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

Pressure Injuries

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  • RNAO BPG - Assessment and Management of Pressure Injuries for the Interprofessional Team, Third
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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

  • RNAO BPG Gap Analysis- Assessment and Management of Pressure Injuries for the Interprofessional
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    A tool to assist with comparing your organization’s current practice with evidence-based RNAO best practice recommendations.

    Registered Nurses Association of Ontario (2022) Gap Analysis-Assessment and Management of Pressure Injuries for the Interprofessional Team. Toronto. ON

  • Abbey Pain Scale
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    The Abbey Pain Scale is an instrument designed to assist in the assessment of pain in patients who are unable to clearly articulate their needs, for example, patients with dementia, cognition or communication issues. The scale does not differentiate between distress and pain, so measuring the effectiveness of pain-relieving interventions is essential.

    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.

    https://www.apsoc.org.au/PDF/Publications/Abbey_Pain_Scale.pdf

     

     

     

     

     

     

     

     

     

  • Assessment for Infection – RNAO Appendix K (PI)
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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.

  • Assessment of Goals of Care – RNAO Appendix P (PI)
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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.

  • Bates-Jensen Wound Assessment Tool© (BWAT)
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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. 

    Retrieved from: https://www.woundscanada.ca/docman/public/health-care-professional/1428-bwat/file 

    Reference: Bates-Jensen, Barbara (2001). Bates-Jenson Wound Assessment Tool (BWAT). Copyright 2001 Barbara Bates-Jensen

  • Braden Risk Assessment Scale
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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

  • Cleansing Solutions – RNAO Appendix R (PI)
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    A list of cleansing solutions and their actions for chronic wounds (including pressure injuries), identified by an expert panel and stakeholders providing feedback.

    Reference: Registered Nurses’ Association of Ontario. (2016). Appendix R of Assessment and Management of Pressure Injuries for Interprofessional Team, Third Edition. Toronto, Canada: R. G. Sibbald, H. Orsted, P. M. Coutts and D. H. Keast. Pp 147. http://rnao.ca/sites/rnao-ca/files/PI_BPG_FINAL_WEB_June_10_2016.pdf

  • Dressing Categories and Indications for Use – RNAO Appendix S (PI)
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    This resource uses a generic classification to describe wound dressings, local wound care outcomes and care considerations.

    Web Source: Appendix S of Assessment and Management of Pressure injuries for the Interprofessional Team, Third Edition http://rnao.ca/sites/rnao-ca/files/PI_BPG_FINAL_WEB_June_10_2016.pdf 

    Reference: Registered Nurses’ Association of Ontario. (2016). Appendix S of Assessment and Management of Pressure Injuries for Interprofessional Team, Third Edition. Toronto, Canada: R. G. Sibbald, J. A. Elliott, E. A. Ayello, and R. Somayaj Glasgow P.148

  • Educational Workshop for Unregulated Care Providers: Assessment and Management of pressure
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    This resource has been designed to teach Registered Nurses (RNs), Registered Practical Nurses (RPNs) and Unregulated Care Providers how to implement the recommendations outlined in the RNAO Best Practice Guideline, Assessment and Management of Stage I to IV Pressure Ulcers.

    There are two parts to this program; Part A is directed towards RNs and RPNs while Part B is aimed towards Unregulated Care Providers (UCP). These materials are for use by the workshop facilitator, and include a list of components, questionnaires and case studies for participants, and answer keys.

    Retrieved from: http://rnao.ca/bpg/guidelines/resources/assessment-and-management-pressure-ulcers-education-program

  • Key Factors in Deciding the Method of Debridement – RNAO Appendix U (PI)
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    This resource outlines the key factors in deciding the method of debridement. Includes definition and examples of debridement. Taken from RNAO's Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition Best Practice Guideline, (Appendix U, pp 151

    Reference: Registered Nurses’ Association of Ontario (2007). Appendix U - Key Factors in Deciding Method of Debridement. RNAO Assessment & Management of Pressure Injuries for the Interprofessional Team, Third Edition Best Practice Guideline. Toronto, Canada. Sibbald, Orsted et al. Page 151 http://rnao.ca/sites/rnao-ca/files/PI_BPG_FINAL_WEB_June_10_2016.pdf

  • List of Topical Antimicrobial and Antispetic Agents – RNAO Appendix T (PI)
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    This resource provides a non-exhaustive list of topical antiseptic agents and their effects on wounds. This list was identified by experts and stakeholder feedback

    Reference: Registered Nurses’ Association of Ontario. (2016). Appendix T of Assessment and Management of Pressure Injuries for Interprofessional Team, Third Edition. Toronto, Canada: R. Sibbald, J. A. Elliott, E. A. Ayello, and R. Somayaji, P.150 http://rnao.ca/sites/rnao-ca/files/PI_BPG_FINAL_WEB_June_10_2016.pdf

  • McCaffrey Initial Pain Assessment Tool
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    This tool can be used to guide healthcare professionals with assessment of patient pain. It includes diagrams of the human body to help patients locate the pain they experience and questions to prompt the patient to describe the intensity, quality, causes, effects, and contributing factors of their pain.

    Retrieved from: https://www.sdsma.org/resources/PrescriptionDrugsToolkit/Patient%20Assessment%20Tool%20-%20McCaffrey%20Initial%20Pain%20Assessment%20-%2020170814.pdf

    Reference: McCaffrey M, Pasero C. (1999). McCaffrey Initial Pain Assessment Tool

  • National Pressure Injury Advisory Panel (NPIAP) - Website
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    The National Pressure Injury Advisory Panel (NPIAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research.

    Website: https://learn.npiap.com 

  • NPUAP Pressure Injury Stages
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    NPUAP Pressure Injury Stages webpage provides definitions for the new pressure injury stages.

    Reference: National pressure ulcer advisory panel (n.d.). NPUAP Pressure Injury Stages. Copyright 2013. Retrieved from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/

  • Numeric Pain Scale (NRS)
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    Asks persons to rate their pain from 0 to 10

    • Scored 0-10 with the anchors of 0 being ‘no pain’ and 10 being ‘pain as bad as it can be’ Used in adults, older adults, and adolescents and children over age 8.
    • Well established evidence of reliability, validity, and ability to detect change
    • No equipment is needed to administer this measure
    • High feasibility (quick and easy to use)

     

    Reference:

    Registered Nurses’ Association of Ontario. (2013). Appendix E of Assessment and Management of Pain, Third Edition.Toronto, Canada: Author. 81-82.

    McCaffery, M., Beebe, A., et al. (1989). Pain: Clinical manual for nursing practice, Mosby St. Louis, MO

  • Nutrition Screening and Assessment Tools - RNAO Appendix M (PI)
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    This table discusses two tools which can provide a quick assessment of nutrition status: Canadian Nutrition Screening Tool and the Subjective Global Assessment

    Reference: Registered Nurses Association of Ontario (RNAO). 2016. Appendix M: Nutrition Screening and Assessment Tools. 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. 138.

  • Ontario Regulation 246/22
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    Ontario Regulation 246/22 was made under The Fixing Long-Term Care Act, 2021 (FLTCA) was proclaimed into force to regulate Ontario's long-term care home sector April 11, 2022.

    Government of Ontario (2022) Ontario Regulation 246/22. Toronto ( ON) retrieved from O. Reg. 246/22: GENERAL (ontario.ca)

  • Ontario Wound Interest Group - Website
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    This link to the RNAO Interest Group website leads to resources and information regarding the benefits of membership and the role of interest group members in leading, promoting and influencing wound related public policy in Ontario.

    Reference: Ontario Wound Interest Group. Website http://ontwig.rnao.ca

  • Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
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    PACSLAC is a tool to observe and assess both common and subtle pain behaviours. Copyright © Shannon Fuchs-Lacelle and Thomas Hadjistavropoulos. The PACSLAC may not be reproduced without permission. For permission to reproduce the PACSLAC, please contact the copyright holders (Thomas.Hadjistavropoulos@uregina.ca).

    Retrieved from http://www.geriatricpain.org/content/Assessment/Impaired/Pages/default.aspx

  • Pain Assessment in Advanced Dementia (PAINAD) Scale
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    This resource from Interior Health, is a pain assessment tool useful for scoring pain levels of people with dementia who are unable to verbally express their pain. It focuses on assessing behaviours and provides a score rating of mild, moderate or severe pain levels.

    Retrieved from: https://www.interiorhealth.ca/sites/default/files/PDFS/810310-pain-assessment-advance-dementia-scale.pdf

    Warden, V., Hurley, A. & Volicer. L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. JAMDA, 4(1), 9 -15. Horgas, A., & Miller, L. (2008). Pain assessment in people with dementia. American Journal of Nursing, 108(7), 62-70.

     

  • Pain Assessment Tools – RNAO Appendix N (PI)
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    The following is not an exhaustive list of pain assessment tools but rather suggestions of tools identified within the systematic review; AGREE II appraised guidelines, by the expert panel or external stakeholder feedback.

    Reference: Registered Nurses 'Association of Ontario. (2016). Appendix N of Assessment and Management of Pressure Injuries for the Interprofessional Team. Toronto, Canada: Author. pp 139. http://rnao.ca/bpg/guidelines/pressure-injuries

  • Photographic Wound Assessment Tool (PWAT) – Revised
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    The Photographic Wound Assessment Tool© (PWAT) Revised is a valid and reliable tool for assessing wound status over time, recognizing that standardized equipment and a consistent technique should be used with serial wound photography.

    Reference: Hodgkinson, Bowles H, Gordey L, Parslow N, and Houghton P. 2010. Photographic Wound Assessment Tool (PWAT) Revised. http://www.southwesthealthline.ca/healthlibrary_docs/B.9.3b.PWATInstruc.pdf

  • Pressure Injury Assessment Tools – RNAO Appendix I (PI)
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    This table is an overview and comparison of the strengths and weakness of wound assessment tools including the: Pressure Ulcer Scale for Healing (PUSH); Photographic Wound Assessment Tool (PWAT); and the Bates-Jensen Wound Assessment Tools.

    Reference: Registered Nurses Association of Ontario (RNAO). 2016. Appendix I: Pressure Injury Assessment Tools. In Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition http://rnao.ca/sites/rnao-ca/files/PI_BPG_FINAL_WEB_June_10_2016.pdf

  • Pressure Injury Staging Illustrations - NPUAP
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    This webpage provides links to illustrations for each of the new pressure injury stages.

    Copyright: These illustrations can be downloaded by clicking on the links below directly to your computer at no cost, if for educational purposes. There is no cost to use these illustrations; however donations to support the work of NPUAP are graciously accepted. For profit uses of the drawings are subject to a charge, please contact Jen Bank for more information. **Use of drawings is permitted for educational purposes only.

    Reference: National pressure ulcer advisory panel (n.d.). Pressure Injury Staging Illustrations. Retrieved from http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/

  • Pressure Ulcer Risk Scale – RNAO Appendix K (Risk Assessment)
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    This tool identifies seven areas related to PURS assessment. A high score indicates high risk for pressure ulcer.

    Registered Nurses’ Association of Ontario. (2011) Appendix K of Risk assessment and prevention of pressure ulcers: Guideline Supplement. Toronto, Canada. P.40. Retrieved from:

    http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
     

     

  • Pressure Ulcer Scale for Healing (PUSH Tool)
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    Pressure Ulcer Scale for Healing (PUSH) Tool 3.0 was developed by the National Pressure Ulcer Advisory Panel (NPUAP) as a valid and reliable tool to assess the change in status of pressure ulcers over time.

    The link takes you to the NPUAP website where you will find the tools and information on use and copyright.

    • PUSH Tool (web version)
    • PUSH Tool (PDF version)
    • Reprint Agreement (PDF)
    • Information and Resgistration Form
    • Instructions for Using PUSH
    • Copyright Policy and Contract

    Reference: National Pressure Ulcer Advisory Committee (1998). Accessed Sept. 14, 2016. Retrieved from: http://www.npuap.org/resources/educational-and-clinical-resources/push-tool/

  • Pressure Ulcers - Change Concepts and Ideas - HQO
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    This table developed through the Residents First Initiative provides examples of clinical and organizational change strategy options in the area of pressure ulcers.
    Health Quality Ontario. (2011, February). Pressure Ulcers – Clinical and Organizational Change Concepts and Ideas.
    Retrieved from: http://www.hqontario.ca/quality-improvement/long-term-care/tools-and-resources

  • Pressure Ulcers - Change Poster - HQO
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    This poster outlines key steps in the development of a pressure ulcer Quality Improvement plan. The poster is intended for use as a worksheet that can support the needs of individual organizations.

    Reference: Health Quality Ontario, (2011), Pressure Ulcer Change Poster, http://www.hqontario.ca/portals/0/Documents/qi/rf-poster-pressure-ulcers-en.pdf

     

  • Progression from Bacterial Balance to Bacterial Damage – RNAO Appendix J (PI)
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    This table uses graphs, pictures and words to illustrate the impact of high, medium and low bacterial contamination/colonization on wound healing.

    Reference: Registered Nurses Association of Ontario (RNAO). 2016. Appendix J: Progression from Bacterial Balance to Bacterial Damage. 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.130-133.

  • Seating Assessment – RNAO Appendix O (PI)
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    The following is one method of how to perform a seating assessment for people with pressure injuries. This is not an exhaustive list but rather an example of a seating assessment identified within the systematic review, AGREE II appraised guidelines, by the expert panel or external stakeholder feedback. The term “pressure ulcer” used in this appendix, refers to “pressure injury.”

    Reference: Registered Nurses 'Association of Ontario. (2016). Appendix O of Assessment and Management of Pressure Injuries for the Interprofessional Team. Toronto, Canada: Author. pp 140-141.

  • Support Surface Selection Tool – RNAO Appendix Q (PI)
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    The following is one method of how to select the appropriate support surface for people with pressure injuries. This is not an exhaustive list but rather an example of a tool for support surface selection identified within the systematic review, AGREE II appraised guidelines, by the expert panel or external stakeholder feedback. The term “pressure ulcer” used in this appendix, refers to “pressure injury.”

    Reference: Registered Nurses 'Association of Ontario. (2016). Appendix Q of Assessment and Management of Pressure Injuries for the Interprofessional Team. Toronto, Canada: Author. pp 143-146.

  • Swabbing Technique – RNAO Appendix L (PI)
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    This appendix describes the Levine technique, a method of obtaining a semi-quantitative wound culture swab in order to guide the use of appropriate anti-infective agents

    Reference: Registered Nurses Association of Ontario (RNAO). 2016. Appendix L: Swabbing Technique. 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. 137.

  • Taking the Pressure Off – Preventing Pressure Ulcers – RNAO Fact Sheet
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    Pressure ulcers or bedsores are caused by constant pressure that damages the skin and underlying tissue. They can develop in a very short time period and take longer to heal. They may have a huge impact on your every day life, as normal activities can be restricted while the ulcer heals.

    If you spend long periods of time in a bed, chair or wheelchair and have lost your feeling in your lower body, you maybe at increased risk of getting pressure ulcers. In most cases, pressure ulcers can be prevented.

    Retrieved from: http://rnao.ca/bpg/fact-sheets/taking-pressure-preventing-pressure-ulcers