Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Assessment Recommendations

 

1.1  A comprehensive head-to-toe skin assessment should be carried out with all clients at admission, and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences and skin adjacent to external devices.
 
1.2a  The client’s risk for pressure ulcer development is determined by the combination of clinical judgment and the use of a valid reliable risk assessment tool. The use of a structured tool that has been tested for validity and reliability, such as the Braden Scale for Predicting Pressure Sore Risk, the Norton Pressure Sore Risk Assessment Scale and the Waterlow Pressure Ulcer Risk Assessment Tool are recommended.
 
1.2b Assess for intrinsic/extrinsic risk factors that are associated with the development of pressure ulcers.
 
1.3  Assessment scales to assess and re-assess risk for skin breakdown and overall skin condition specific to vulnerable populations such as the elderly, palliative patients, the neonate/the child, spinal cord injured patients, and bariatric patients should be considered.
 
1.4 Assessment and documentation of skin changes amongst palliative patients at the end of life should be conducted as recommended by the consensus statement Skin Changes At Life’s End (SCALE).
 
1.5 All sectors of the health care system, programs, and services should conduct risk assessments and re-assessments to plan prevention strategies that will minimize the risk of pressure ulcer development.
 
1.6a All pressure ulcers should be identified and described using standardized systems and language (e.g. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel pressure ulcer classification system).
 
1.6b If pressure ulcers are identified, utilization of the RNAO best practice guideline Assessment and Management of Stage I to IV Pressure Ulcers along with other related guidelines is recommended.
 
1.7 All findings should be documented at the time of assessment and reassessment.