Prevention and Treatment of Pressure Ulcers/Injuries

Publication Date: November 1, 2019
Last Updated: March 14, 2022

Recommendations

Risk Factors and Risk Assessment

1.1 Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries. (A, ↑↑)
348298
1.2 Consider individuals with a Category/Stage I pressure injury to be at risk of developing a Category/Stage II or greater pressure injury. (A, ↑↑)
348298
1.3 Consider the potential impact of an existing pressure injury of any Category/Stage on development of additional pressure injuries. (C, ↑)
348298
1.4 Consider the potential impact of a previous pressure injury on additional pressure injury development. (GPS, )
348298
1.5 Consider the potential impact of alterations to skin status over pressure points on pressure injury risk. (GPS, )
348298
1.6 Consider the potential impact of pain at pressure points on pressure injury risk. (GPS, )
348298
1.7 Consider the impact of diabetes mellitus on the risk of pressure injuries. (A, ↑↑)
348298
1.8 Consider the impact of perfusion and circulation deficits on the risk of pressure injuries. (B1, ↑)
348298
1.9 Consider the impact of oxygenation deficits on the risk of pressure injuries. (C, ↑)
348298
1.10 Consider at the impact of impaired nutritional status on the risk of pressure injuries. (C, ↑)
348298
1.11 Consider the potential impact of moist skin on the risk of pressure injuries. (C, ↑)
348298
1.12 Consider the impact of increased body temperature on the risk of pressure injuries. (B1, ↑)
348298
1.13 Consider the potential impact of older age on the risk of pressure injuries. (C, ↑)
348298
1.14 Consider the potential impact of impaired sensory perception on the risk of pressure injuries. (C, ↑)
348298
1.15 Consider the potential impact of laboratory blood test results on the risk of pressure injuries. (C, ⟷)
348298
1.16 Consider the potential impact of general and mental health status on pressure injury risk. (GPS, )
348298
1.17 Consider the impact of time spent immobilized before surgery, the duration of surgery and the American Society of Anesthesiologists (ASA) Physical Status Classification on surgery-related pressure injury risk. (B2, ↑)
348298
1.18 Consider the following as additional risk factors for the development pressure injuries in critically ill individuals:
* Duration of critical care stay
* Mechanical ventilation
* Use of vasopressors
* Acute Physiology and Chronic Health Evaluation (APACHE II) score.
(GPS, )
348298
1.19 Consider the impact of skin maturity, perfusion and oxygenation, and presence of a medical device on pressure injury risk in neonates and children. (B1, ↑↑)
348298
1.20 Consider the impact of illness severity and the duration of critical care unit stay on pressure injury risk in neonates and children. (B2, ↑)
348298
1.21 Conduct a pressure injury risk screening as soon as possible after admission to the care service and periodically thereafter to identify individuals at risk of developing pressure injuries. (GPS, )
348298
1.22 Conduct a full pressure injury risk assessment as guided by the screening outcome after admission and after any change in status. (GPS, )
348298
1.23 Develop and implement a risk-based prevention plan for individuals identified as being at risk of developing pressure injuries (GPS, )
348298
1.24 When conducting a pressure injury risk assessment:
• Use a structured approach
• Include a comprehensive skin assessment
• Supplement use of a risk assessment tool with assessment of additional risk factors
• Interpret the assessment outcomes using clinical judgment.
(GPS, )
348298

Overview

Title

Prevention and Treatment of Pressure Ulcers/Injuries

Authoring Organization

National Pressure Injury Advisory Panel