Pressure Injuries

The purpose of this guideline is to provide nurses, members of the interprofessional team and other collaborators (i.e., administrators and policy-makers) with evidence-based recommendations for risk assessment, prevention, and treatment of pressure injuries . 

This BPG provides evidence-based recommendations for nurses, and the interprofessional team, and persons and their caregivers across all care settings and sectors. The recommendations address the prevention of pressure injuries for at-risk people, and the assessment and management of those living with pressure injuries.

Overall, the scope includes: all domains of nursing practice; all health-care settings and sectors; all populations across the lifespan (e.g., pediatric, adult and older adult), including their caregiver/chosen family and all types of pressure injuries, including those medical device-related.

Registered Nurses’ Association of Ontario. (2024).   Pressure injury management: Risk assessment, prevention and treatment, Fourth Edition. Toronto, ON: Author. Retrieved from: https://rnao.ca/bpg/guidelines/pressure-injuries

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

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

The Leading Change Toolkit includes two frameworks- the Social Movement Action (SMA) Framework and the Knowledge-to-Action (KTA) Framework. Both frameworks outline the concept of implementation and its interrelated components. The toolkit is based on available evidence, theoretical perspectives and consensus. We recommend the Leading Change Toolkit for guiding the implementation of any BPG in health care or social service organizations, including academic centres.

Reference: Registered Nurses’ Association of Ontario, (2024). Appendix R of Pressure injury management: Risk assessment, prevention and treatment - Fourth edition. Toronto, Canada: Author. pp. 118-119.

RNAO clinical BPGs included education recommendations directed to those responsible for the academic and in-service education of nursing students, nurses and the interprofessional team. These recommendations outlined core content and training strategies required for entry-level health programs, continued education and professional development.

Reference: Registered Nurses’ Association of Ontario, (2024). Appendix D of Pressure injury management: Risk assessment, prevention and treatment - Fourth edition. Toronto, Canada: Author. pp. 92-96.

Emerging health technologies for assessment and detection, outlines additional or emerging health technologies which may be available for the assessment and early detection of pressure injuries. It does not represent an exhaustive list.

Reference: Registered Nurses’ Association of Ontario, (2024). Appendix L of Pressure injury management: Risk assessment, prevention and treatment - Fourth edition. Toronto, Canada: Author. pp. 108-109.

This resource from the Canadian Nutrition Society, is an example of a nutrition screening tool which can be used to identify those who may be at risk for malnutrition.

Reference: Registered Nurses’ Association of Ontario, (2024). Appendix J of Pressure injury management: Risk assessment, prevention and treatment - Fourth edition. Toronto, Canada: Author. pp. 104-105.

This resource illustrates two examples of wound care frameworks: the wound bed preparation paradigm, reprinted with permission from Sibbald RG, Elliott JA, Persaud-Jaimangal R, et al. Wound Bed Preparation 2021. Adv Skin Wound Care. 2021 Apr 1;34(4):183–95.

And, the wound prevention and management cycle, reprinted with permission from Orsted HL, Keast DH, Forest-Lalande L, et al. Best practice recommendations for the prevention and management of wounds. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017. 74 pp. Available from: https://www. woundscanada.ca/docman/public/health-care-professional/bpr-workshop/165-wc-bpr-prevention-and-management-of-wounds/file 

Reference: Registered Nurses’ Association of Ontario, (2024). Appendix D of Pressure injury management: Risk assessment, prevention and treatment - Fourth edition. Toronto, Canada: Author. pp. 97-98.

A two-page summary of the European Wound Management Association (EWMA) guidance on holistic management of wound-related pain. It includes a decision-aid to guide holistic management of wound-related pain.
Source: Reprinted with permission from: The European Wound Management Association. Holistic management of wound-related pain. J Wound Management. 2024; 24 (1 Sup 1). Available from: http://https://ewma.org/wp-content/uploads/2024/04/A4_Holistic-one-page_030424.pdf

Reference: Registered Nurses’ Association of Ontario, (2024). Appendix K of Pressure injury management: Risk assessment, prevention and treatment - Fourth edition. Toronto, Canada: Author. pp 106-107.

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

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

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

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.

Pan Pacific Pressure Injury Alliance outlines some considerations for risk assessment and treatment of pressure injuries in people with dark skin tones. Additionally, it includes classification based on the NPIAP/EUPAP classification system with examples of each stage in people with dark skin tones.

Source: Reprinted with permission from: Pan Pacific Pressure Injury Alliance (PPPIA). Pressure ulcers in people with dark skin tones: PPPIA; 2014. Available from: https://talleygroup.com/medias/documents/PPPIA-Pressure-Ulcers-in-People-with-Dark-Skin-Tones-PosterA3L-01604484440.pdf   Reference:

Registered Nurses’ Association of Ontario, (2024). Appendix I of Pressure injury management: Risk assessment, prevention and treatment - Fourth edition. Toronto, Canada: Author. pp. 103.

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/

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

Examples of 4 pressure injury risk assessment tools, however this list is not an exhaustive. These tools were identified, by the expert panel and external reviewers or through the systematic review process. The most common, valid, and reliable wound assessment tools for use in adults are the following (not in order of importance):

Braden scale; Norton scale; interRAI Pressure Ulcer Risk Scale (PURS) and the Waterlow scale.

Source: Table adapted from Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline 2019. interRAI PURS Pressure Ulcer Risk Scale (PURS) from Canadian Institute for Health Information. interRAI Home Care (HC) Outcome Scales [job aid]. Ottawa, ON: CIHI; 2024

Reference: Registered Nurses’ Association of Ontario, (2024). Pressure injury management: Risk assessment, prevention and treatment - Fourth edition. Toronto, Canada: Author. pp. 100-101.

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