Nipissing University BScN Learning Module
Best Practice Guideline:
Assessment and Management of Pressure Injuries for the Interprofessional Team
(RNAO, 2016)
The Nipissing University BScN program is undergoing a pre-designation to become a Best Practice Spotlight Organization (BPSO). This project is funded by the RNAO in conjunction with the Ministry of Health and Long Term Care.
Disclosure: This presentation is based on the RNAO best practice guideline; Assessment and Management of Pressure Injuries for the Interprofessional Team.
First Year
Knowledge of BPG, and assessment using BPG’s (Introduce BPG order sets).
Second Year
Clinical exposure to application of BPG’s
Third Year
Knowledge and use of BPG’s in complex settings.
Fourth/Fifth Year
Application of BPG’s in complex scenarios (critical thinking).
How to Use BPG's based on your Academic Year- A General Guideline
When reviewing this guideline for application, it should be applied in accordance with the individual with the pressure injury, and the organizations needs and practice setting. This guideline provides an overview of supports, and appropriate structures in order to provide the best possible evidence based (EB) care.
(RNAO, 2016)
(RNAO, 2016)
What is a pressure injury?
In accordance to the National Pressure Ulcer Advisory Panel (2016), a pressure injury is known as a localized area of skin or underlying soft tissue that is
typically over a bony prominence. Presentation can vary from intact skin to an open ulcer and has the potential to be painful. This injury occurs as a result of prolonged/hard pressure or shearing. The factors that can cause soft tissue to be susceptible to pressure injuries can be revovled around perfusion, nutrition, co- morbidities, condition of the soft tissue, or microclimate.
(National Pressure Ulcer Advisory Panel [NPUAP], 2016, para 3)
Staging of Pressure Ulcers
(RNAO, 2019)
Things to Keep in Mind
Lighter complexions will present with reddened skin and darker complexions will present with purple/blue skin.
Those with poor immune systems, may develop pressure injuries in a quick manner.
Those who are bed ridden, or lie in bed for long periods may develop these injuries where their weight is rested, especially on bony prominence's including elbows, knees, tailbone, buttocks, ankles, heels, hips, back of head, or shoulder blades. Those who use a wheelchair for long periods have a higher risk of developing sores on there buttocks as well.
(RNAO, 2019)
(Queensland Government 2019).
Purpose of Guideline:
To outline EB recommendations that apply to both the decisions and best practices of all interprofessioanl team members who work with the assessment and management of exisiting pressure ulcers in a population of those 18 years old and above.
As some evidence may relate to the prevention of ulcers, most of the research considered in this guideline applies to the management of those with exisiting pressure injuruies.
(RNAO, 2016)
Scope
(RNA0, 2016)
Best practice recommendations are provided in three areas:
As nursing students, the focus will be on practice recommendations.
It is benefical to be aware of the educational, and system, organization, and policy recommendations.
Gap Analysis
The difference between current knowledge/practices (what we are doing) and current Evidence Based Practices (what we should be doing).
Gaps can occur in knowledge, skills or practice.
Reflect on the following questions, and be specific:
Where is our current practice?
Where do we wish we were/where should we be? Why has this gap occurred?
How are we going to close the gap?
(Anthony J. Jannetti, Inc. 2012)
Performing a gap analysis on best practice guidelines is an essential part of reflecting on practice. When reviewing the recommendations identify where there are gaps in current practice or knowledge, and take the time to reflect.
Steps to Conduct a Gap Analysis
(Anthony J. Jannetti, Inc., 2012)
Practice Recommendations
Assessment and Management of Pressure Injuries for the Interprofessional Team
1.0 Assessment
(RNA0, 2016)
1.1 Conduct a health history, a psycho-social history, and physical exam on initial examination and whenever there is a significant change in the person’s medical status.
1.2 Assess the risk for developing additional pressure injuries on initial examination �and if there is a significant change in the person’s medical status using a valid and �reliable pressure injury risk assessment tool.
�
1.3 Assess the person’s pressure injury using the same valid and reliable wound assessment tool on initial examination and whenever there is a significant change in the pressure injury.
�
1.4 Assess the person’s pressure injury for signs and symptoms of infection (superficial critical colonization/localized infection and/or deep and surrounding
infection/systemic infection) using a standardized approach on initial examination and at every dressing change.
(RNA0, 2016)
1.5 a) Screen all persons with pressure injuries for risk of malnutrition using a valid
and reliable screening tool on first examination and if there is a delay in pressure injury healing.
1.6 Assess for pressure injury pain on initial examination and continue to monitor pain at subsequent visits, including prior to and after every wound care intervention, using the same valid and reliable tool consistent with the person’s cognitive ability.
1.7 Perform a vascular assessment (i.e., medical history, physical exam) of all persons with pressure injuries in the lower extremities on initial examination.
1.8 Conduct a mobility and support surface assessment on initial examination and whenever there is a significant change in the person’s medical condition, weight, equipment, mobility, and/or pressure injury healing.
(RNA0, 2016)
2.0 Planning
(RNA0, 2016)
2.1 Obtain the referral or consultations required to plan and coordinate a pressure injury plan of care
2.2 Develop a pressure injury plan of care that incorporates goals mutually agreed upon by the person, the person’s circle of care, and the inter-professional team.
(RNA0, 2016)
3.0 Implementation
(RNA0, 2016)
3.1 Reposition the person at regular intervals (i.e., every two to four hours) based on person-centered concerns. While sitting, weight-shift the person every 15 minutes.
3.2 Position all persons with a pressure injury on a pressure redistribution support surface at all times.
3.3 Implement an individualized nutritional plan of care in collaboration with the person and his/her circle of care that addresses nutritional requirements and provides adequate protein, calories, fluid, and appropriate vitamin and mineral supplementation to promote pressure injury healing.
(RNA0, 2016)
3.4 Provide local pressure injury care consisting of the following, as appropriate: cleansing
moisture balance (healable) or moisture reduction (nonhealable, maintenance) infection control (i.e., superfi cial critical colonization/
localized infection and/or deep and surrounding infection/systemic infection) and debridement
�
3.5 Provide electrical stimulation (when available) as an adjunct to best practice
wound care in order to speed healing and promote wound closure in stalled but healable stage 2, 3, and 4 pressure injuries.
3.6 Implement, as an alternative, the following treatments in order to speed closure/ of stalled but healable pressure injuries, as appropriate and if available:
electromagnetic therapy ultrasound , and ultraviolet light
(RNA0, 2016)
3.7 Provide negative pressure wound therapy to people with stage 3 and 4 pressure injuries in exceptional circumstances, including enhancement of quality of life and in accordance with other person-/familycentred preferences.
3.8 Collaborate with the person and his/her circle of care to implement a pressure injury self-management plan.
�3.9 Implement a person-centred pain management plan using pharmacological and non-pharmacological interventions.
(RNA0, 2016)
4.0 Evaluation
(RNA0, 2016)
4.1 Use the initial risk assessment tool to reassess the person’s risk for developing additional pressure injuries on a regular basis and whenever a change in the person’s health status occurs.
4.2 Use the initial wound assessment tool to monitor the person’s pressure injuries for progress toward person-centred goals on a regular basis and at dressing changes.
(RNA0, 2016)
Listed below are the education and system, organization and policy recommendations related to this BPG for your reference.
5.0 Education Recommendations
(RNA0, 2016)
5.1 Develop and implement comprehensive and sustainable interprofessional pressure injury education programs for clinicians and students entering health-care professions.
5.2 Assess health-care professionals knowledge, attitudes, and skills related to the assessment and management of existing pressure injuries before and following educational interventions using an appropriate, reliable, and validated assessment tool.
(RNA0, 2016)
Policy Recommendations
6.0 System, Organization, and
(RNA0, 2016)
6.1 Organizations must lead and provide the resources to integrate pressure injury management best practices into standard and interprofessional clinical practice, with continuous evaluation of outcomes
6.2 Lobby and advocate for investment in pressure injury management as a strategic quality and safety priority in jurisdictions in order to improve health outcomes for people with pressure injuries.
(RNA0, 2016)
Research Gaps and Future Limitations
(RNA0 2016, p. 84-85)
Collaborate with the individuals circle of care, and develop
goals.
(RNA0, 2016)
References
Anthony J. Jannetti, Inc. (2012). A representation: Incorporating a needs assessment and gap analysis into the educational design. Pitman, NJ: Author.
Queensland Government (2019). Pressure Injury Prevention. Clinical Excellence Queensland. Retrieved from https://clinicalexcellence.qld.gov.au/priority-areas/safety-and-quality/pressure-injury-prevention .
Registered Nurses’ Association of Ontario. (2016). Assessment and Management of Pressure Injuries for the Interprofessional Team (Rev. ed.). Retrieved from http://rnao.ca/
Registered Nurses’ Association of Ontario. (2016). Assessment and Management of Pressure Injuries for the Interprofessional Team; Nursing/Interprofessional Team Order Set (Rev. ed.). Retrieved from http://rnao.ca/
Registered Nurses’ Association of Ontario. (2016). Taking the Pressure Off: Preventing & Managing Pressure Injuries (Rev. ed.). Retrieved from http://rnao.ca/
Registered Nurses’ Association of Ontario. (2005). Risk Assessment & Prevention of Pressure Ulcers (Rev. ed.).
Retrieved from http://rnao.ca/