- Skin inspection should be based on a head-to-toe assessment of those areas known to be vulnerable for each patient
- Locations of pressure ulcer development:
- Prone positioning and non-invasive facemask ventilation
- Anterior weight bearing sites including the face, thorax, iliac crest, breast and knee
- 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
- 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
- Parts of the body in contact with equipment
- Intensive Care Unit patients à sacrum, coccyx and heels
- Additional areas should be inspected as determined by the individual’s condition
- The following notes the timeline for when pressure ulcers can develop in specific clinical settings:
- Acute Care: Within the first two weeks of hospitalization
- Intensive Care Unit: 72 hours from admission
- Home Health Care: First four weeks of admission to agency
- Long Term Care: First four weeks of admission
- Palliative Care: Within two weeks prior to death
- Elderly Clients: First week of hospitalization
- Critically Ill Children: First day of admission to hospital
Clinical Management
Risk Assessment and Prevention of Pressure Ulcers
Point of Care Resources