1. Practice Recommendations: Assessment

Recommendation	Level of Evidence
1.1 A head-to-toe skin assessment should be carried out with all clients at admission, IV and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences.	IV
1.2 The client's risk for pressure ulcer development is determined by the combination of clinical judgment and the use of a reliable risk assessment tool. The use of a tool that has been tested for validity and reliability, such as the Braden Scale for Predicting Pressure Sore Risk, is recommended. Interventions should be based on identified intrinsic and extrinsic risk factors and those identified by a risk assessment tool, such as Braden's categories of sensory perception, mobility, activity, moisture, nutrition, friction and shear. Risk assessment tools are useful as an aid to structure assessment.	IV
1.3 Clients who are restricted to bed and/or chair, or those experiencing surgical intervention, should be assessed for pressure, friction and shear in all positions and during lifting, turning and repositioning.	IV
1.4a All pressure ulcers are identified and staged using the National Pressure Ulcer Advisory Panel (NPUAP) criteria.	IV
1.4b If pressure ulcers are identified, utilization of the RNAO best practice guideline Assessment and Management of Stage I to IV Pressure Ulcers is recommended.	IV
1.5 All data should be documented at the time of assessment and reassessment.	IV