Summary of Practice Recommendations

RECOMMENDATION

*Type of Evidence

Status

1.0

Assessment

Recommendation 1.1:

Conduct a health history, a psychosocial history, and a physical exam on initial examination and whenever there is a significant change in the person’s medical status.

V

+

Recommendation 1.2:

Assess the risk for developing additional pressure injuries on initial examination and if there is a significant change in the person’s medical status using a valid and reliable pressure injury risk assessment tool.

V

+

Recommendation 1.3:

Assess the person’s pressure injury using the same valid and reliable wound assessment tool on initial examination and whenever there is a significant change in the pressure injury.

V

+

Recommendation 1.4:

Assess the person’s pressure injury for signs and symptoms of infection (superficial critical colonization/localized infection and/or deep and surrounding infection/systemic infection) using a standardized approach on initial examination and at every dressing change.

V

+

Recommendation 1.5:

a) Screen all persons with pressure injuries for risk of malnutrition using a valid and reliable screening tool on first examination and if there is a delay in pressure injury healing.

b) Determine the nutritional status of all persons at risk for malnutrition using a valid and reliable assessment tool within 72 hours of initial examination, and whenever there is a change in health status and/or the pressure injury.

c) Perform a comprehensive nutrition assessment of all persons with poor nutritional status within 72 hours of initial examination, and if there is a change in health status or delayed healing.

V

NEW

Recommendation 1.6:

Assess for pressure injury pain on initial examination and continue to monitor pain at subsequent visits, including prior to and after every wound care intervention, using the same valid and reliable tool consistent with the person’s cognitive ability.

V

+

Recommendation 1.7:

Perform a vascular assessment (i.e., medical history, physical

exam) of all persons with pressure injuries in the lower extremities on initial examination.

V

+

Recommendation 1.8:

Conduct a mobility and support surface assessment on initial examination and whenever there is a significant change in the person’s medical condition, weight, equipment, mobility, and/ or pressure injury healing.

V

+

2

Planning

Recommendation 2.1:

Obtain the referral or consultations required to plan and coordinate a pressure injury plan of care.

V

+

Recommendation 2.2:

Develop a pressure injury plan of care that incorporates goals mutually agreed upon by the person, the person’s circle of care, and the interprofessional team.

Ia

+

3

Implementation

Recommendation 3.1:

Reposition the person at regular intervals (i.e., every two to four hours) based on person-centred concerns. While sitting, weight-shift the person every 15 minutes.

V

+

Recommendation 3.2:

Position all persons with a pressure injury on a pressure redistribution support surface at all times.

V

+

Recommendation 3.3:

Implement an individualized nutritional plan of care in collaboration with the person and his/her circle of care that addresses nutritional requirements and provides adequate protein, calories, fluid, and appropriate vitamin and mineral supplementation to promote pressure injury healing.

V

+

Recommendation 3.4:

Provide local pressure injury care consisting of the following,

as appropriate:

 cleansing (level of evidence = V);

 moisture balance (healable) or moisture reduction (nonhealable,

maintenance) (level of evidence = Ia–b, V);

 infection control (i.e., superficial critical colonization/localized infection and/or deep and surrounding infection/systemic infection) (level of evidence Ia-b, V);and

 debridement (level of evidence = V).

la, lb, V

+

Recommendation 3.5:

Provide electrical stimulation (when available) as an adjunct to best practice wound care in order to speed healing and promote wound closure in stalled but healable stage 2, 3, and 4 pressure injuries.

Ia

+

Recommendation 3.6:

Implement, as an alternative, the following treatments in order to

speed closure of stalled but healable pressure injuries, as appropriate

and if available:

 electromagnetic therapy (level of evidence = Ib),

 ultrasound (level of evidence = Ib), and

 ultraviolet light (level of evidence = Ib).

Do not consider the following treatment in order to speed closure of

stalled but healable pressure injuries:

 laser therapy (not recommended) ***STOP PRACTICE***

Ib

+

Recommendation 3.7:

Provide negative pressure wound therapy to people with stage 3 and

4 pressure injuries in exceptional circumstances, including enhancement of quality of life and in accordance with other person-/family-centred preferences.

V

+

Recommendation 3.8:

Collaborate with the person and his/her circle of care to implement a pressure injury self-management plan.

Ia

+

Recommendation 3.9:

Implement a person-centred pain management plan using pharmacological and non-pharmacological interventions.

V

+

4

Evaluation

Recommendation 4.1:

Use the initial risk assessment tool to reassess the person’s risk for developing additional pressure injuries on a regular basis and whenever a change in the person’s health status occurs.

V

NEW

Recommendation 4.2:

Use the initial wound assessment tool to monitor the person’s pressure injuries for progress toward person-centred goals on a regular basis and at dressing changes.

V

+