Implementing and sustaining evidence-based practices in long-term care.

Pressure Injuries

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    The purpose of this Guideline is to present evidence-based recommendations that apply to the decisions and best practices of interprofessional teams working to assess and manage existing pressure injuries in people 18 years of age and above. This Best Practice Guideline (BPG) replaces the RNAO BPG Assessment and Management of Stage I to IV Pressure Ulcers (2007). It provides evidence-based practice, education and policy recommendations for interprofesssional teams across all care settings who are assessing and providing care to people with existing pressure injuries. Moreover, this Guideline refers to “pressure ulcers” as “pressure injuries.” This new terminology aligns with the National Pressure Ulcer Advisory Panel (NPUAP).

    This Guideline provides best practice recommendations in three main areas:

    • Practice recommendations are directed primarily to the front-line interprofessional teams who provide care for people with existing pressure injuries across all practice settings.
    • Education recommendations are directed to those responsible for interprofessional team and staff education, such as educators, quality improvement teams, managers, administrators, and academic institutions.
    • System, organization, and policy recommendations apply to a variety of audiences, depending on the recommendation. Audiences include managers, administrators, policy-makers, health-care professional regulatory bodies, and government bodies.

    Registered Nurses’ Association of Ontario. (2016). Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition. Toronto, ON: Author. Retrieved from: http://rnao.ca/bpg/guidelines/pressure-injuries

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    Define early interventions for pressure ulcer prevention, and to manage Stage I pressure ulcers.

    This best practice guideline assists nurses who work in diverse practice settings to identify adults who are at risk of 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 • 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.

    Revised: 2011 Supplement: 2005

    This best practice guideline assists RN’s and RPN’s to identify adults who are at risk for pressure ulcers and provides direction to nurses in defining early interventions.

    Registered Nurses’ Association of Ontario (2013). Risk Assessment and Prevention of Pressure Ulcers Best Practice Guideline (rev.2011) Toronto, ON: Author. Retrieved from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers

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    Pressure Injury Gap Analysis

    Organizational assessment tool to assist with implementation and evaluation of the RNAO Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition by comparing current practice to evidence-based practice.
    Source: Registered Nurses' Association of Ontario's Long-Term Care Best Practices Program, Toronto, ON. 2016. Retrieved from http://rnao.ca/bpg/guidelines/pressure-injuries

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    Pressure Ulcer Gap Analysis

    Organizational assessment tool to assist with implementation and evaluation of the RNAO Risk Assessment & Prevention of Pressure Ulcers by comparing current practice to evidence-based practice.
    Source: Registered Nurses' Association of Ontario's Long-Term Care Best Practices Program, Toronto, ON. September 2013.

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    Abbey Pain Scale is an assessment tool for the measurement of pain in people with dementia who cannot verbalize

    Source: Dementia Care Australia Pty Ltd. Website: www.dementiacareaustralia.com

    Reference: Abbey, J; De Bellis, A; Piller, N; Esterman, A; Giles, L; Parker, D and Lowcay, B. Funded by the JH & JD Gunn Medical Research Foundation 1998 – 2002 (This document may be reproduced with this acknowledgment retained)Retrieved from: http://www.wales.nhs.uk/sitesplus/documents/862/FOI-286f-13.pdf

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    This resource describes two mnemonics for wound assessment. ‘NERDS’ is used to systematically assess for superficial critical colonization (localized infection) and STONEES to access deeper and surrounding infection (systemic infection) in people with pressure injuries. NERDS: N – non-healing wound; E – exudate; R – red and bleeding. D – debris; and S – smell. STONEES: S – size; T – temperature: O – os; N – new or satellite areas of breakdown: E – exudate; E – erythema and/or edema (cellulitis); and S – smell.

    Reference: Registered Nurses Association of Ontario (RNAO). 2016. Appendix K: Assessment for Infection. Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition. Accessed July 28, 2016 http://rnao.ca/sites/rnao-ca/files/PI_BPG_FINAL_WEB_June_10_2016.pdf  pp. 135-136.

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    The following is not an exhaustive list of methods on assessing a person’s goals of care. This mnemonic has been suggested as an example identified within the systematic review, AGREE II appraised guidelines, by the expert panel or external stakeholder feedback. It is an example of how to identify the goals of symptom management in people for whom wound healing is not a clinical expectation and where maintaining the person’s comfort is key

    Reference: Registered Nurses 'Association of Ontario. (2016). Appendix P of Assessment and Management of Pressure Injuries for the Interprofessional Team. Toronto, Canada: Author. pp 139.

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    Bates-Jenson Wound Assessment Tool (BWAT) is a validated tool that measures the status of a wound. It is most appropriate for use by experienced wound-care clinicians as a discriminative tool to fully describe wounds during the initial wound assessment. 

    Copyright 2001 Barbara Bates-Jensen

    Reference: Bates-Jensen, Barbara (2001). Bates-Jenson Wound Assessment Tool (BWAT). Retrieved from: http://geronet.med.ucla.edu/centers/borun/modules/Pressure_ulcer_prevention/puBWAT.pdf

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    This one page document describes the areas that should be assessment when using medical devices in LTC in order to prevent pressure related injuries.

    Reference: National pressure ulcer advisory panel (2013). Best Practices for prevention of medical device-related pressure ulcers in long-term care . Copyright 2013. Retrieved from http://www.npuap.org/wp-content/uploads/2013/04/BestPractices-LongTermCare1.pdf

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    The Braden Scale can be used to assess a resident’s level of risk for developing pressure injuries by evaluating six areas of risk: sensory perception, moisture, activity, mobility, nutrition, and friction or shear.

    Reference: Braden Scale (1988). Retrieved from http://www.education.woundcarestrategies.com/coloplast/resources/BradenScale.pdf

    © Copyright Barbara Braden and Nancy Bergstrom, 1988