Nursing Best Practice Guidelines

Risk Assessment and Prevention of Pressure Ulcers

Background Information
Node Name	Weight
Purpose & Scope
Pressure Ulcers Defined

Practice Recommendations
Node Name	Weight
Practice Recommendations
Levels of Evidence

Point of Care Resources
Node Name	Weight
Pain on Local Tissues Perfusion
Skin Integrity
Head-to-Toe Skin Assessment
Plan of Care
Proper positioning, transferring and turning techniques
Bed Rest
Nutrition and Hydration
Risk Assessment Tools
Clients Restricted to Bed and/or Chair
Transfer of Care Arrangements
Pressure Management Surfaces
Re-Positioning Schedule

Sample Tools
Node Name	Weight
Braden Scale for Predicting Pressure Sore Risk
Consensus Statement Skin Changes at Life’s End (SCALE)
Skin Assessment
Standardized Systems and Language to Identify Pressure Ulcers
InterRAI Pressure Ulcer Risk Scale

Client and Family Education
Node Name	Weight
Taking the Pressure Off: Preventing Pressure Ulcers Health Education Fact Sheet
References