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

Nursing Best Practice GuidelinePractice RecommendationsAssessmentRecommendation 1.1Conduct a history and focused physical assessment.Level of Evidence – IVDiscussion of EvidencePressure ulcers should be assessed in the context of the patient’s overall physical and psychological health(AHCPR, 1994; Compliance Network Physicians, 1999; Consortium for Spinal Cord Medicine, 2000). A focused physicalassessment includes a risk assessment for pressure ulcer development – Appendix C provides a descriptionof the Braden Scale for Predicting Pressure Sore Risk. A French translation of this scale has recently beenshown to be reliable and valid in clinical practice (Denis & St-Cyr, 2006). The guideline development panelstrongly supports consultation with interdisciplinary team members in the assessment process; inparticular, the involvement of members who have wound care expertise.Recommendation 1.2Conduct a psychosocial assessment to determine the client’s goals and their ability and motivationto comprehend and adhere to the treatment plan of care options.Level of Evidence – IVRecommendation 1.3Assess quality of life from the client’s perspective.Level of Evidence – IVDiscussion of EvidenceThe goal of a psychosocial assessment is to collect the information necessary to develop a plan of care withthe client that is consistent with individual and family preferences, goals and resources (personal, financial,etc.). The findings regarding an individual’s psychological health and the impact on pressure ulcerdevelopment is mixed; however, it is evident that many of the recommendations for prevention andmanagement of existing ulcers require the understanding, cooperation and initiative of clients and theircaregivers (Consortium for Spinal Cord Medicine, 2000). These complex behaviours suggest that a psychosocialassessment should be conducted to identify factors for consideration in developing prevention andmanagement strategies.25