Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Interventions Recommendation

3.1a Clients identified to be at risk for developing a pressure ulcer should be resting on a pressure management surface such as a high-specification foam pressure redistribution mattress.
3.1b A re-positioning schedule of at least every two hours should be promptly implemented when using a standardized mattress, emergency stretcher or operating table surface. When using a pressure management surface (re-distribution mattress or cushion) use a re-positioning schedule of at least every four hours or as required by the patient’s condition. Consider other patient factors such as the development of redness to increase the frequency of repositioning.
3.2 Heels must be completely off loaded in all positions. If not feasible, reason(s) must be documented, the heels must be monitored, and other prevention strategies implemented.
3.3 Use proper positioning, transferring and turning techniques. Consult an Occupational or Physical Therapist (OT/PT) regarding transfer and positioning techniques and strategies,as well as devices to reduce pressure friction and shear in all positions, and how to optimize client independence.
3.4 Assess, document and effectively manage pain to enable implementation of the most appropriate plan of care for pressure ulcer prevention without compromising comfort and quality of life.
3.5 Massaging over bony prominences and reddened areas should be avoided.
3.6 Implementation of intraoperative pressure management devices is recommended for surgical procedures lasting more than 90 minutes.
3.7a Before implementing localized pressure management devices (e.g. heel boots, wedges,etc.) consider:
  • Potential for increased pressure over surrounding areas of the skin by the device;
  • Caregiver training and education to ensure correct use of the device; and/or
  • Factors that enable client adherence.
3.7b Complete bed rest is not recommended for the prevention and healing of pressure ulcers. Determine the rationale for bed rest and focus on getting the client up into an appropriate wheelchair for part of the day, as appropriate.
3.8 Protect skin from excessive moisture and incontinence to maintain skin integrity:
  • Monitor fluid intake to ensure adequate hydration;
  • Use a pH balanced, non-sensitizing skin cleanser with warm water for cleansing;
  • Minimizing force and friction during care (e.g. use a soft wipe or spray cleanser);
  • Maintain skin hydration by applying moisturizing agents that are non-sensitizing, pH balanced, fragrance free and/or alcohol free;
  • Use topical protective barriers to protect skin from moisture. Avoid ingredients and excess application of products that may compromise the absorptive capacity of the incontinent brief;
  • Use protective barriers (e.g. liquid barrier films, transparent films, hydrocolloids) or protective padding to reduce friction injuries;
  • If skin irritation persists due to moisture, consult with advanced practice nurses and/or with the appropriate interdisciplinary team for evaluation and topical treatment; and/or
  • Establish a bowel and bladder program.
3.9 A nutrition and hydration assessment with appropriate interventions should be implemented on entry to any health-care setting and when the client’s condition changes. If nutritional deficit and/or dehydration is suspected:
  • Consult with a registered dietitian;
  • Investigate factors that compromise an apparently well nourished individual’s dietary intake (especially protein or calories) and/or fluid intake and offer the individual support with eating/drinking;
  • Plan and implement a nutritional support and/or supplementation program for nutritionally compromised/ dehydrated individuals; and
  • If dietary/fluid intake remains inadequate, consider alternative nutritional interventions.
3.10 Institute a rehabilitation/restorative/activity program with the interprofessional team to maximize client’s functional status that is consistent with the overall goals of care. Consult with an occupational therapist or physical therapist as appropriate.