Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Assessment
Recommendation Level of Evidence
1.1  Conduct a history and focused physical assessment. IV
1.2  Conduct a psychosocial assessment to determine the client's goals and their ability and motivation to comprehend and adhere to the treatment plan of care options. IV
1.3  Assess quality of life from the client's perspective. IV
1.4  Ensure adequate dietary intake to prevent malnutrition or replace existing deficiencies to the extent that this is compatible with the individual's wishes. III
1.5  Prevent clinical nutrient deficiencies by ensuring that the patient is provided with optimal nutritional support through one or more of the following: Level of Evidence Ia-IV.
  • Consultation with a Registered Dietitian for assessment (Level of Evidence IV)
  • Consultation with a speech language pathologist for swallowing assessment (IV)
  • A varied, balanced diet to meet clinical requirements for healing and co-existing diseases (e.g., renal failure and diabetes) (Level of Evidence IV)
  • Nutritional supplements if needed (Level of Evidence Ia)
  • Multivitamin and mineral preparations (Level of Evidence Ib)
  • Enteral tube feeding (Level of Evidence IV)
  • Parenteral nutrition (Level of Evidence IV)
  • Ongoing monitoring of nutritional intake, laboratory data and anthropometric data (Level of Evidence IV).
IV
1.6  Assess all patients for pain related to the pressure ulcer or its treatment. IV
1.7 Assess location, frequency and intensity of pain to determine the presence of underlying disease, the exposure of nerve endings, efficacy of local wound care and psychological need. IIb
1.8  Assess all patients with EXISTING PRESSURE ULCERS to determine their risk for developing additional pressure ulcers using the "Braden Scale for Predicting Pressure Sore Risk". IV
1.9  If the patient remains at risk for other pressure ulcers, a high specification foam mattress instead of a standard hospital mattress should be used to prevent pressure ulcers in moderate to high risk patients Ia
1.10  Vascular assessment (e.g., clinical assessment, palpable pedal pulses, capillary refill, ankle/brachial pressure index and toe pressure) is recommended for ulcers in lower extremities to rule out vascular compromise. IV

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