Registered Nurses' Association of Ontario

Practice Recommendations

                                        Practice Recommendations
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. Ia
1.2a 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 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. III
1.2 b Assess for intrinsic/extrinsic risk factors that are associated with the development of pressure ulcers. III
1.3 Assessment scales to assess and re-assess risk for skin breakdown and overall skin condition specific to vulnerable populations such as the elderly, palliative patients, the neonate/the child, spinal cord injured patients, and bariatric patients should be considered. III
1.4 Assessment and documentation of skin changes amongst palliative patients at the end of life should be conducted as recommended by the consensus statement Skin Changes At Life’s End (SCALE). IV
1.5 All sectors of the health care system, programs, and services should conduct risk assessments and re-assessments to plan prevention strategies that will minimize the risk of pressure ulcer development. IV
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). IV

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.

1.7 All findings should be documented at the time of assessment and reassessment. IV
                                   2.0 PLANNING RECOMMENDATIONS
2.1 An individualized plan of care should be developed in collaboration with the client, significant others and an interdisciplinary team, including consulting health care providers as appropriate. The team uses assessment and reassessment data in combination with clinical judgment to identify risk factors and to recommend the plan of care. Client centered care aligns with the recommendations and the client’s choice of goals. IV
                         3.0 INTERVENTION RECOMMENDATIONS
3.1a Clients identified to be at risk for developing a pressure ulcer should be resting on a pressure management surface such as a high-specification foam pressure redistribution mattress. Ia
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. Ia
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. III
3.3 Use proper positioning, transferring and turning techniques. Consult an Occupational or Physical Therapist (OT/PT) regarding transfer and positioning techniques and strategies, as well as devices to reduce pressure friction and shear in all positions, and how to optimize client independence. Ib
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. IV
3.5 Massaging over bony prominences and reddened areas should be avoided. IV
3.6 Implementation of intraoperative pressure management devices is recommended for surgical procedures lasting more than 90 minutes. Ib

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.
3.7b Complete bed rest is not recommended for the prevention and healing of pressure ulcers. Determine the rationale for bed rest and focus on getting the client up into an appropriate wheelchair for part of the day, as appropriate. III

Protect skin from excessive moisture and incontinence to maintain skin integrity:

• Monitor fluid intake to ensure adequate hydration;

• Use a pH balanced, non-sensitizing skin cleanser with warm water for cleansing;

• Minimizing force and friction during care (e.g. use a soft wipe or spray cleanser);

• Maintain skin hydration by applying moisturizing agents that are non-sensitizing, pH balanced, fragrance free and/or alcohol free;

• Use topical protective barriers to protect skin from moisture. Avoid ingredients and excess application of products that may compromise the absorptive capacity of the incontinent brief;

• Use protective barriers (e.g. liquid barrier films, transparent films, hydrocolloids) or protective padding to reduce friction injuries;

 • If skin irritation persists due to moisture, consult with advanced practice nurses and/or with the appropriate interdisciplinary team for evaluation and topical treatment; and/or

• Establish a bowel and bladder program.


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.
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. IV

Provide the following information for clients moving between care settings:

• Risk factors identified;

• Details of pressure points and skin condition prior to discharge;

• Current plan to minimize pressure, friction and shear:

- Type of bed/mattress

- Type of seating

- Current transfer techniques used by the client (bed-chair-commode);

• History of ulcers, previous treatments, products used and products not effective:

- Stage/Category, site and size of existing ulcers

- Type of dressing currently used and frequency of dressing change

 - Allergies and adverse reactions to wound care products

 - Summary of relevant laboratory results

 - Client and family response/ adherence to prevention and treatment plan

- Requirement for pain management;

• Details of ulcers that are closed; and

• Need for on-going interprofessional support.



Clinical Management
Risk Assessment and Prevention of Pressure Ulcers
Practice Recommendations