuries, particularly on elbows and heels. Any agent that eliminates this contact or decreases the friction that occurs between the skin and the bed surface (including linens) will reduce the potential for injury (AHCPR, 1992).
Risk factors associated with the surgical experience include (Armstrong & Bortz, 2001): length of surgery (time); position during surgery; use of a standard foam mattress; positioning devices; warming devices; anesthetic agents; sedation; vasoactive medications; hemodynamics; retractors; operating room personnel; and the nature of the surgery. More specifically, intraoperative risks can be summarized as pooled moisture from prep solutions, skin shearing and friction during positioning, patient's position and use of postioning devices, negativity (layering of materials between the patient and the pressure-reducing surface), intraoperative hypotension, alteration in hemodynamic and circulatory status related to position and blood loss (Armstrong & Bortz, 2001).

# Recommendation 1.4a
All pressure ulcers are identified and staged using the National Pressure Ulcer Advisory Panel (NPUAP) criteria.

# Level of Evidence -IV

# 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.

# Level of Evidence -IV

# Discussion of Evidence:
Several classification systems exist to describe pressure ulcers in terms of observed tissue damage. The use of a classification tool allows for universal assessment and consistent communication of the severity of tissue damage among health care professionals (Armstrong & Bortz, 2001). The four-stage National Pressure Ulcer Advisory Panel system is the framework most widely accepted (Consortium for Spinal Cord Medicine, 2000;CREST, 1998;Ferguson et al., 2000;Ferrell, Josepheson, Norvid & Alcorn, 2000). It was accepted by the AHCPR panel in 1994 and has since become a clinical standard (Weir, 2001). Indeed, the development panel, through a consensus building process, recognized the universality of the defining criteria, as they are understood and utilized by clinicians in a wide range of practice settings.

# STAGE DEFINITION
Pressure ulcer is an observable pressure-related alteration of intact skin whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching).
The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues (1998).
Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is usually superficial and presents clinically as an abrasion, blister, or shallow crater.
Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

# Recommendation 1.5
All data should be documented at the time of assessment and reassessment.

# Level of Evidence -IV

# Discussion of Evidence:
Documentation is essentially communication that reflects the client's perspective on his/her health, the care provided, the effect of the care and the continuity of care. This record allows nurses and other members of the health care team to assist clients in making future care decisions (College of Nurses of Ontario, 2004;RCN, 2000). Proper documentation provides an accurate record of a client's progress and risk status. Any skin changes should be documented immediately, including a detailed description of what was observed and what actions were taken (RCN, 2000) and should be made accessible to all members of the health care team (NICE, 2001).

# Planning 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.

# Level of Evidence -IV

# Discussion of Evidence:
The risk factors identified in the assessment phase provide the framework for the development of the plan of care. Including the client and family in the development of the plan of care is essential for the establishment of mutual goals and adherence to the plan. Gage (1994) reports on the development of a client-driven interdisciplinary care plan that provides a shared vision for the client, health care professionals and family members involved in the individual's care. The client's concerns become outcomes that can be evaluated, to ensure that the plan of care is meaningful to the individual. Client and family involvement and partnership in care are central to client-centred care delivery. Individuals at risk for pressure ulcers should be involved in all aspects of pressure ulcer risk assessment and prevention, from involvement in assessment to shared decision-making about planning care (Consortium for Spinal Cord Medicine, 2000;RCN, 2000). Braden (2001) describes a care planning protocol by level of risk, based on the results of the Braden Scale for Predicting Pressure Sore Risk:
 For individuals at risk (15)(16)(17)(18), the plan of care should include a turning schedule, maximum remobilization, heel protection, the management of moisture, nutrition, friction and shear as well as the use of pressure-reduction support surfaces if bed or chair-bound. Braden suggests that if other major risk factors are present, care should advance to the next level.
 At moderate risk (13)(14), the interventions for mild risk are to continue, with the addition of a turning schedule with the 30rule.
 For individuals at high risk (10)(11)(12), the frequency of turning and the use of foam wedges to facilitate 30l ateral turns should be supplemented with small shifts in weight. All the interventions for moderate risk are to continue.
 For very high risk individuals (< 9), the plan needs to continue with the previous risk interventions, plus the possibility of static air overlay if adequate monitoring is possible. Consider the use of a low-air-loss bed if the individual at very high risk has additional risk factors ameliorated by a low air-loss bed, or uncontrolled pain, or severe pain exacerbated by turning. Braden (2001) cautions that the use of low air-loss beds does not substitute for an appropriate turning schedule, and that positioning should be a component of the plan of care.
Refer to Appendix D for a summary of level of risk and prevention interventions.

# Recommendation 2.2
The nurse uses clinical judgment to interpret risk in the context of the entire client profile, including the client's goals.

# Level of Evidence -IV

# Discussion of Evidence
The literature addresses the need for the use of clinical judgment, in conjunction with a recognized risk assessment tool, in the identification of risk (Consortium for Spinal Cord Medicine, 2000;CREST, 1998;RCN, 2000).
Research evidence indicates that there is insufficient evidence to recommend a particular risk assessment scale that is appropriate in all settings, and that clinical judgment continues to play a critical role in the care of clients at risk for pressure ulcers.
Both the development and revision panel strongly support the need for clinical nursing judgment in conjunction with the overall client profile as a basis for determining risk and planning of appropriate care. This recommendation is based on current practice, clinical experience and opinion. The Royal College of Nursing (2000) supports this approach, stating that "risk assessment scales should only be used as an aide memoire and should not replace clinical judgment" (pg. 12).

# Interventions Recommendation 3.1
For clients with an identified risk for pressure ulcer development, minimize pressure through the immediate use of a positioning schedule.

# Level of Evidence -IV

# Discussion of Evidence
Interventions related to the prevention of pressure ulcers should be based on clinical assessment and an established plan of care. When developing the care plan, the need for pressure reducing/relieving equipment should be determined by the overall assessment of the client, and not based on risk assessment scores alone (RCN, 2000). A review of several guidelines on pressure ulcer prevention establishes consensus on the need for the immediate use of preventative intervention in the form of pressure reducing/relieving equipment and/or repositioning schedules for those identified at risk (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000;CREST, 1998;NICE, 2001;RCN, 2000;WOCN, 2003).
Little research exists to provide nurses with guidelines on optimum turning schedules (Cullum, Deeks, Fletcher, Sheldon & Song, 1995). However, current clinical practice recommendations support the use of repositioning schedules for clients identified at risk for pressure ulcer development (AHCPR, 1992;NHS Centre for Reviews & Dissemination, 1995;Consortium for Spinal Cord Medicine, 2000;CREST, 1998;RCN, 2000;WOCN, 2003). Researchers have recommended every two hours for turns, however, alternatives have not been evaluated (Cullum et al., 1995; NHS Centre for Reviews & Dissemination, 1995). A systematic review reported by Cullum et al. (1995) found that only one small randomized controlled trial (RCT) evaluated routine manual repositioning compared with the standard routine, however only ten clients received the intervention, and the repositioning schedule was found difficult to implement. This same review identified two randomized controlled trials that evaluated unscheduled turning, but in both cases the sample sizes were small and the results were not statistically significant.
In the absence of strong evidence, the Royal College of Nursing (2000) supports a written repositioning schedule that is determined by the results of a skin inspection and individual needs and not by a predetermined 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.

# Level of Evidence -IV

# Discussion of Evidence
The techniques involved in positioning, turning or transferring are an important component in the implementation of care. Individuals should never be dragged across surfaces as this increases the risk of friction and shear damage. Most friction injuries can be avoided with appropriate techniques.
Voluntary and involuntary movements by individuals themselves can lead to friction injuries, especially on elbows and heels. The use of products to minimize contact with surfaces (including bed linens) can reduce the potential for injury (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000;WOCN, 2003). Use turning devices such as sheets, trapezes, or manual or electric lifts that will decrease the risk of skin damage (AHCPR, 1992; Turning and repositioning devices should be used appropriately in order to minimize shear and friction damage (NICE, 2001). All staff should be trained in the correct moving and handling of clients (CREST, 1998).

# 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 nonpharmacological interventions. Monitor level of pain on an on-going basis, using a valid pain assessment tool.

# Level of Evidence -IV

# 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.).

# Level of Evidence -IV

# Recommendation 3.3c
Consider the impact of pain on local tissue perfusion.

# Level of Evidence -IV

# Discussion of Evidence
Pain is a factor that may result in decreased mobility in clients who are dealing with chronic conditions such as arthritis, multiple sclerosis, cancer, and musculoskeletal injuries. Any decrease in mobility as a result of such pain may increase the risk for the development of pressure ulcers. At the same time, however, analgesia and sedatives may depress the central nervous system. This may result in reduced mental alertness, activity and mobility, thereby altering the individual's ability to respond effectively to ischemic pain (Lindquist et al., 2003).
In general, clinical guidelines on prevention of pressure ulcers do not address the assessment of pain, however the revision panel reached consensus on the importance of addressing pain issues within the context of pressure ulcer prevention. A recent study comparing pain assessment tools for use in the leg ulcer population (Nemeth et al., 2003) found that of the five tools that met the inclusion criteria (pain ruler, numerical rating, visual analogue, verbal descriptor, short-form McGill Pain Questionnaire), none had been studied for validity or reliability in this population. It was concluded that the current evidence was insufficient to recommend any one pain assessment tool for individuals with leg ulcers, however they did suggest that a two-step pain assessment process might be useful in practice. Initially, the assessment should include a self-report related to the presence and level of pain, and in situations where pain is present, a more comprehensive assessment of the quality of the pain should be conducted. More research is needed in the area of pain and its impact as a risk factor for pressure ulcer development. For details regarding comprehensive pain assessment and management, refer to the RNAO nursing best practice guideline Assessment and Management of Pain (2002a).

# Recommendation 3.4
Avoid massage over bony prominences.

# Level of Evidence -IIb

# Discussion of Evidence
The AHCPR (1992) reports on studies by Ek, Gustavsson & Lewis (1985) and Dyson (1978) which provide evidence to suggest that massage over bony prominences may be harmful. Lower blood flow to the skin after massage, significant decreases in skin temperature, and tissue degeneration were noted in those studied. Several clinical practice guidelines support this recommendation (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000;CREST, 1998;WOCN, 2003).

# 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.

# Level of Evidence -Ia
Nursing Best Practice Guideline

# Discussion of Evidence
A systematic review conducted by  examined to what extent pressure-relieving surfaces reduced the incidence of pressure ulcers compared with standard support surfaces, and reviewed how effective different pressure-relieving surfaces were in preventing pressure ulcers, compared to one another. It was concluded, from the 41 randomized controlled trials included in the review, that in those at high risk of pressure ulcers, the use of a higher specification foam mattress (low interface pressure) should be considered rather than the standard hospital foam mattress. Standard hospital mattresses have been consistently outperformed by a range of foam-based, low pressure mattresses and overlays, and also by "higher-tech" pressure-relieving beds and mattresses in the prevention of pressure ulcers.
Clients at very high risk of developing pressure ulcers may benefit from an alternating pressure mattress or other high-tech pressure redistributing systems (Consortium for Spinal Cord Medicine, 2000;RCN, 2000).
Alternating pressure devices generate alternating high and low interface pressures between the body and support surface (bed), usually by alternate inflation and deflation of air-filled cells. These devices are available as mattress overlays, and single or multi-layer mattress replacements. The systematic review conducted by  indicates that the relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear. Fleck (2001) outlines criteria and selection modalities for the use of support surfaces in the prevention of pressure ulcers. Regardless of the type of surfaces used for high-risk clients, thorough and frequent skin assessments should be conducted for evidence of tissue damage WOCN, 2003).
Refer to Appendix F for a further discussion of pressure reducing and pressure relieving surfaces.

# Recommendation 3.6
For high risk clients experiencing surgical intervention, the use of pressure-relieving surfaces intraoperatively should be considered.

# Level of Evidence -Ia

# Discussion of Evidence
Clients experiencing surgery are at risk for development of pressure ulcers because of factors that cannot be controlled -length of procedure hemodynamic state and the use of vasoactive medications during surgery. There are, however, many risk factors that can be controlled to reduce the incidence of pressure ulcer development, including pooled prep solutions, negativity, shearing, friction and the use of warming blankets beneath the client. Another factor that can be controlled in order to decrease pressure ulcers is the surface on which the person is placed during the surgical procedure  included four RCTs in a systematic review that evaluated different methods of pressure relief on the operating table. The results of three of the four trials suggest that pressure-relieving overlays are beneficial in reducing subsequent pressure ulcer incidence in high risk surgical patients. Nixon McElvenny, Mason, Brown & Bond (1998), one of the trials included in this review, found that the use of a dry visco-elastic polymer pad during the intra-operative period reduced the probability of pressure sore development by half.  concluded that "organizations might consider the use of pressure relief for high risk patients in the operating theatre, as this is associated with a reduction in post-operative incidence of pressure ulcers". Currently, the most effective means of pressure relief on the operating table is unclear, and further research is this area is recommended.

# 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.

# Level of Evidence -IV

# Recommendation 3.8
For individuals restricted to chair:
 Use 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.

# Level of Evidence -IV Nursing Best Practice Guideline

# Discussion of Evidence
Appropriate positioning of individuals restricted to bed and/or chair is aimed at reducing pressure and allowing for adequate tissue perfusion. Current clinical practice guidelines and other literature reviewed all support the need to position clients confined to bed/chair in such a way as to provide optimum pressure reduction (AHCPR, 1992;Braden, 2001;Consortium for Spinal Cord Medicine, 2000;CREST 1998;Folkedahl, Frantz & Goode, 2002;NICE, 2001;RCN, 2000;WOCN, 2003). In addition, it has been noted that equipment used for the provision of care and transfer of clients (slings, sleeves, or other equipment accessories) should not be left under individuals as these objects act as a source of pressure (NICE, 2001;RCN, 2000).
Careful attention must be paid to effective chair positioning, as very high interface pressure and shearing forces can develop with poor posture or inappropriate seating surfaces (Braden, 2001;Consortium for Spinal Cord Medicine, 2000). For clients at high risk, avoid prolonged sitting -less than two hours (NICE, 2001) -and provide them with pressure reduction/relief chair and bed surfaces (NICE, 2001;WOCN, 2003). In addition, if able, chair-bound individuals should use a mirror to inspect areas that they cannot see, or get others to inspect for them (Consortium for Spinal Cord Medicine, 2000;NICE, 2001;RCN, 2000). The recommended seating position includes a chair that is slightly tilted back with foot support (feet should never be left dangling), and arm rests (Braden, 2001).
It is important to consult with the interdisciplinary team, particularly the occupational therapist or physiotherapist, for seating assessments and necessary adaptations (AHCPR, 1992;CREST, 1998;RCN, 2000). Seating assessments for aids and equipment should be carried out by trained assessors who have acquired specific knowledge and expertise, such as Physiotherapists and Occupational Therapists (NICE, 2001;WOCN, 2003).

# 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.

# Level of Evidence -IV

# Discussion of Evidence
Adequate hydration of the stratum corneum protects against mechanical injury of the skin. Decreased hydration of the skin results in reduced pliability and severely dried skin is at risk for the development of fissures and cracks. Moisturizers should be applied to areas of dry skin, while care is taken not to rub or massage over areas of bony prominence. Maintenance of environmental conditions such as relative humidity and temperature minimize the incidence of dry skin (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000).
Hygienic practices to remove foreign material has been studied in relation to cleansing pressure ulcers, but not as a preventative measure (Consortium for Spinal Cord Medicine, 2000). However, it is noted in practice that frequent removal of metabolic wastes such as urine and feces is necessary to prevent chemical irritation of the skin (AHCPR, 1992). Skin may be exposed to a variety of moist substances such as urine, feces, perspiration, wound drainage and saliva all increasing susceptibility to injury (Braden, 2001;NICE, 2001;RCN, 2000). During routine cleansing of the skin, and at times of soiling, use of mild cleansing agents (pH balanced, non-sensitizing) and warm (rather than hot) water is recommended to minimize drying and irritation (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000;RCN, 2000;WOCN, 2003).

# 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. Level of Evidence -IV

# Discussion of Evidence
Wet skin is fragile and more susceptible to friction and tearing injuries, especially during cleansing. Moist skin also has a tendency to adhere to bed linens, potentially leading to damage when linen is removed. In addition, it is more susceptible to irritation, rashes and infections, such as candida. When the source of moisture cannot be controlled, use of protective barriers and moisture absorbing products are recommended. Absorbent pads, dressings or briefs should be changed as they become saturated, rather than delaying until they reach their absorptive capacity. These products should not interfere with any pressure-redistributing surface an individual may be placed on (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000;RCN, 2000). When skin is moist from perspiration, cotton linens are recommended to promote evaporation, skin aeration and faster drying. Frequent changing of moist linens is recommended to maintain dry intact skin.
Effective continence management is an essential component of skin care. An RCT examining skin health outcomes of an exercise and incontinence intervention found that intervention subjects were significantly better in urinary and fecal incontinence, physical activity and skin wetness outcome measures than the control group, but despite these improvements, skin health improvements were limited to specific areas of the body (back, distal perineal area) and there was no difference between groups in the incidence rates of pressure ulcers (Bates-Jensen, Alessi, Al Samarrai & Schnelle, 2003). To manage incontinence, consider use of a collection device (i.e., condoms) or a pouching system to contain urine or stool and to protect the skin.
When urinary incontinence has contributed or may contribute to a pressure ulcer, a urinary catheter may be necessary for a short period of time (WOCN, 2003). A referral to a continence advisor or enterostomal therapist should be considered on an individual basis. Refer to the RNAO nursing best practice guideline Promoting Continence Using Prompted Voiding (2005) for further information regarding continence management.

# Discussion of Evidence
There is a strong relationship between nutritional status (including hydration) and pressure ulcer development. Nutrition plays an important role in pressure ulcer prevention and healing, and is critical in maintaining tissue integrity (Consortium for Spinal Cord Medicine, 2000;Ferguson et al., 2000;RCN, 2000). Specific factors that are significantly associated with the development and prolonged healing of pressure ulcers are impaired nutrition and reduced nutritional intake. Nutritional status influences the integrity of the skin and support structures (WOCN, 2003). Lack of vitamins and trace elements may predispose the patient to an increased risk of pressure damage (RCN, 2000). Ferguson et al. (2000) indicate that nutritional intervention begins with nutrition screening and assessment; the goal is to ensure that dietary intake contains adequate nutrients to maintain or improve nutritional status. Nutritional assessment should be performed on entry to a new health care setting and whenever there is a change in an individual's condition that may increase the risk of malnutrition. Detailed screening and assessment may be beneficial, and referral to a registered dietitian is encouraged (Ferguson et al., 2000;RCN, 2000). This assessment should include (WOCN, 2003): current and usual weight; history of involuntary weight gain/loss; nutritional intake versus needs (including protein, calorie and fluid needs); appetite; dental health; chewing/swallowing difficulties; person's ability to feed him/herself; medical/surgical history that may impact on nutrient absorption; drug/nutrient interaction; psychosocial factors (finances, food preferences, availability of food preparation facilities) and cultural/lifestyle influences. It is essential to ensure that the individual can tolerate and/or manage the recommended diet.
A referral to a speech-language pathologist should be made for a swallowing assessment in situations where the nutritional screen indicates chewing or swallowing difficulties.
Laboratory parameters should be monitored to identify nutritional status and impact of interventions. No single measurement or combination of measurements has been shown to accurately predict the risk of pressure ulcer development, however standard measurements of protein status -albumin, transferrin and pre-albumin -should be considered. Low serum albumin may be indicative of a chronic disease state rather than represent overall nutritional status and, due to its 20 day half-life, is not a sensitive measure of the effects of intervention. Pre-albumin, on the other hand, with a half-life of 2-3 days is more reflective of the individual's current protein stores. Protein-calorie malnutrition may also be noted in those with a decreased total lymphocyte count (WOCN, 2003).
Two cohort prospective studies document the role that deficiencies of calories, protein and iron play in the development of pressure ulcers (AHCPR, 1992). The National Pressure Ulcer Advisory Panel recommends that patients with pressure ulcers who are underweight or losing weight receive enhanced caloric and protein supplementation. Recommendations for calorie and protein requirements in those with pressure ulcers are 35-40 kcal/kg of body weight/day for total calories, and 1.0-1.5 g protein/kg of body weight/day for total protein (WOCN, 2003). There is no evidence to support the practice of vitamin C and zinc supplementation for pressure ulcer prevention (WOCN, 2003). Langer et al (2004) concluded in a systematic review that it was not possible to reach a conclusion on the effect of enteral and parenteral nutrition on the prevention and treatment of pressure ulcers. -Marchasson et al. (2000) conducted a multi-centre RCT of 622 patients to assess the effect of nutritional supplementation on dietary intake and on pressure ulcer development in critically ill older patients. A nutritional intervention group received two oral supplements per day in addition to the normal diet. It was found that nutritional supplement intervention was associated with a decreased risk of pressure ulcer incidence.

# 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.

# Level of Evidence -IV

# Discussion of Evidence
Immobility and inactivity has been associated with larger ulcers, and bed and chair-bound persons are at higher risk for pressure ulcer development. Researchers have reported that the use of active and passive range of motion exercises promotes activity and reduces the effects of pressure on tissue. Exercise, ambulation, proper positioning, strengthening and increased range of motion all assist in the prevention process (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000).

# Nursing Best Practice Guideline
Discharge/Transfer of Care Arrangements

# Level of Evidence -IV

# Discussion of Evidence
In order to ensure a smooth transfer of clients who have been identified at risk for developing pressure ulcers between practice settings, and to provide consistency of care, it is essential to ensure that funding and equipment is in place to prevent an interruption in the plan of care. The Royal College of Nursing (2000) recommends that there should be policies and procedures for the transfer of individuals between care settings in order to enhance continuity of care. This information should be provided in writing as well as verbally in order to enhance communication (Consortium for Spinal Cord Medicine, 2000;CREST, 1998). Similar approaches to care in various settings will provide continuity and consistency for the client and their caregivers. The use of clinical practice guideline recommendations across the continuum of care can facilitate decision making by practitioners and clients regarding appropriate health care for specific clinical circumstances (Field & Lohr, 1990).

# Education Recommendations
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. Programs should be directed at all levels of health care providers including clients, family or caregivers.

# Level of Evidence -III

# Discussion of Evidence
All health care providers should receive relevant education in pressure ulcer risk assessment and prevention (NICE, 2001). The Royal College of Nursing ( 2000) identified several studies (Bergstrom Braden, Boynton & Bruch, 1995;Moody et al, 1988) reported in a systematic review by McGough (as cited in RCN, 2000) that support the concept that education programs may reduce the incidence and prevalence of pressure ulcer development. They state that "a continuous quality assurance approach would advocate that increasing people's awareness about pressure ulcer risk assessment and prevention via a coordinated and structured educational program, is more likely to result in benefits for patients than providing no program" (pg. 34). In addition, several clinical practice guidelines support educational intervention for improvement of pressure ulcer prevention (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000;NICE, 2001;RCN, 2000;WOCN, 2003).
In our current health care environment, individuals experience significantly shorter hospital stays.
Frequently, the focus of care is on maximizing functional gains in activities of daily living and mobility, and education is informal or minimal. It is essential, however, that individuals be provided with the basic knowledge necessary to return them to home and their communities (Consortium for Spinal Cord Medicine, 2000), and have this knowledge provided in a way that is meaningful and useful to the client and caregiver. Boyd (1987) in a systematic review indicates that the majority of people in the United States have a reading comprehension level at or below the eighth grade. This has implications for the development of patient education programs and patient teaching materials. There is extensive discussion in the literature that supports the need to ensure education programs are directed at all levels of clinicians, patients and other caregivers (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000;RCN, 2000;Wiechula, 1997).
Individuals at risk for pressure ulcers should be informed and educated about risk assessment and prevention strategies, and this education should include family and other caregivers, where appropriate. NICE ( 2001) indicate that patient/caregiver education should provide information regarding personal risk factors for pressure ulcer development, sites that are of the greatest personal risk for ulcer development, how to inspect for skin damage and recognize changes in the skin, how to care for the skin (including methods for pressure relief/reduction), and where the individual or family can get assistance and advice when required, with an emphasis on the need for immediate assessment by a health care professional should signs of deterioration be noted.

# Nursing Best Practice Guideline
The educational program for prevention of pressure ulcers should be based on the principles of adult learning, the level of information provided and the mode of delivery. Programs must be evaluated for their effectiveness in preventing pressure ulcers through such mechanisms as quality assurance standards and audits. Information on the following areas should be included:
 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 and ensure effective care planning.

# Discussion of Evidence
Principles of adult learning should guide the development of educational programs, and a variety of educational methods, including lectures (didactic presentations), demonstrations, and written guides with illustrations are recommended (AHCPR, 1992). In order to ensure that education programs are effective, they need to be monitored for outcomes, for example the reduction of prevalence and incidence of ulcers (AHCPR, 1992;RCN, 2000).
The AHCPR (1992) reviewed many educational programs in various clinical settings -spinal cord injury, rehabilitation centres, long-term care and hospitals -in order to identify the essential information for effective pressure ulcer prevention programs. NICE (2001) suggest that education programs should include a focus on the limitations and potential applications of risk assessment tools. The Royal College of Nursing (2000) confirms and further defines the content areas to be included. Specifically, they expand the focus on selection, use and maintenance of pressure redistributing equipment, and the roles and responsibilities of the interdisciplinary team members in pressure ulcer prevention and management as well as the inclusion of patient education.
Effective intervention strategies require the communication of the roles and responsibilities of the interdisciplinary team members (CREST, 1998). Enhanced continuity of care occurs when a team approach is used and each team member's roles and responsibilities are identified (AHCPR, 1992;Consortium for Spinal Cord Medicine, 2000;RCN, 2000). In addition, adopting a team approach requires each team member to take responsibility for facilitating and improving communication, sharing care and responsibility for care. This approach requires that health professionals and clients understand and respect each others roles in the delivery of care (RCN, 2000). The articulation of these roles can be addressed in educational programming aimed at various audiences.
Refer to Appendix G for selected educational resources. Organizations need to ensure that resources are available to clients and staff. These resources include, but are not limited to, appropriate moisturizers, skin barriers, access to equipment (therapeutic surfaces) and relevant consultants (OT, PT, ET, wound specialists, etc.).

# Level of Evidence -IV

# Recommendation 6.5
Interventions and outcomes should be monitored and documented using prevalence and incidence studies, surveys and focused audits. Level of Evidence -IV Nursing Best Practice Guideline

# Discussion of Evidence
Organizational Commitment A critical initial step in the implementation of guidelines must be the formal adoption of the guidelines. For example, the organization may consider formally incorporating the recommendations to be adopted into their policy and procedure structure (Graham, Harrison, Brouwers, Davies, & Dunn, 2002). This initial step paves the way for general acceptance and integration of the guideline into such systems as the quality management process.
New initiatives such as the implementation of a best practice guideline require strong leadership from nurses who are able to transform the evidence-based recommendations into useful tools that will assist in directing practice. The role of the project leader (facilitator) is to enable the implementation of the recommendations by assessing, interpreting and acting on the organizational context (RCN, 2003). It is suggested that the RNAO Toolkit (2002c) and opportunities for leadership development in facilitating change be considered to assist organizations to develop the leadership required for successful implementation. Appendix H provides a description of the Toolkit.

# Implementation Strategies
Organizations must consider ensuring the acquisition of the resources needed not only to implement, but also to sustain practice that is based on the guideline recommendations. Partridge and Hill (2000) suggest the following key findings from systematic reviews that address guideline implementation in clinical areas other than pressure ulcer prevention:
 Application of the guideline to the characteristics of the local community and setting;  An initial, specific educationally based strategy to implement the guideline;  Consideration to amending commonly utilized education and documentation tools to include cues that assist in implementation of the recommendations;
 Outreach by an expert or implementation leader directly to practicing clinicians to impact the success of implementation and maintenance;
 Multiple strategies for implementation are more likely to produce the desired change in clinical practice, including continuing education, ongoing feedback about benchmarks achieved and/or quality indicators monitored; and  Target barriers to adapting the guideline, including work load and administrative support for change.

# Quality Indicator Monitoring
The presence or absence of pressure ulcers is often seen as an indicator of the quality of care and these numbers are often used to make policy and funding decisions (RCN, 2000). Prevalence and incidence measures are defined as follows:
Prevalence of pressure ulcers -a cross-sectional count of the number of cases at a specific point in time. The rate includes all old and new cases during the defined prevalence period, e.g., 12 hours. The formula for prevalence is based on one ulcer per case, thus the highest stage of ulcer is counted on those with multiple ulcers. The results are expressed as a percentage of the total number of clients assessed. Prevalence is calculated by determining the number of individuals with pressure ulcers divided by the total population at a fixed period of time. This rate provides a snapshot of the distribution of pressure ulcers, however, the rate is effected by factors such as admission of new patients, healing rates, effectiveness of treatment, discharge practices, etc. (CREST, 1998;RCN, 2000).

# Risk Assessment & Prevention of Pressure Ulcers
Incidence of pressure ulcers -the new cases appearing during a specified period in the "at risk" population identified in the prevalence survey. For instance, a surgical nursing unit that had admitted 100 patients over a month and showed documentation of 10 ulcers would have an incidence rate of 10%. The rate is generally calculated by case with a new occurrence ( 10) over all the cases (100) present during a specified time period (1 month). A definition for quality improvement purposes may take into account all new occurrences, even if it is a multiple occurrence during the timeframe for an individual. For example, if five of the ten cases on the surgical unit had two ulcers during the one month period, the incidence rate would be 15%. It is important to make the formula you are using explicit. Incidence measures how many clients develop pressure ulcers during their hospital admission/community care (CREST, 1998;RCN, 2000).
Prevalence rates are difficult to compare between and within care settings and are challenging to interpret because they are affected by incidence, healing rates, admission and discharge practices and policies (RCN, 2000). Incidence rates give an increasingly accurate picture of the effectiveness of risk assessment and preventative interventions as it identifies those who have developed ulcers over time in a specific place of care. However, the measures of incidence need to be considered in conjunction with the type and number of at risk patients admitted into the care setting (RCN, 2000). Evaluation and audits should form an integral component of the quality assurance activities of practice settings (CREST, 1998;RCN, 2000). CREST (1998) suggests that the audit of prevention of pressure ulcers could be divided into two components:
a) Client Audit (CREST, 1998)  Has a risk assessment been carried out with the client?  Is this client identified as being at risk for pressure ulcer development?  If this client is at risk for developing pressure ulcers, has a plan of care been instigated which highlights the following:
- Strategies to reduce identified risks (type of bed surface, frequency of position changes)?
- Involvement of other disciplines?
b) Facility Audit (CREST, 1998)  Is there a policy for prevention of pressure ulcers?  Is there a mattress replacement policy for the unit?
 Is there guidance provided on allocation of pressure relieving equipment?  Does the facility advocate the use of a single risk assessment tool?
 Is there guidance provided on the use of staging criteria?  Do staff know about the existing policies?
The development panel, through a consensus building approach, identified the need to include an evaluation of care being provided in the community by professionals, family and other care providers.
c) Community Audit  Is there a provision to educate clients, family and health care professionals?  Are adequate resources in place to assist care providers? Documentation of ongoing monitoring of outcome indicators is essential in order to monitor the success of guideline implementation. Tools that facilitate the monitoring of client outcomes and the quality of care need to be integrated into the organization's quality management process. Sample tools developed for this purpose can be found in Appendix I.

# Research Gaps & Future Implications
The revision panel, in reviewing the evidence for the updating of this guideline, has identified several gaps in the research literature related to pressure ulcer prevention. In considering these gaps, they have identified the following priority research areas:
 The optimum frequency and effectiveness of positioning schedules.
 The effectiveness of positioning schedules for those individuals receiving care on pressure relieving surfaces.
 The effectiveness of pressure relieving interventions for pressure-related ulcers to the heels.
 The most effective surface for prevention of pressure ulcers during the intra-operative period.
 The impact of pain on pressure ulcer development and healing.
The above list, although in no way exhaustive, is an attempt to identify and prioritize the research gaps in this area. Some of the recommendations in this guideline are based on evidence gained from qualitative or quantitative research, while others are based on consensus or expert opinion. Further substantive research is required in some areas to validate the expert opinion and impact knowledge that will lead to improved practice and outcomes for those at risk of developing pressure ulcers.
Nursing To evaluate the impact of implementing the recommendations.
Best Practice Guideline Risk Assessment &
Presence of a process to monitor incidence/prevalence of pressure ulcers within the practice setting.
Decrease in incidence/prevalence of pressure ulcers within the practice setting.
Policies and procedures related to assessing pressure ulcer risk are consistent with the guidelines.

# Structure Process Outcome

# Implementation Strategies
The Registered Nurses' Association of Ontario and the guideline revision panel have compiled a list of implementation strategies to assist health care organizations or health care disciplines who are interested in implementing this guideline. A summary of these strategies follows:
 Have at least one dedicated person such as an advanced practice nurse or a clinical resource nurse who will provide support, clinical expertise and leadership. The individual should also have good interpersonal, facilitation and project management skills.
 Conduct an organizational needs assessment related to prevention of pressure ulcers to identify current knowledge base and further educational requirements.
 Initial needs assessment may include an analysis approach, survey and questionnaire, group format approaches (e.g., focus groups), and critical incidents.
 Establish a steering committee comprised of key stakeholders and interdisciplinary members committed to lead the change initiative. Identify short term and long term goals. Keep a work plan to track activities, responsibilities and timelines.
 Create a vision to help direct the change effort and develop strategies for achieving and sustaining the vision.
 Program design should include:
- Target population;
- Goals and objectives;
- Outcome measures;
- Required resources (human resources, facilities, equipment); and
- Evaluation activities.
 Design educational sessions and ongoing support for implementation. The education sessions may consist of presentations, facilitator's guide, handouts, and case studies. Binders, posters and pocket cards may be used as ongoing reminders of the training. Plan education sessions that are interactive, include problem solving, address issues of immediate concern and offer opportunities to practice new skills (Davies & Edwards, 2004).
 Provide organizational support such as having the structures in place to facilitate the implementation. For example, hiring replacement staff so participants will not be distracted by concerns about work and having an organizational philosophy that reflects the value of best practices through policies and procedures. Develop new assessment and documentation tools (Davies & Edwards, 2004).
 Identify and support designated best practice champions on each unit to promote and support implementation. Celebrate milestones and achievements, acknowledging work well done (Davies & Edwards, 2004).
 Organizations implementing this guideline should adopt a range of self-learning, group learning, mentorship and reinforcement strategies that will over time, build the knowledge and confidence of nurses in implementing this guideline.
 Beyond skilled nurses, the infrastructure required to implement this guideline includes access to specialized equipment and treatment materials. Orientation of the staff to the use of specific products and technologies must be provided and regular refresher training planned.
 Teamwork, collaborative assessment and treatment planning with the client and family and interdisciplinary team are beneficial in implementing guidelines successfully. Referral should be made as necessary to services or resources in the community or within the organization.

# Risk Assessment & Prevention of Pressure Ulcers
In addition to the strategies mentioned above, the RNAO has developed resources that are available on the website. A Toolkit for implementing guidelines can be helpful if used appropriately. A brief description about this Toolkit can be found in Appendix H. A full version of the document in pdf format is also available at the RNAO website, www.rnao.org/bestpractices.

# Process for Update/Review of Guideline
The Registered Nurses' Association of Ontario proposes to update this best practice guideline as follows:
- Each nursing best practice guideline will be reviewed by a team of specialists (Review Team) in the topic area every three years following the last set of revisions.
- During the three-year period between development and revision, RNAO Nursing Best Practice Guidelines program staff will regularly monitor relevant literature in the field.
- Based on the results of the monitor, program staff may recommend an earlier revision period.
Appropriate consultation with a team of members comprised of original panel members and other specialists in the field will help inform the decision to review and revise the guideline earlier than the three-year milestone.
- Three months prior to the three-year review milestone, program staff will commence the planning of the review process by: a. Inviting specialists in the field to participate in the Review Team. The Review Team will be comprised of members from the original panel as well as other recommended specialists. b. Compiling feedback received, questions encountered during the dissemination phase as well as other comments and experiences of implementation sites. c. Compiling new clinical practice guidelines in the field, systematic reviews, meta-analysis papers, technical reviews, randomized controlled trial research, and other relevant literature. d. Developing detailed work plan with target dates and deliverables.
The revised guideline will undergo dissemination based on established structures and processes.

# Nursing Best Practice Guideline
The search strategy utilized during the revision of this guideline focused on two key areas. One was the identification of new guidelines published on the topic of pressure ulcer risk assessment and prevention since the original guideline was published in 2002, and the second was to identify systematic reviews, and primary studies published in this area from 2001 to 2004. 5. What education do nurses need around strategies for the prevention of pressure ulcers? 6. What support does the organization need to provide to ensure nurses have the knowledge and skills for pressure ulcer prevention?

# STEP 1 -DATABASE Search
- What supports are needed for successful implementation of a pressure ulcer prevention program?
Detailed search strings developed to address these questions are available on the RNAO web site at www.rnao.org/bestpractices.

# STEP 2 -Structured Web Site Search
One individual searched an established list of web sites for content related to the topic area in July 2004. This list of sites, reviewed and updated in May 2004, was compiled based on existing knowledge of evidence-based practice web sites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched as well as date searched. The web sites at times did not house a guideline but directed to another web site or source for guideline retrieval. Guidelines were either downloaded if full versions were available or were ordered by phone/email.

# STEP 3 -Search Engine Web Search
A web site search for existing practice guidelines on pressure ulcer risk assessment and prevention was conducted via the search engine "Google", using key search terms. One individual conducted this search, noting the results of the search, the web sites reviewed, date and a summary of the results. The search results were further reviewed by a second individual who identified guidelines and literature not previously retrieved.

# STEP 4 -Hand Search/Panel Contributions
Additionally, panel members were asked to review personal archives to identify guidelines not previously found through the above search strategy. Results of this strategy revealed no additional clinical practice guidelines.

# SEARCH RESULTS:
The search strategy described above resulted in the retrieval of 1,818 abstracts on the topic of pressure ulcers. These abstracts were then screened by a Research Assistant in order to identify duplications and assess for inclusion/exclusion criteria. A total of 106 abstracts were identified for article retrieval and quality appraisal. The quality appraisal was conducted by a Masters prepared nurse with expertise in critical appraisal. The tool used to conduct this work was one developed by the Effective Public Health Practice Project (EPHPP) for appraising quantitative studies.
In addition, three recently published clinical practice guidelines were identified for review and critical appraisal by the panel, using the Appraisal of Guidelines for Research and Evaluation (AGREE Collaboration, 2001) instrument. These guidelines included:

# CHECKING SKIN FOR CHANGES
- Check the whole body, make sure you pay special attention to bony areas.
- By inspecting skin regularly, you can spot a problem at the very beginning. Checking the skin is the way to spot the warning signals of a problem.
- Use prevention products on those areas that may be affected by pressure.
- What should you look for?
- Redness, blisters, opening in skin, rashes, etc. Feel for heat in red areas with the back of your fingers.
- Check any areas that may have been previously broken and have since healed over -scar tissue breaks easily.
- How often should a skin inspection occur?
- At least twice daily: Morning and evening when dressing or undressing is recommended.
- Check more frequently if there is an increase in sitting or lying times.
- It is recommended that you check whenever changing positions.
Your caregiver can check your skin, or you can check your skin using a long-handled mirror.

# Risk Assessment & Prevention of Pressure Ulcers 58
If you have been lying on your back, observe these areas for changes.
If you have been resting on your side, observe these areas for changes.
- Which parts to check?
- Check the front, back, and sides of the body.
- Also check the areas where there may have been pressure.
- What to do if you notice a change:
- Apply creams to areas of redness (your nurse will have shown you the barrier creams to use).
- Show your nurse or doctor as soon as possible (especially if redness does not go away after the pressure has been removed for longer than 15 minutes).
- Do not massage area.
- Avoid lying or sitting on reddened area, if possible.

# Constantly Moist
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
Confined to bed.

# Completely Immobile
Does not make even slight changes in body or extremity position without assistance.

# Very Poor
Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IVs for more than 5 days.
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction.

# Very Limited
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR has a sensor impairment that limits the ability to feel pain or discomfort over 1/2 of body.

# Very Moist
Skin is often, but not always, moist. Linen must be changed at least once a shift.
Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

# Very Limited
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

# Probably Inadequate
Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding.

# Potential Problems
Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.
Patient's Name ___________________________ Evaluator's Name ______________________________

# Slightly Limited
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned, OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

# Occasionally Moist
Skin is occasionally moist, requiring an extra linen change approximately once a day.

# Walks Occasionally
Walks occasionally during day, but for very short distances with or without assistance. Spends majority of each shift in bed or chair.

# Slightly Limited
Makes frequent though slight changes in body or extremity position independently.
Eats over half of most meals. Eats a total of 4 servings of protein (meat or dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered OR is on a tube feeding or TPN regimen, which meets most of nutritional needs.

# No Apparent Problem
Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.

# No Impairment
Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

# Rarely Moist
Skin is usually dry, linen only requires changing at routine intervals.

# Walks Frequently
Walks outside the room at least twice a day and inside room at least every 2 hours during waking hours.

# No Limitation
Makes major and frequent changes in position without assistance.
Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

# Date of Assessment

# TOTAL SCORE
Note: Individuals with a score of 18 or less are considered to be at risk of developing pressure ulcers. At risk -15 to 18; Moderate Risk -13 to 14; High Risk -10 to 12; Very High Risk -9 or below.

# Braden, 2001

# Appendix D: Risk and Related Interventions

# Nursing Best Practice Guideline

# Appendix E: Staging of Pressure Ulcers
National Pressure Ulcer Advisory Panel (1989) Stage I: A Stage I pressure ulcer is an observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues (NPUAP, 1998).
Stage II: Partial thickness skin loss involving epidermis, dermis or both. The ulcer is usually superficial and presents clinically as an abrasion, blister or shallow crater.
Stage III: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (e.g., tendon, joint, capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

# Appendix F: Pressure Reduction and Pressure Relief
Pressure (Interface): The force per unit area that acts perpendicularly between the body and the support surface. It is affected by the stiffness of the support surface, the composition of the body tissue, and the geometry of the body being supported (AHCPR, 1994).
Pressure Reducing Surface: A surface that reduces the interface pressure between the body surface and the resting surface, but does not consistently maintain pressure below capillary closing pressure (AHCPR, 1994;Mulder, Fairchild & Jeter, 1991;WOCN, 1987).
Pressure Relieving Surface: A surface that consistently reduces the interface pressure between the body surface and resting surface below capillary closing pressure (AHCPR, 1994;Mulder et al., 1991;WOCN, 1987).
- To prevent skin breakdown, or further skin breakdown. 2. To promote healing in the patient who already has skin breakdown involving multiple surfaces (Bryant, 1992).
There are seven basic requirements that a support surface must meet in order to prevent pressure and shear. The surface must: 1. Conform to bony prominences without resistance; 2. Not have significant memory; 3. Allow patient immersion; 4. Not "bottom out"; 5. Relieve shear caused by patient movement; 6. Prevent skin maceration; and 7. Provide patient comfort (Jay, 1995).
To determine if a patient has bottomed out, the caregiver should place an outstretched hand (palm up) under the mattress overlay below the part of the body at risk for ulcer formation. If the caregiver can feel that the support material is less than an inch thick at this site, the patient has bottomed out. Bottoming out should be checked at various anatomical sites and while the patient assumes various body positions.
Overlay mattresses are devices that are applied over the surface of the hospital mattress. Most overlays provide pressure reduction. Overlays may be static (foam, gel, water, air filled) or dynamic (low air loss, alternating air).

# Nursing Best Practice Guideline

# Static Devices
These support surfaces remain motionless except in response to body movement and seek to redistribute the body weight by shifting the extra weight or load from areas with bony prominences to areas under low pressure (Holzapfel, 1993).
When selecting a static support surface made of foam, consider the following characteristics of foam: stiffness, density and thickness. Indentation load deflection (ILD) is a measure of stiffness. Typical values for foam mattress overlays would be a 25% ILD of 30 lbs., a density of 1.3 pounds per cubic foot, and thickness of 3 to 4 inches (Kemp & Krouskop, 1994).
Use a static support surface if a patient can assume a variety of positions without bearing weight on a pressure ulcer and without "bottoming out" (AHCPR, 1994).

# Dynamic Devices
Use a dynamic support surface if the patient cannot assume a variety of positions without bearing weight on a pressure ulcer, if the patient fully compresses the static support surface, or if the pressure ulcer does not show evidence of healing (AHCPR, 1994).
Dynamic devices have moving parts and are attached to an electrical power source. These devices compensate for the motionless or compromised body movement by shifting the weight or load from areas with bony prominences to areas under lower pressure. If a patient has large Stage III or IV pressure ulcers on multiple turning surfaces, a low-air loss bed or an air-fluidized bed may be indicated (AHCPR, 1994).
When excess moisture on intact skin is a potential source of maceration and skin breakdown, a support surface that provides airflow can be important in drying the skin and preventing pressure ulcers (AHCPR, 1994). Moist skin is more likely to abrade and blister. National Pressure Ulcer Advisory Panel: www.npuap.org
The National Pressure Ulcer Advisory Panel (NPUAP) provides multidisciplinary leadership for improved patient outcomes in pressure ulcer prevention and management through education, public policy and research.

# Wound, Ostomy & Continence Nurses Society (WOCN): www.wocn.org
The WOCN Society is a professional nursing society which supports its members by promoting educational, clinical and research opportunities to advance the practice and guide the delivery of expert health care to individuals with wounds, ostomies and incontinence.

# Wound Care Sites:
Ostomy/Wound Management: www.o-wm.com/owm Ostomy/Wound Management is an online resource for clinical, practical, and professional information about skin, wound, ostomy and incontinence care. This peer reviewed journal is published eleven times per year.
Prevention Plus: www.bradenscale.com
The mission of Prevention Plus is to provide health care professionals with a simple way to obtain information related to the Braden Scale for Predicting Pressure Sore Risk and its appropriate use in a program of prevention of pressure ulcers. They provide accurate, evidence-based information and practical tools to the many health professionals who are striving to improve the quality of care in their facilities or agencies.

# World Wide Wounds: www.worldwidewounds.com
The mission of World Wide Wounds is to be the premier online resource for peer-reviewed information on dressing materials providing practical guidance on all aspects of wound management to health professionals worldwide.

# Industry Resources
Companies manufacturing pressure ulcer products often have educational resource material specific to product use. Many also have educational programs about wound care in general, and risk assessment and prevention/treatment of pressure ulcers specifically. Consult your vendor company representative to determine educational resources that may be appropriate for your specific needs and clinical setting.
Best Practice Guideline Risk Assessment & Prevention of Pressure Ulcers 70

# Appendix H: Description of the Toolkit
Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support as well as appropriate facilitation. RNAO, through a panel of nurses, researchers and administrators has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a health care organization.
The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline:
- Identifying a well-developed, evidence-based clinical practice guideline.
- Identification, assessment and engagement of stakeholders.
- Assessment of environmental readiness for guideline implementation. 4. Identifying and planning evidence-based implementation strategies.
Planning and implementing evaluation. 6. Identifying and securing required resources for implementation.
Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.
The Toolkit is available through the Registered Nurses Association of Ontario. The document is available in a bound format for a nominal fee, and is also available free of charge from the RNAO website. For more information, an order form or to download the Toolkit, please visit the RNAO website at www.rnao.org/bestpractices.
The Toolkit is available through the Registered Nurses' Association of Ontario.
The document is available in a bound format for a nominal fee, and is also available free of charge from the RNAO website. For more information, an order form or to download the Toolkit, please visit the RNAO website at www.rnao.org/bestpractices.
For each patient receiving the prevention of pressure ulcer protocol, please complete the chart below. This chart should be completed at least weekly for each patient who is receiving the pressure ulcers management program. For each patient receiving the management intervention, please keep a record of the changes observed in his or her patient records.
Please make a copy of the chart on the next page and place it in the chart of each patient who is receiving the prevention of pressure ulcers protocol. The outcomes on this chart should be assessed and recorded for each patient on a weekly basis. Add any outcomes that are suited to individual patient needs.
To use the chart: Place the appropriate key criteria next to each separate outcome for each patient assessment.
The example below is for the first outcome (Patient Interview) and displays the various criteria keys:
Criteria Key Y = Yes/met criteria N = No/criteria not met J = Justified variation/patient not included in the monitor (Note why patient is not included)
Please place the appropriate key next to the outcomes for each assessment period.

# Documentation reveals that skin integrity has been maintained
Braden Score Documented Comments:
Sample 2: Pressure Ulcer Risk Assessment and Prevention: Implementation Guide and Audit Protocol
The Royal College of Nursing ( 2003) has developed a series of audit forms to evaluate the implementation of guideline recommendations related to pressure ulcer prevention. These audits include a ward/nursing home/caseload audit, a patient audit, and knowledge test. A summary of the details of the patient audit tool follows, however the full protocol Pressure Ulcer Risk Assessment and Prevention: Implementation Guide and Audit Protocol 2003 is available at www.rcn.org.uk.

# Patient Audit Form:
 Patient information -gender, age, reason for admission, date of initial nursing assessment following admission.
 Pressure ulcer risk -date of initial assessment, assessment tool used, score. Evidence of other factors being taken into account in identifying risk should be included. Evidence of reassessments and their frequency should be included.
 Skin inspection -requires information from the client's chart and skin inspection by the reviewer. This requires identification of the pressure ulcer scoring tool used, the presence of any pressure ulcers and grading (documented and actual) based on skin inspection.
 Equipment -review of equipment provided, including whether it is in use, requested and not received, or not available.
 Other aids -pressure relieving/redistributing devices.
 Repositioning/moving and handling -planning, implementing and reviewing repositioning schedules and movement and handling procedures.

# Supplement Integration
Similar to the original guideline The comprehensive data tables and references were provided to all panel members.

# Review Findings
In October 2010, the panel was convened to achieve consensus on the need to revise the existing set of Review Process Flow Chart

# Summary of Evidence
The following content reflects the changes made to the RNAO Risk Assessment and Prevention of Pressure Ulcers ( 2005) best practice guideline based on the consensus of the review panel. The literature review does not support dramatic changes to the recommendations, but rather suggests refinements and stronger evidence for the approach. Changes to the 2005 guideline recommendations are highlighted in bold.
unchanged changed additional information new recommendation

# Practice Recommendations
New recommendations have been added to further expand assessment of pressure ulcers to vulnerable populations.
Furthermore, new recommendations related to pressure management were also added under the Intervention Section, which resulted in changes to the original numbering of the recommendations.

# 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.

# Level Ia Evidence
The discussion of evidence for this recommendation found on page 22 of the 2005 guideline has been revised to reflect new emerging literature supports related to new pressure ulcer sites. The following information has been added:  2009) identified the most common sites for pressure ulcer development in Intensive Care Unit patients to be the sacrum, coccyx and heels. Accordingly, a comprehensive head to toe skin assessment should include the anterior and posterior body surfaces, particularly when prone or semi-prone patient positioning is implemented.
A number of studies cited as secondary sources by the Guideline for Prevention and Management of Pressure Ulcers (WOCN, 2010, p. 6) reinforce the importance of reassessment to minimize the risk of pressure ulcer development following admission to specific clinical settings. The following notes the timeline for when pressure ulcers can develop in specific clinical settings: Although this best practice guideline is focused on risk assessment and prevention of pressure ulcers in the adult client, the panel has included reference to the child in recognition of the child as a vulnerable population. Also, as the care of a critically ill child may cross several care settings, the importance of this information is one to be shared amongst all care settings and care providers.
Additional Literature Support Brink et al. (2006).

# Recommendation 1.2 of the 2005 guideline (pg. 27) has been divided into two sub-recommendations for clarity.
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.

# Level III Evidence
The discussion of evidence for this recommendation found on page 23 of the 2005 guideline has been revised to reflect new emerging literature supports for pressure ulcer risk assessment tools. The following information has been added:
Discussion of Evidence Shukla et al. (2008) conducted a prospective study which assessed surgical and medical patients using the Waterlow Pressure Ulcer Risk Assessment Tool. Their investigation supported the use of structured assessment tools for: 1) identifying multiple risk factors which need to be addressed in a preventative plan of care; and 2) for identifying risk factors for clinicians less experienced in considering all relevant factors related to pressure ulcer risk. Several studies using other risk assessment tools assisted in the identification of risk factors for various care settings Gunningberg, 2004a;Terekeci et al., 2009). Some of these studies implemented structured pressure ulcer risk assessment tools along with other assessments specific to a clinical area such as the Subjective Global Assessment that categorizes nutritional status. However, a systematic review by Moore and Cowman (2008) revealed that there is no high quality evidence to support that the use of a structured pressure ulcer risk assessment reduces the incidence of pressure ulcers. What is encouraging though is the use of standardized assessment tools to gain a better understanding of risk factors for specific clinical settings and client populations. These tools, along with clinical judgment, increase the ability to identify risk factors that are then incorporated into a client specific prevention plan of care Vanderwee et al., 2007). Magna and Makleburst (2009) conducted a descriptive correlational study analyzing Braden subscale ratings and preventive nursing interventions. In this study, they found that nurses were more likely to endorse and use preventive interventions that were identified by a decrease in Braden subscale scores indicating increased risk. They described how the subscales for sensory perception, activity and mobility assessed the degree of risk associated with intense and prolonged pressure, while moisture, nutrition, friction and shear assessed risks associated with decreased tissue tolerance. They concluded that the Braden Scale for Predicting Pressure Sore Risk should be conducted for the purpose of planning preventive interventions and that the prevention plan should be based on assessment of individual Braden subscale scores (see Appendix J).
Additional Literature Support Capon et al. (2007).

# Recommendation 1.2b
Assess for intrinsic/extrinsic risk factors that are associated with the development of pressure ulcers.

# Level III Evidence
The discussion of evidence for this recommendation found on page 24 of the 2005 guideline has been revised to reflect new emerging literature supports related to those intrinsic and extrinsic risk factors that influence pressure ulcer development. The following information has been added:

# Discussion of Evidence
As identified in Recommendation 1.2a, additional research conducted using standardized pressure ulcer risk assessment tools in specific clinical settings and client populations has yielded a greater number of probable intrinsic and extrinsic risk factors. The following risk factors specific to client populations are being included for consideration:

# Clinical Setting Risk Factors Reference
Intensive Care Unit - organ failure, sepsis
- interface pressure, skin moisture, smoking, body temperature
- level of consciousness, activity, cooperation, bowel incontinence, length of stay, C-reactive protein level
- intermittent hemodialysis, mechanical ventilation, vasopressor therapy and pain
- impaired perfusion/hemodynamic instability, pharmacologic or mechanical support to maintain normal blood pressure or adequate cardiac output, global or regional perfusion that is not adequate to support normal organ function including the skin Fogerty et al., 2008Suriadi et al., 2007Sayar et al., 2009Nijs et al., 2009 Medical/Surgical - having two co-morbidities, neuropsychiatric disorder, infection Reddy et al., 2006;Terekeci et al., 2009 Medical Client - length of time of hospitalization  Surgical Client - weight, serum albumin  Acute Care (surgery, internal medicine, neurology, geriatric)
- age greater than 75 years, weight on admission, abnormal appearance of skin, planned surgery in coming week
- presence of malignant tumor, arterial obstructive disease of abdominal and pelvic arteries Schoonhoven et al., 2007Nonnemacher et al., 2009 Orthopedic - age greater than 71 years, pulmonary disease, diabetes
- cerebral vascular accident Lindholm, 2008Walsh & Plonczynski, 2007 These additional risk factors are adding to the understanding of specific risk factors and the predisposition to the development of pressure ulcers for specific client populations and care settings.
Additional Literature Supports. Wolverton et al. (2005).
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.

# Level III Evidence

# Discussion of Evidence
While key risk factors that predispose the general population to pressure ulcers have been identified by several standardized assessment tools, specific factors may need to be considered in certain vulnerable patient populations. For instance, a study of patients with spinal cord injuries identified an 85 per cent lifetime risk of pressure ulcer development, with socioeconomic, neurological and behavioral factors being important elements in the occurrence (New et al., 2004). Concerns regarding pressure or friction from equipment and skin texture are more relevant in the pediatric and neonate populations (Fuji, et al., 2010). Bariatric, palliative patients and the frail elderly may also benefit from specific assessment (NPUAP & EPUAP, 2009).
A number of studies cited as secondary sources by the Guideline for Prevention and Management of Pressure Ulcers (WOCN, 2010) have suggested the following risk assessment tools specific to the palliative patients and the pediatric population: Furthermore, the interRAI Pressure Ulcer Risk Scale (PURS) based on the Minimum Data Set (MDS) assessment has been shown to be useful in identifying risk for pressure ulcer development among residents in long-term care homes and home care recipients (Poss et al., 2010). This tool is detailed in Appendix K.
Although a validated assessment tool to determine and compare pressure ulcer risk among obese and bariatric individuals remains elusive, high body mass index (BMI) has been demonstrated to be a significant predictor for pressure ulcer development (Elsner & Gefen, 2008). People with BMIs of more than 40 were almost three times more likely to have a pressure ulcer compared to those with BMIs of 40 or less (Drake et al., 2010).
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).

# Level IV Evidence

# Discussion of Evidence
The Skin Changes at Life's End (SCALE) consensus statement was developed to facilitate implementation for knowledge-transfer-into-practice for quality patient outcomes (Sibbald et al., 2009). Not to be considered or used as a skin assessment tool, it does however, provide 10 valuable consensus statements which discuss changes of the skin as a result of the dying process. It also identifies risks of injury such as pressure ulcers and the Kennedy Terminal Ulcer, a pressure ulcer "usually shaped like a pear, butterfly, a horseshoe, and are located predominantly in the coccyx or sacrum" (Sibbald et al., 2009, p 4).
In light of these revisions to RNAO's Risk Assessment and Prevention of Pressure Ulcers, the following statements have specific relevance:
Source: Sibbald, R.,

# Reprinted with Permission from Wolters Kluwer Health

# Statement 1
Physiologic changes that occur as a result of the dying process (days to weeks) may affect the skin and soft tissues and may manifest as observable (objective) changes in skin color, turgor (integrity), or as subjective symptoms such as localized pain. These changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care. (Sibbald et al., 2009, p 6).

# Statement 4
Skin changes at life's end are a reflection of compromised skin (reduced soft tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes) (Sibbald et al., 2009, p 7).

# Statement 6
Risk factors, symptoms, and signs associated with SCALE have not been fully elucidated, but may include: weakness and progressive limitation of mobility, suboptimal nutrition including loss of appetite, weight loss, cachexia and wasting, low serum albumin/pre-albumin, and low hemoglobin as well as dehydration; diminished tissue perfusion, impaired skin oxygenation, decreased local skin temperature, mottled discoloration, and skin necrosis; loss of skin integrity from any of a number of factors including equipment or devices, incontinence, chemical irritants, chronic exposure to body fluids, skin tears, pressure, shear, friction and infections; and impaired immune function. (Sibbald et al., 2009, p 8).

# Statement 7
A total skin assessment should be performed regularly and document all areas of concern consistent with the wishes and condition of the patient. Pay special attention to bony prominences and skin areas with underlying cartilage. Areas of special concern include the sacrum, coccyx, ischial tuberosities, trochanters, scapulae, occiput, heels, digits, nose and ears. Describe the skin or wound abnormality exactly as assessed. (Sibbald et al., 2009, p 9).
The RNAO review panel believes that the use of the SCALE consensus statements adds to the body of knowledge which helps to differentiate the skin care needs of the dying client from the client receiving palliative care. Although, there are similarities, there are also differences and it is these differences that facilitate the identification of skin at risk and subsequent preventative plans of care for this vulnerable population.
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.

# Level IV Evidence

# Discussion of Evidence
Patients are at risk for pressure ulcer development across the entire spectrum of health care settings including acute care, intensive care, home care, long-term care, palliative and others (refer to Recommendation 1.1 for information on the timeline for when pressure ulcers can develop in these clinical settings). Various programs and services such as nursing, medicine, rehabilitation, social work, and support services are responsible for pressure ulcer prevention. Clinicians, administrators, risk managers, and other leaders in quality assurance should be involved in addressing pressure ulcers.

# 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).

# Level IV Evidence
Recommendation 1.6a originally was recommendation 1.4a. The discussion of evidence for this recommendation found on page 25 of the 2005 guideline has been revised to reflect new emerging literature supports related to the use of standardize systems and changes in the language for pressure ulcer identification. The following information is added:
Although adopted by several practice guidelines, validity and reliability of the current classification systems of pressure ulcers remain contentious. The accuracy of grading a pressure ulcer can be affected by skin pigmentation, presence of moisture associated skin damage, deep tissue injury and deep ulcers that are progressively becoming shallower.
Misuse and misinterpretation of the current pressure ulcer classification systems is common. Staging/Grading connotes a faulty assumption that pressure ulcers progress from I to III or IV. Some clinicians advocate the description of skin damage as superficial (partial thickness) versus deep (full thickness). The revised National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) (2009) guideline suggests "Category" to replace "stage" or "grade", Appendix E. The term category is neutral and does not imply a hierarchical designation.

# Recommendation 1.6b
If pressure ulcers are identified, utilization of the RNAO best practice guideline Assessment and Management of Stage I to IV Pressure Ulcers along with other related guidelines is recommended.

# Level IV Evidence
All findings should be documented at the time of assessment and reassessment.

# Level IV Evidence
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.

# Level IV Evidence
This recommendation is an amalgamation of both recommendations 2.1 and 2.2 of the 2005 guideline. Discussion of evidence found on pgs. 27-28 of the original guideline is still reflective of the current evidence. The guideline review panel encourages the use of other RNAO guidelines such as the "Establishing Therapeutic Relationship", "Client Centered Care", and "Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients" to gain better understanding of the importance of collaboration in the development of individualized plan of care and interventions according to the risk factors identified by the Braden Risk Assessment Tools, Appendix C.
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.

# Level Ia Evidence
Recommendation 3.5 of the 2005 guideline now becomes 3.1a.

# Discussion of Evidence
A systematic review conducted by  examined the extent to which therapeutic support surfaces, in comparison with standard support surfaces, reduced the incidence of pressure ulcers and compared how effective different pressure-management surfaces were in preventing pressure ulcers. From the 41 randomized controlled trials included in the review it was concluded that for those at high risk of pressure ulcers, the use of a higher specification foam mattress (low interface pressure) should be considered rather than the standard hospital foam mattress (non-powered foam or spring-based mattress). Standard hospital mattresses have been consistently outperformed by a range of foam-based, low pressure mattresses and overlays, and by "higher-tech" pressure-relieving beds and mattresses in the prevention of pressure ulcers.
The  review also indicates that the relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear, and suggests that alternating air mattresses are more effective than alternating air overlays. However, other studies have shown that there are no significant differences between the types of pressure reducing mattresses used (i.e. low air loss and alternating pressure air mattresses), in the reduction of pressure ulcer incidence (Theaker et al., 2005;Weststrate, 2005). Nevertheless, the De Laat et al. ( 2007) study found a decrease in pressure ulcer incidence with the increased use of pressure reducing mattresses for critically ill patients in the Intensive Care Unit (ICU).
The NPUAP ( 2007) has created standard terminology for the discussion of support surfaces. The terms pressure reduction, pressure relief, static and dynamic are no longer used to describe support surfaces. Support surfaces are now divided into two main categories: - Reactive support surface: "A powered or non-powered support surface with the capability to change its load distribution properties only in response to applied load" (p. 5). - Active support surface: "A powered surface with the capability to change its load distribution properties, with or without applied load" (p. 5).
The NPUAP has also created standard definitions for support surface features such as low air loss, alternating air, envelopment and immersion. Norton et al. (2008) have created a support surface selection tool for the prevention and management of pressure ulcers (see Appendix L for further discussion of support surface selection). Regardless of the type of surfaces used for high-risk clients, thorough and frequent skin assessments should be conducted for evidence of tissue damage WOCN, 2003).

# 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.

# Level Ia Evidence

# Discussion of Evidence
Repositioning is a key component in preventing pressure ulcers for patients at risk. Prior to the revision of this guideline, little research existed to help guide a re-positioning schedule for clinicians other than clinical assessment.  investigated the effect of four different preventative regimes and their effect on pressure ulcer development in 838 geriatric long-term care patients. They compared frequent turning every two or three hours on a standard mattress to less frequent turning every four or six hours on a pressure management surface. It was found that turning every four hours on a support surface, a high-specification mattress or bed, was associated with the occurrence of significantly less pressure ulcers than the second group on a standard mattress, a non-powered foam or spring-based mattress.
The study also suggested that patients at risk of breakdown who were placed on a standard mattress must still be turned every two hours for prevention. The Vanderwee et al. (2007) study of 235 long-term care patients, all lying on viscoelastic foam mattresses, yielded similar results. In their study, the experimental group had patients repositioned alternately two hours in a lateral position and four hours in a supine position. The control group patients were repositioned every four hours, first in lateral and then in supine. The study also found that more frequent repositioning on a pressure-reducing mattress did not lead to fewer pressure ulcers. Rich et al. (2010) studied the incidence of pressure ulcers among bed-bound elderly hip fracture patients and found no association between frequent repositioning of bedbound patients and lower pressure ulcer incidence, regardless of being on a standard mattress or pressure-reducing mattress. Furthermore, Westrate ( 2005) also found that regular repositioning alone as a measure of pressure reduction is unlikely to be successful in the ICU. The findings from these two studies support the need for an individualized plan of care tailored to each patient based on characteristics such as mobility and general medical condition, regardless of the surface they are on.
The NPUAP & EPUAP ( 2009) also supports the use of repositioning as a prevention strategy that must take into consideration the patient and the support surface in use.
Reproduced with permission: Norton L. (2010). Support Surface Selection Guide. Shoppers Home Health Care. Toronto. Revised June 2011.
When choosing a therapeutic support surface, special attention needs to be given to the issue of entrapment. Between 1980 and 2008, 54 per cent of the 67 life-threatening entrapments reported to Health Canada lead to death. The risk of entrapment may be increased when using a therapeutic support surface as it may not have exactly the same dimensions as the original mattress. Although Health Canada does provide guidance as to the maximum measurements for the seven zones of entrapment, standard measurements are not available for powered active support surfaces as the air bladders on some of these surfaces compress, making valid measurement difficult.
Seven Zones of Entrapment 1. Within the rail.
- Under the rail (between the rail supports or next to a single rail support).
- Between the rail and the mattress. 4. Under the rail at the ends of the rail. 5. Between split bed rails. 6. Between the end of the rail and the side edge of the headboard or footboard. 7. Between the head board or footboard and the mattress end.
To minimize the risk of entrapment consider:
- Selecting a surface that has a transfer boarder as it may be less likely to compress as the client approaches the side of the surface; - Evaluating the use of bed rails -the client may be at less risk when these are not in place; - Implementing other devices, such as positioning wedges or a mattress cover with built in bolsters; and/or - Consulting with an occupational or physical therapist skilled in this area to complete a client assessment and make specific recommendations.
Additional Literature Support Kaitani et al. (2010).

# 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.

# Level III Evidence
In the 2005 guideline, use of devices to totally relieve pressure on the heels and bony prominences of the feet was included within recommendation 3.7 for individuals restricted to bed. Given the unique vulnerability of the heels and that heel pressure ulcers are the second most prevalent location of pressure ulcer, heel ulcer prevention warrants to be a recommendation on its own.

# Discussion of Evidence
Multiple factors make offloading (complete elevation of the heel off a surface) important in heel ulcer prevention. These include the small amount of subcutaneous tissue covering the calcaneous bone, the shape of the calcaneous bone, and the risk for ischemia with minimal pressure and shear forces. Nicosia et al. (2007) published a meta analysis on the effect of pressure relieving surfaces for the prevention of heel ulcers. This study found that pressure management surfaces were associated with a significantly lower incidence of heel ulcers as compared with a standard hospital mattress. There is also evidence to support the use of certain air or foam mattresses or overlays in prevention of heel pressure ulcers. However, there exists insufficient research to determine if heel-protective devices could prevent heel pressure ulcers (Nicosia et al., 2007). Similarly, a systematic review conducted by Junkin and Gray (2009) found that pressure redistribution surfaces vary in their ability to prevent heel pressure ulcers, but there was insufficient evidence to determine which surfaces were optimal for this purpose. Insufficient evidence also exists in the determination of whether heel protection devices were more effective than a standard hospital foam pillow (Junkin and Gray, 2009). Campbell et al. (2010) recognized the significant impact heel pressure ulcers have in the acute orthopedic population and implemented a heel pressure ulcer prevention program. Development of the program included consensus exercises with clinical staff and administrators and use of a two-inch foam wedge covered in washable vinyl to offload patient's heels in bed. This device allowed elevation of the heel while distributing the weight of the leg along the calf to avoid pressure on the Achilles tendon and allow for maximum heel perfusion. The incidence of heel ulcers in the orthopedic program decreased from 13.8 to 0 per cent over a four-week period.
Additional Literature Support Schoonhoven et al. (2006).

# Discussion of Evidence
All surfaces upon which the client sits or lies, the transfers to and from these surfaces and the repositioning techniques used need to be assessed regarding pressure, friction and shear forces (Kaitani et al., 2010). The NPUAP (2007) has created standard definitions for these terms. They are:
- Pressure as: "the force per unit area exerted perpendicular to the plane of interest" (p. 127). - Friction as: "the resistance to motion in a parallel direction relative to the common boundary of two surfaces" (p.124). - Shear as: "the force per unit area exerted parallel to the plane of interest" (p.127).
Efforts need to focus on reducing the forces of pressure, friction and shear. Particular attention should be paid to reducing shearing forces, as shear force doubles the impact of pressure (Ohura et al., 2008).
Use devices to enable independent positioning, lifting and transfers (e.g. trapeze, transfer board, bed rails). Lifting devices or low friction sheets should be used to avoid dragging clients during transfers and position changes. The use of safe patient handling techniques has been shown to decrease staff injuries, but also to decrease skin tears and pressure ulcers (Kaitani et al., 2010).
Refer to Appendix F for further discussion on force management.
Skin protection cushions (i.e. cushions which reduce pressure, friction and shearing forces) should be used when clients are using a wheelchair to help prevent pressure ulcers. In a randomized clinical trial on preventing pressure ulcers with wheelchair cushions, it was found that skin protection cushions used with fitted wheelchairs lower pressure ulcer incidence for elderly nursing home residents (Brienza et al., 2010). Brienza et al. (2010) goes on to say that residents who are identified to be at high risk as determined by their Braden Scale score and who use a wheelchair as their primary means of mobility should be provided with a wheeled mobility and seating assessment, and properly fitted wheelchair with a skin protection cushion.
An Occupational or Physical Therapist with expertise in seating and mobility should conduct a wheeled mobility and seating assessments. When prescribing the wheelchair and cushion, consideration should be given not only to pressure, friction and shear but also to issues such as postural alignment, impact on function, cost, maintenance, comfort, distribution of weight, balance, stability, support of the feet, client goals and cognitive status.
Ensure that that wheelchair and cushion are prescribed for that individual client sitting in the wheelchair, that the components of the wheelchair are assembled appropriately and that the cushion is in the chair correctly. If the cushion has bottomed out, is leaking, the wheelchair is in disrepair or the client's condition has changed, a reassessment by the Occupational or Physical Therapist is recommended (see Appendix M for more information).
When the client is restricted to bed, it is essential to utilize an interdisciplinary approach to prevent pressure ulcers. Use of pillows or foam wedges to avoid contact between bony prominences had been shown to minimize pressure ulcer incidence (NPUAP/EPUAP, 2009). A 30 degree turn to either side is also recommended to avoid positioning directly on the trochanter, as this results in the lowest interface pressure. Young (2004) however found that 78 per cent of at risk medical patients could not tolerate this type of position. Accordingly, use of specialty pillows to help patients maintain this position is suggested (Vanderwee et al., 2007).
A 30 degree elevation or lower (maintaining the head of the bed at the lowest elevation consistent with medical conditions and restrictions) was a recommended position for reducing shearing forces. A prone position may also result in low interface pressure measurements if medically appropriate (NPUAP & EPUAP, 2009). An advanced dressing could be used to further decrease friction or shear in individuals who are restricted to bed. A study by Bots and Apotheker (2004) found a 76.7 per cent reduction of heel pressure among surgical patients with use of an adhesive foam dressing. Similarly, Nakagami et al. (2006) also found a reduction of shear force on the heel with use of a low-friction dressing. The study also stipulated that although dressings reduce friction or shear, they couldn't be a substitute for heel offloading in the immobile patient.

# 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.

# Level IV Evidence
This recommendation replaces recommendation 3.3c found on pg. 30 of the 2005 guideline to emphasize pain assessment, management and documentation. The following information is an addition to the discussion of evidence found on pg. 30 of the guideline.
Pressure ulcer prevention includes pain management. Pain interferes with patients' mobility and their acceptance of potentially painful procedures such as turning and repositioning, thereby increasing their risk for pressure ulcer development. Accordingly, adequate pain assessment, management and documentation are critical to pressure ulcer prevention and should be incorporated into the plan of care.
The guideline review panel strongly recommends the use of the RNAO Assessment and Management of Pain (2002; 2007S) best practice guideline for guidance related to pain assessment and interventions.

# Recommendation 3.5
Massaging over bony prominences and reddened areas should be avoided

# Level IV Evidence
The discussion of evidence for this recommendation (formally 3.4) found on page 30 of the 2005 guideline has been revised to include subsequent literature related to the use of massage for pressure ulcer prevention.
The NPUAP and EPUAP ( 2009) provided a succinct review of seven articles on the utilization of therapeutic massage to prevent pressure ulcers. These articles in aggregate suggested massage to be contraindicated in the presence of acute inflammation, as this indicate the possibility of damaged blood vessels or fragile skin. Because the majority of pressure ulcers occur over areas of bony prominence where tissue thickness is already minimized and cushioning of blood vessels is not optimal, reddened areas suggest presence of inflammation. Accordingly, such areas should not be massaged.
Additional Literature Support WOCN (2010) Recommendation 3.6 Implementation of intraoperative pressure management devices is recommended for surgical procedures lasting more than 90 minutes.

# Level Ib Evidence
The discussion of evidence for this recommendation will be congruent to the information provided on pgs. 31-32 of the original guideline (under recommendation 3.6). However, changes to the last sentence of the second paragraph is made to reflect the following information: Individuals undergoing surgery face multiple risks for pressure ulcer development. These risks include the length of time of the procedure, any hypotensive episodes during the surgery, low core temperature during surgery and limited mobility on the first postoperative day (NPUAP & EPUAP, 2009). It is important to note that pressure ulcers are not always visible immediately and can develop three to five days after surgery, making it difficult to clearly identify causative factors Nijs et al., 2009;. Nevertheless, pressure ulcers continue to occur more frequently in surgical patients during the first week of admission than in medical, neurological and geriatric patients (Schoonhoven et al., 2006). Hence, the use of a pressure-distributing mattress on the operating table is suggested (Nixon et al., 2006). In particular, a quality support surface (foam or gel) is recommended for those individuals undergoing surgery greater than 90 minutes in length (Medical Advisory Secretariat, 2009). A study conducted by Pham et al. (2011) found a 0.51 per cent decrease in intraoperative incidence of pressure ulcers with use of pressure redistribution overlays on operating tables. The study also found that though the average cost of operating table overlays is $1.66 per patient, its use improves patient's health and yields a cost saving of $46 per patient -ranging from $13 to $116 by different surgical populations. Intentional positioning such as elevating heels completely off the surface without increasing pressure on the Achilles tendon and deliberate positioning pre-and post-surgery that would be different than the positioning used in the operating theatre could also prevent pressure ulcer development for this patient population (NPUAP & EPUAP, 2009). Ultimately, the high incidence of pressure ulcer development in surgical patients suggests that prevention interventions focus on the preoperative and immediate postoperative period must be implemented immediately on admission to prevent pressure ulcer occurrence during the first week of hospitalization (Schoonhoven et al., 2006).
Additional Literature Support WOCN (2010).
Note: For recommendations 3.7a and 3.7b, consider referral to occupational or physical therapist (OT/PT) for seating assessment, pressure management selection and adaptations for special needs (Appendix L).

# Recommendation 3.7 a
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.

# Level IV Evidence

# Discussion of Evidence
When implementing a pressure management device, it is imperative to consider the consequences of focal pressure that can inadvertently be caused from improper use or application. Techniques such as offloading patient's heels with an intravenous solution bag, or having patients sit on a donut device to off load the ischial tuberosities can potentially increase pressure of the surrounding skin and cause ischemia resulting in further breakdown of the vulnerable area. It is important to use a pressure redistribution model that enables any device to distribute load over the contact areas of the human body (NPUAP & EPUAP, 2009). This is also the case when additional padding is used to protect an area, as it is likely increasing focal pressure.
Positioning patients onto medical devices such as tubes or drains can increase localized pressure resulting in tissue damage (NPUAP & EPUAP, 2009). In some cases, use of local pressure devices may be of benefit (i.e. the use of doughnut type devices around the ear when side lying). It is essential to include education and training to caregivers and clients when using these techniques to minimize improper use and risk of ischemia.
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.

# Level III Evidence

# Discussion of Evidence
There is no evidence that bed rest is effective in preventing or managing pressure ulcers, yet both physical and physiological complications are well documented Norton et al., 2007). Recumbent positioning has been associated with a decrease in serum liver proteins such as albumin, pre-albumin and transferrin (Doweiko & Nompleggia, 1991;Lacy, 1991). Furthermore, Brown et al. (2004), in a study of hospitalized older patients found that lower mobility scores were also associated with adverse outcomes such as decreased independence in activities of daily living, increase institutional care after discharge and death. Their study also found that patients' with decreased mobility is often recorded as involuntary bed rest orders, and in almost 60 per cent of the cases, there was no documented additional medical indication for the use of bed rest (Brown et al., 2004).
When considering prevention and management of pressure ulcers, evaluate all surfaces upon which the client sits or lays, the transfers to and from these surfaces, and the repositioning techniques and equipment used on these surfaces in terms of pressure, friction and shear. Consult an occupational or physical therapist familiar with seating, mobility, transfers and support surfaces.
An appropriate wheelchair is one that has been prescribed by an occupational or physical therapist and recently reviewed by the therapist. The wheelchair fits the client's stature (height and weight), is in good working order, has a pressure management cushion that is positioned correctly and is not worn. See Recommendation 3.3 and Appendix M for further information.

# 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)
-r 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.

# Level III Evidence
This recommendation is an amalgamation of recommendations 3.9 and 3.10 of the 2005 guideline. The following information is an addition to the discussion of evidence found on pg. 33 (3.9) and pg. 34 (3.10) of the 2005 guideline.
The use of skin emollients to hydrate dry skin, and the use of barrier products on skin already compromised due to excessive moisture and/or incontinence is suggested to reduce risks for pressure damage (NPUAP & EPUAP, 2009). The choice of products for standardized performance indicators such as breathability, air permeability and other factors can guide continence management. The American-based National Association for Continence (www.nafc.org) is currently developing standards for continence products.
Consider the impact of incontinence products on pressure, friction and shear and use the minimum number of layers/amounts. Additional Literature Supports Bots & Apotheker (2004). Jolley et al. (2004). Reddy et al. (2006).

# 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.

# Type III Evidence
The following information replaces the discussion of evidence found on pgs. 35-36 of the 2005 guideline.

# Discussion of Evidence
Nutritional assessment on admission to a health care facility or agency and with each change in patient's condition is critical to the prevention of pressure ulcers. Key components of a nutrition assessment that must be considered for pressure ulcer prevention and/or management are as follows: a) Adequacy of intake of nutrition and hydration from all sources (e.g. calories, protein, micronutrients fluid); b) Precautions and contraindications to nutrient and fluid supplementation; c) Routes and extent of nutrition/hydration loss (e.g. gastrointestinal tract, urinary tract, wound exudate, fistulae, diaphoresis, negative pressure therapy); d) Weight status -significant unintentional weight loss, weight stability, overweight/ obesity and the importance of frequent weight monitoring. (For patients who are obese, Donner et al. (2009) suggested that weight loss efforts may need to be modified or postponed temporarily to provide sufficient nutrients for prevention and/or healing of pressure ulcers); e) Nutrition/hydration-related blood work; f) Ability to self-feed/need for assistance with eating and drinking; and g) Other barriers to optimal food/fluid intake (e.g. impaired dentition, dysphagia, impaired cognition/communication, advanced age, psychosocial factors, inadequate screening/assessment and monitoring).
It has been well documented that significant weight loss (greater than or equal to 5 per cent change in 30 days or greater than or equal to 10 per cent change in 180 days), low BMI (less than 22 kg/m2), dehydration, reduced appetite, protein-energy malnutrition and impaired ability to eat independently are associated with increased incidence of pressure ulcers and delayed wound healing (Dorner et al., 2009;Fraser, 2007;Fraser, 2009;Stechmiller, 2010). Therefore, nutritional interventions directed at preventing and correcting such issues are critical for pressure ulcer prevention.
A meta-analysis conducted by Stratton et al., (2005) showed that provision of an oral nutrition supplement (ONS) (250 -500 kcal per serving) given over two to 26 weeks was related to a significantly lower incidence of pressure ulcer development in at-risk populations (i.e. elderly, post-surgical, long-term care) compared with standard care. This systematic review also showed that the risk of developing pressure ulcers could be reduced by 25 per cent with oral and/or enteral (tube feeding) nutrition support. Although oral nutrition is the preferred route for nutrition and should be supported whenever possible, enteral and parenteral (delivered outside the alimentary tract) nutrition are necessary when oral nutrition is inadequate or not possible based on the patient's condition and goals (NPUAP & EPUAP, 2009).
Literature suggests that patients with nutritional risk and pressure ulcer risk factors be offered:
- A minimum of 30-35 kcal /kg body weight/ day with 1.25-1.5 g/kg/day protein (Dorner et. al., 2009; NPUAP & EPUAP, 2009); - A minimum of 1 ml of fluid/ kcal/ day (NPUAP & EPUAP, 2009); for patients with dehydration, diarrhea, vomiting, elevated temperature, profuse sweating or heavily draining wound(s), provide additional fluid (Dorner et al., 2009); and - A well balanced diet that includes appropriate sources of vitamins and minerals.
If dietary intake is poor or deficiencies are suspected, offer vitamin/mineral supplements (Dorner et. al., 2009).
It should be noted that implementation of greater amounts of calories, protein and fluid, and initiation of vitamins and minerals must be based on clinical assessment and judgment by a registered dietitian based on a comprehensive nutrition assessment that considers concurrent disease processes and the inherent precautions and contraindications to supplementation.
An essential component of a comprehensive assessment is a patient's nutrition/ hydration-related blood work that may identify underlying barriers to skin integrity and healing. Although a patient's pressure ulcer risk and "heal-ability", from the nutrition perspective, is not based on his or her blood work alone, blood work screening is an essential step to assist with the identification of resolvable barriers to healing. Appendix N outlines some of the nutrition/hydration-related blood work important to pressure ulcer prevention.
Whether or not blood work is readily available, it is essential that the patient be assessed for the following clinical signs and symptoms of dehydration (Fraser, 2009, p.19

# 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.

# Type IV Evidence
The following is an addition to the discussion of evidence found on pg. 36 of the original guideline.
Physical therapists and occupational therapists have unique training and skills to minimize patient risk for pressure ulcers such as specialization in biomechanics, exercise program development, equipment prescription and positioning. Rehabilitation to maximize range of motion, strength and mobility reduces patient risk for tissue damage. In addition, stretching and positioning devices can decrease muscle spasms to reduce friction and shear.
Institution of a rehabilitation program across all spectrums of care will increase a client's functional mobility, ensure safe and proper use of equipment, and allow for ongoing education to clients and caregivers to achieve their goals of care.

# Discharge/ Transfer of Care Arrangements

# Discussion of Evidence
Ensuring a smooth transfer of clients between care settings and care units requires an interdisciplinary team approach (McInnes, 2008). Clients at risk of developing pressure ulcers require clear consistent communication of their needs in order to ensure that equipment and funding is in place prior to the transfer of care to another practice setting. This ensures that provision of consistent care is maintained. Communication prior to transfer may include client and family conferences, the writing of equipment prescription letters and/or funding requests.
When transferring clients between care settings identified risk factors need to be shared with the interdisciplinary team, including the current status of the skin, any pressure points and any alterations to the skin integrity. Communicate established client care plans that support the minimization of pressure, friction and shear. For clients at risk of developing pressure ulcers, the type of bed/mattress, type of seating support/device and current transfer techniques used by the client (i.e. their bed-to-chair-to-commode) are required (Feutchtinger et al., 2006;Frankel et al., 2007). Rockwood et al. (2005) identified that new pressure ulcers are more likely to develop and existing ones are more likely to deteriorate when residents from long-term care are transferred to acute care. They also stated that prevention strategies are required for long-term care residents on admission to hospital and should be targeted to high risk patients such as those admitted with hip fractures and pneumonia.
For clients with a history of previous ulcers, communicate previous treatments, offloading strategies, wound care products used that were effective and those that were not effective; any adverse effects to wound care products need to be recorded and reported in the clients' care plan (Chaves et al., 2006).
Categorize/Grade any existing pressure ulcers and include the type of dressing used and frequency of dressing changes. Communicate the goal of the wound care plan, including if the wound is closing or if the wound is palliative, maintenance status, pain assessment and management strategies. Having the client and family perspective on the prevention care plans supports open communication to discuss any further and ongoing care plan changes that may be required. Pressure ulcer prevention requires an interprofessional team support; consider interprofessional referrals to enhance patient outcomes (Feuchtinger et al., 2006).

# Education Recommendations
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.
Level III Evidence
Programs should be directed at all levels of health care providers including clients, family or caregivers.

# Level III Evidence
Recommendation 5.1 from the original guideline is divided into 5.1a and 5.1b for clarity.

# Level IIb Evidence
The discussion of evidence for this recommendation found on pg. 39 of the 2005 guideline has been revised to reflect additional literature supports. The following content has been added:
The principles of adult education indicate that a variety of methods are needed to adequately disseminate information to the bedside and thus impact care. This concept is supported by studies addressing various methods to change practice related to pressure ulcer prevention.
Recent literature provides support for web-based training program as an effective mode of delivering information. In a study conducted by Magnan and Maklebust (2008), they found web-based training modules to be both effective and efficient in strengthening nurses' capabilities in pressure-ulcer risk assessment and in preparing nurses in making reliable assessments of pressure-ulcer risk when patients are at extreme risk. Similarly,  found the National Databases of Nursing Quality Indicators (NDHQI) Pressure Ulcer Training Program (www.nursingquality.org/ NDNQIPressureUlcerTraining/Default.aspx) to be an effective educational method for training healthcare professionals in pressure ulcer identification and staging. Another study related to technology assisted pressure ulcer training also yielded positive results. Elliott et al. (2008) used quasi experimental methods with a quality improvement project in which surveys of patients' skin were conducted during 22 audits of critically ill patients in an Australian ICU over 26 months. Education of the nursing staff was done using one on one clinical instruction, monthly newsletters, positive feedback and reinstruction. The authors' noted that the prevalence of pressure ulcers decreased from 50% to 8.3% and concluded that the use of quality improvement approaches to practice improvement resulted in a significant change in culture.
To date, the components of the curriculum identified above continue to provide the essential information required for an effective pressure ulcer prevention programs. However, in keeping with guidelines published by the NPUAP & EPUAP (2009) and the Association for the Advancement of Wound Care (2009), the term "support surfaces" is changed to "pressure management devices". Emphasis on the use and maintenance of pressure management devices has also been found to be critical to include in educational programs related to pressure ulcer prevention (Association for the Advancement of Wound Care, 2009;NPUAP & EPUAP, 2009;Wedge & Gosnet, 2005).
Additional Literature Supports Gunningberg (2004b). Howe, L. (2008). Tetterton et al. (2004).

# Organization and Policy Recommendations
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.

# Level IV Evidence
The following information is an addition to the discussion of evidence found on pg. 41 of the 2005 guideline under the heading "Organizational Commitment".
In order to prevent the development of pressure ulcers, transferring a client between and within care settings may require a site visit, a client/family conference, and advance notice to access funding for resources to ensure pressure management equipment is in place at the time of transfer to prevent the development of pressure ulcers.

# 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.

# Level III Evidence
The following information is an addition to the discussion of evidence found on pg. 41 of the 2005 guideline under the heading "Implementation Strategies".  utilized a quality management approach that explored the use of a bundled concept (Table 1) for pressure ulcer prevention, a concept from the Institute for Health Care Improvement. In this study, interventions were geared toward the development of a pressure ulcer prevention program with the theme "Check, Rock and Roll around the Clock", combined with education and audits. Overall, they found the program to be effective, with reduction of pressure ulcer prevalence and incidence rates to below national levels over the one-year period of the study.  (Baldelli & Paciella, 2008, p. 138) - Risk assessment using a recognized tool - Skin assessment on admission and eight-hourly - Head of bed to be raised by <30 degrees - Management of incontinence - Turning and positioning at specified frequencies - Heel elevation - Nutritional assessment - Pressure relief surface Recommendation 6.3
Best practice guidelines can be successfully implemented only when there are adequate planning, resources, organizational and administrative supports, as well as appropriate facilitation. Organizations are recommended to develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to implementation;
- 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.
In this regard, a panel of nurses, researchers and administrators developed the RNAO Toolkit: Implementation of Clinical Practice Guideline (2002) based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the RNAO guideline Risk Assessment and Prevention of Pressure Ulcers (2005).

# Level IIb Evidence
The following information is an addition to the discussion of evidence found on pg. 41 of the 2005 guideline under the heading "Implementation Strategies" et al. (2005) looked at strategies for implementing pressure ulcer clinical practice guidelines across the continuum of care. They compared prevalence and incidence before and after implementation. In addition, they also looked at barriers or facilitators for implementation. Overall, the study found barriers to implementation to be: a) under resourced in computer infrastructure; b) increased demand of nurses' time to learn new technology and computer skills; and c) lack of administrative supports. On the other hand, factors supporting implementations were: a) leadership support; b) risk assessment tools, plans of care and wound care grids; and c) increased communication between the interprofessional team. Indeed, all these supportive factors had been found to increase the likelihood of staff identification of issues related to pressure management, increased use of available resources, and improved consistency of care.
In addition,  also found that employees of nursing homes with a greater degree of quality improvement implementation are more likely to report adoption of pressure ulcer clinical guidelines and are more satisfied with their job. Quality improvement implementation is most likely to be successful in nursing homes with an underlying culture that promotes innovation. However, while such implementation may result in staff who are more satisfied with their jobs and who believe that they are providing better care, the association with improved care is uncertain.
Additional Literature Supports Davies, Edwards, Ploeg & Virani (2008).
Ploeg, Davies, Edwards, Gifford & Elliott-Miller (2007).
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.

# Level IIa Evidence
The following information is an addition to the discussion of evidence found on pg. 41 of the 2005 guideline under the heading "Implementation Strategies" Milne et al. (2009) did a failure mode and effect analysis study to improve the care processes that prevent pressure ulcers. They formed wound care teams, provided education, improved documentation, implemented new policies and procedures. Medical records were also reviewed to determine infrastructure process flaws. For 12 months post implementation, this study found pressure ulcer prevalence rates were reduced to a mean rate of 4.2 per cent, from a rate of 41 per cent prior to implementation. Furthermore, an increase in collaboration among disciplines regarding prevention was also evident post implementation.
Adequate access to equipment (pressure management surfaces) is also an important strategy for prevention of pressure ulcers within health care facilities. A study by the Toronto Health Economics and Technology Assessment Collaborative (THETA) (2008) found that implementation of alternative foam mattresses (with or without turning/ repositioning protocols) reduced lifetime risk of pressure ulcer by 11 to 15 per cent, and the lifetime risk of chronic pressure ulcer by 8 to 11per cent. However, gains in health per individual were small -two to eight days of quality-adjusted survival gained. Furthermore, the study also provided information on staff time to care for residents identified at risk for pressure ulcer development. In particular, it had been identified that "a registered nurse (RN) staff time increased by an additional 20 minutes (from 0.27 hours to 0.58 hours) per resident per day for residents at high risk for the development of pressure ulcers in long-term care homes" (THETA, 2008, p. 60). The "proportion of residents in the homes that are at high risk for developing pressure ulcers is 62 per cent, and currently none of these residents receives 0.58 hours of RN time per day" (THETA, 2008, p. 60). Ultimately, this finding enforces the importance for organizations to invest in adequate nursing staff for delivery of quality care leading to prevention of pressure ulcers.
A study by Pham et al. (in press) provided economic evidence of the cost effectiveness of pressure-redistribution foam mattresses on emergency department stretchers and beds for early prevention of pressure ulcers in elderly persons admitted to hospital emergency departments. In particular, they found that early prevention is likely to improve health for elderly patients with 0.0015 quality adjusted life-days gained, and mean hospital costs savings of $32 per patient. Overall, the study demonstrated that if decision-makers are willing to invest $50,000 per quality-adjusted life year gained, early prevention is cost effective even for short emergency department stays of one hour with low hospital acquired pressure ulcer risk (one per cent prevalence), and high unit price of pressure-redistribution mattresses ($3,775).
Interventions and outcomes should be monitored and documented using prevalence and incidence studies, surveys and focused audits.
Level III Evidence 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.
Level III Evidence Recommendation 6.7
Embed annual prevalence of pressure ulcer studies into assessment of risk/quality and professional practice.

# Level III Evidence
The following information is an addition to the discussion of evidence found on pg.41 of the 2005 guideline under the heading "Quality Indicator Monitoring".
Use of validated pressure ulcer surveillance tools is deemed effective for monitoring organizational prevalence and nosocomial pressure ulcer rates and trends. Surveillance programs can also help to identify blind spots in practice and equipment availability. Some databases may already be collecting some of this data in facilities or hospitals.
A study conducted by Harrison et al. (2008) between 2001 and 2007 revealed a decrease of pressure ulcer prevalence from 18 to 14 percent with the implementation of a pressure ulcer monitoring system across a number of health care settings in eastern Ontario. The authors, after 15 years of experience, recommended the following approaches in pressure ulcer monitoring: 1. Create and enable champions to monitor and develop unit-based solutions in response to findings; 2. Embed monitoring in the quality and professional practice infrastructure of the organization; 3. Use existing structures and processes such as unit councils or quality committees -quality processes and practice panels are ideal venues to situate pressure ulcer monitoring at both organizational and unit levels; and 4. Create a data collection process that is as clinically sensible and feasible as possible.
The presence or absence of a pressure ulcer is often seen as an indicator of quality of care. Accreditation Canada (2011) established a new Required Organizational Practice (ROP), an essential practice that an organization must have in place to enhance patient safety and minimize risk, related to pressure ulcer prevention in the long term care sector. As part of the ROP, long term care organizations are required to "assess each client's risk for developing a pressure ulcer and implement interventions to prevent pressure ulcer development" (Accreditation Canada, 2011, p. 49). Specific "Test for Compliance" (outlined below) have been established to assess organizations' compliance to pressure ulcer prevention. These may serve as criteria by which other organizations can guide their practice in relation to preventing pressure ulcer development. For more information regarding Accreditation Canada's ROP, please visit www.accreditation.ca/uploadedFiles/ROP%20Handbook%20EN.pdf Tests for Compliance (Accreditation Canada, 2011, p. 49) - The organization conducts an initial pressure ulcer risk assessment at admission, using a standardized risk assessment tool. - The organization reassesses each client for risk of developing pressure ulcers at regular intervals. - The organization implements documented protocols and procedures to prevent the development of pressure ulcers, which include interventions to prevent skin breakdown, reduce pressure, reposition, manage moisture, maximize nutrition, and enhance mobility and activity. - The organization educates staff on the risk factors and strategies for the prevention of pressure ulcers. - The organization monitors its success in preventing the development of pressure ulcers and makes improvements to its prevention strategies and processes. 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.

# Level III Evidence
Discussion of Evidence Lahmann et al. (2010) looked at the impact of prevention structures and processes on pressure ulcer prevalence in long-term care homes and acute care hospitals. They found that repeated participation of health care professionals in pressure ulcer surveys resulted in lower pressure ulcer prevalence rates and increased use of all guidelines and risk assessment.
It is critical for participants to engage in educational programs prior to carrying out pressure ulcer prevalence studies (Harrison et al, 2008;Milne, 2009). Gallagher et al. (2008) conducted a prevalence study in Ireland using a team of physicians and registered nurses. All team members completed training one week prior to the prevalence study and again the morning of the study. They concluded that an investment in training is an important part of the process of conducting a prevalence study and also is necessary for implementation of pressure ulcer guidelines.
Equally important to consider is the methodology employed for conducting prevalence studies. Gunningberg and Ehrenberg (2004) conducted a study comparing determination of pressure ulcers based on chart review versus patient exam. They found the overall prevalence of pressure ulcers obtained by audit of patient records was 14.3 per cent compared to 33.3 per cent when the patients' skin was examined. They concluded patient records did not present valid and reliable data about pressure ulcers and were under predicting prevalence rates. More attention must be focused on the quality of charting data to make proper use of electronic patient records in the future. Similarly, Whittingdon & Briones (2004) concluded that the frequently used method of chart reviews for incidence data is less accurate than clinical examination. They identified the need for sequential national studies using rigorous, common methodology. Category/Stage IV: Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.
Often includes undermining and tunneling.
The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/ tendon is visible or directly palpable.
Unstageable -Depth Unknown: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determines. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.

# Appendix F: Force Management
Appendix F -Pressure Reduction and Pressure Relief on pg. 65 of the 2005 guideline is replaced by the following information.
Note the change in the title of the appendix.
Decreasing peak points of pressure over the skin has been associated with a decreased risk of pressure ulcer development (Brienza et al., 2001). For this reason, it is important to consider the pressure between the client's skin and the surface upon which they are sitting or lying. Many devices are available to help manage pressure. Pressure is not the only force that contributes to pressure ulcer development; friction and shear also play a factor. To manage these forces caregivers require a solid understanding of these forces.
Pressure is defined as ''the force per unit area exerted perpendicular to the plane of interest'' (NPUAP, 2007, p. 127). To experience pressure, try this activity:
" Place your right hand palm down on a table. Take the index finger of the left hand and press it into the back of your positioned hand. This is pressure. Now, flatten your left hand and press it on top of the dorsum (back) of the right hand that is still palm down on the table. You can tolerate more pressure because it is distributed over a greater surface area." (Norton et al., 2011).
Many devices designed to manage pressure work on this principle of increasing the surface area, to decrease focal areas of pressure.
Shear is defined as "the force per unit area exerted parallel to the plane of interest" (NPUAP, 2007, p. 127). To experience shear, try this activity:
" Reach under your buttocks while you are sitting, and find your ischial tuberosities (backside bones). Rock your upper body forward and backward. Can you feel the movement of the ischial tuberosities? The force between the ischial tuberosity (bone) and the skin is called shear" (Norton et al., 2011).
Friction is defined as "the resistance to motion in a parallel direction relative to the common boundary of two surfaces" NPUAP, 2007, p. 124). To experience friction try this activity:
" Reposition your right hand, palm down on a table. Slide this hand toward you. The force between your hand and the table is friction" (Norton et al., 2011).
Friction and shear are often confused as these forces often occur together. It is friction that holds the skin against the surface, allowing the client's bony structures to slide against the inside of her or his skin. It is especially important to identify shear forces as they double the impact of pressure (Ohura et al., 2008). One sign that shearing forces are occurring is asymmetrical undermining of the wound (Ohura et al., 2008).
Many devices designed to manage friction and shear do this through the cover -decreasing friction against the skin, or designing the cover with two layers that slide against each other, rather than having the skin slide across the top cover.
Clients who are at risk for developing pressure ulcers, or who have developed a pressure ulcer should be referred to an occupational or physical therapist skilled in seating and mobility assessments to address the forces of pressure, friction and shear.

# General Considerations:
- Assess all surfaces upon which the client sits or lies in terms of pressure, friction and shear.
- Assess all transfer and repositioning activities in terms of pressure, friction and shear.
- Ensure that the client is comfortable on all surfaces
- Ensure the equipment is in good working order and is not worn out.
- Ensure the surfaces are positioned and used correctly.
- Check that the surface is not bottomed out:
 Foam -should rebound to its original shape when the client's weight is removed. If it does not rebound, it is considered bottomed out.
 Air -slide your hand, palm down, between the client and the air surface at the lowest bony prominence. The client should be floating in the surface. If there is less than a half an inch of air between the client's lowest bony prominence and the bottom of the surface, the surface has bottomed out.
See Appendix L for more information about selecting therapeutic support surfaces.
See Appendix M for more information about seating.
Hypothyroidism is a metabolic disorder that exerts biochemical and histological effects on tissue integrity and regeneration that can adversely affect wound prevention and healing (Ekmekzoglou & Zografos, 2006). Hypothyroidism and diabetes mellitus can coexist in clinical settings. The influence of these conditions individually and concurrently warrants the screening for, and immediate management of these conditions for optimal wound healing (Ekmekzoglou & Zografos, 2006).
Dehydration is a risk factor for skin breakdown and wound healing. The blood urea nitrogen (BUN):creatinine ratio may be used as an indicator of a patient's hydration status, though may not be accurate in patients with renal failure. An elevated BUN level with a normal or low creatinine level may indicate under-hydration. A BUN:creatinine ratio greater than 20:1 is a red flag for dehydration which must be investigated and addressed. In addition, BUN and creatinine are indicators of renal function. A clinician must be aware of a patient's renal status prior to the recommendation of enhanced protein, fluid, vitamins and minerals as there are precautions and contraindications to supplementation in a case of renal insufficiency as well as in other co-morbidities.

# Risk Assessment & Prevention of Pressure Ulcers

# Appendix A: Search Strategy for Existing Evidence Appendix B: Skin Assessment
Skin inspection should be based on a head-to-toe assessment of those areas known to be vulnerable for each client (see illustrations for at risk areas). This assessment is best conducted when dressing or undressing in order to better visualize vulnerable areas. Any aids (braces, anti-embolic stockings, etc.) should be removed prior to this inspection.

# Vulnerable areas typically include:
 temporal region and occiput of the skull;  ears;  scapulae;  spinous processes;  shoulders;  elbows;  sacrum;  coccyx;  ischial tuberosities;  femoral trochanters;  knees;  malleoli;  metatarsals;  heels;  toes;  areas of the body covered by anti-embolic stockings or restrictive clothing;  areas where pressure, friction and shear are exerted during activities of daily living; and  parts of the body in contact with equipment.
Additional areas should be inspected as determined by the individual's condition (NICE, 2001;Weir, 2001).
A comprehensive skin assessment for sites of non-blanching erythema requires both visual and tactile inspection. Early indications of a developing ulcer include:  Change in colour (redness/erythema), texture and sensation of the skin surface.  In individuals with darkly pigmented skin, observe for persistent erythema, non-blanching hyperemia, blisters and discolouration (purple/blue localized areas), localized heat (replaced by coolness as tissue is damaged), localized edema and localized induration.

# Appendix C: Braden Scale for Predicting Pressure Sore Risk
Risk Assessment & Prevention of Pressure Ulcers

# Appendix G: Educational Resources
The following resources for nurses are intended to assist in supporting pressure ulcer risk assessment and prevention education. These are examples of resources only, and are not intended to be a comprehensive listing.
Joanna Briggs Institute: www.joannabriggs.edu.au/about/home.php
The Joanna Briggs Institute was established to address the need for a collaborative approach to the evaluation of evidence derived from a diverse range of sources, including experience, expertise and all forms of rigorous research and the translation, transfer and utilization of the "best available" evidence into health care practice.

# Appendix I: Monitoring Tools
Tools that facilitate the monitoring of client outcomes and the quality of care need to be integrated into quality management processes. The following samples of monitoring tools have not been extensively tested, however they are provided as examples for organizations to consider in their implementation process.

# Definition of Terms
The following terms are addition/update to the "Definition of Terms" found on page 18 of the 2005 guideline.
Alternating Pressure: "A feature of a support surface that provides pressure redistribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude, and rate of change parameters" (NPUAP, 2006, p.4).
The "ability of a support surface to conform to irregularities in the body" (NPUAP & EPUAP, 2009, p. 127).
Friction: "The resistance to motion in a parallel direction relative to the common boundary of two surfaces."
(National Pressure Ulcer Advisory Panel, 2007, p.124).
The "depth of penetration (sinking) into a support surface" (NPUAP & EPUAP, 2009, p. 127).
Incidence of Pressure Ulcer: New pressure ulcer cases appearing during a specified period in the "at risk" population identified in the prevalence survey. For instance, a surgical nursing unit that had admitted 100 patients over a period of a month and showed documentation of 10 ulcers would have an incidence rate of 10 per cent. Definition of quality improvement purposes may take into account all new occurrences even if it is a multiple occurrence during the

# Appendix B: Skin Assessment
The word "comprehensive" is added in the first paragraph to emphasize that skin inspection should be based on a comprehensive head-to-toe assessment.
The following bullet point is added to the list of typical vulnerable areas to assess.
- Parts of the body in contact with devices, such as taping, restraint, tubes,etc.

# Appendix C:
Additional tools for assessment of pressure ulcer risks are added.

# Reprinted with permission from Wolters Kluwer Health
From the list provided, make a check mark next to the prevention intervention that you think should be implemented for this patient based on YOUR assessment.

# Appendix K: InterRAI Pressure Ulcer Risk Scale