Registered Nurses´ Association of Ontario
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1. Practice Recommendations: Assessment
| Recommendation | Level of Evidence |
|---|---|
| 1.1 Conduct a history and focused physical assessment. | IV |
| 1.2 Conduct a psychosocial assessment to determine the client's goals and their ability and motivation to comprehend and adhere to the treatment plan of care options. | IV |
| 1.3 Assess quality of life from the client's perspective. | IV |
| 1.4 Ensure adequate dietary intake to prevent malnutrition or replace existing deficiencies to the extent that this is compatible with the individual's wishes. | III |
1.5 Prevent clinical nutrient deficiencies by ensuring that the patient is provided with optimal nutritional support through one or more of the following: Level of Evidence Ia-IV.
|
IV |
| 1.6 Assess all patients for pain related to the pressure ulcer or its treatment. | IV |
| 1.7Assess location, frequency and intensity of pain to determine the presence of underlying disease, the exposure of nerve endings, efficacy of local wound care and psychological need. | IIb |
| 1.8 Assess all patients with EXISTING PRESSURE ULCERS to determine their risk for developing additional pressure ulcers using the "Braden Scale for Predicting Pressure Sore Risk". | IV |
| 1.9 If the patient remains at risk for other pressure ulcers, a high specification foam mattress instead of a standard hospital mattress should be used to prevent pressure ulcers in moderate to high risk patients | Ia |
| 1.10 Vascular assessment (e.g., clinical assessment, palpable pedal pulses, capillary refill, ankle/brachial pressure index and toe pressure) is recommended for ulcers in lower extremities to rule out vascular compromise. | IV |
