RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Nursing Best Practice GuidelineDefinition of TermsFor clinical terms not identified here, please refer to Appendix B – Glossary of Clinical Terms.Clinical Practice Guidelines or Best Practice Guidelines: Systematically developedstatements (based on best available evidence) to assist practitioner and patient decisions aboutappropriate health care for specific clinical (practice) circumstances (Field & Lohr, 1990).Education Recommendations: Statements of educational requirements and educationalapproaches/strategies for the introduction, implementation and sustainability of the bestpractice guideline.Evidence: Evidence is information that comes closest to the facts of a matter. The form ittakes depends on context. The findings of high-quality, methodologically appropriate researchare the most accurate evidence. Because research is often incomplete and sometimescontradictory or unavailable, other kinds of information are necessary supplements to orstand-ins for research. The evidence base for a decision is the multiple forms of evidencecombined to balance rigour with expedience – while privileging the former over the latter.(Canadian Health Services Research Foundation, 2006).Organization & Policy Recommendations: Statements of conditions required for apractice setting that enables the successful implementation of the best practice guideline. Theconditions for success are largely the responsibility of the organization, although they may haveimplications for policy at a broader government or societal level.Practice Recommendations: Statements of best practice directed at the practice of health careprofessionals, which are ideally evidence-based.Pressure Ulcer: Any lesion caused by unrelieved pressure that results in damage to underlyingtissue. Pressure ulcers usually occur over a bony prominence and are staged to classify the degree oftissue damage observed.Stages of Pressure Ulcers –Defined by the National Pressure Ulcer Advisory Panel (NPUAP, 2007)Suspected Deep Tissue Injury: Purple or maroon localized area of discoloured intact skin or blood-filledblister due to damage of underlying soft tissue from pressure and/or shear. The area may be precededby tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deeptissue injury may be difficult to detect in individuals with dark skin tones.Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence.Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area.21