Title: Guidelines for the prevention of pressure ulcers
Abstract: The Wound Healing Society is a professional organization of physicians, nurses, physical therapists, basic scientists, clinical researchers, and industrial researchers dedicated to assuring that every patient receives optimal wound care. Its mission is to advance the science and practice of wound healing. To that end, the following comprehensive, evidence- and consensus-based guidelines were developed to address the Prevention of Pressure Ulcers. The guidelines are presented in generic terms; the details of specific tests, therapies, and procedures are the discretion of an interdisciplinary team of health care professionals who establish, implement, and evaluate policies and procedures directed at the prevention of pressure ulcers. PubMed, EMBASE, and CINAHL and the Cochrane Database of Systematic Reviews were searched and reviewed for evidence on pressure ulcer prevention. In addition, a search of health care databases for current evidence-based guidelines addressing the prevention of pressure ulcers was conducted using electronic and online resources. The panel classified studies based on whether the intervention being evaluated addressed pressure ulcer risk screening (PURS) and assessment (PURA), pressure ulcer prevention plans of care (PUPCP) (including interdisciplinary approaches), selection of support surfaces, friction and shear prevention, management of moisture and incontinence, nutrition, and patient and caregiver education. Evidence references for each standard are listed and coded. The code abbreviations for the evidence citations were as follows: The strength of evidence supporting a guideline is listed as Level I, Level II, or Level III using the following definitions: Level I: Meta-analysis of multiple RCTs or at least two RCTs supporting the intervention in the guideline or multiple laboratory or animal experiments with at least two clinical series supporting the laboratory results. Level II: Less evidence than Level I, but at least one RCT and at least two significant clinical series or expert opinion papers with literature reviews supporting the intervention. Experimental evidence that is quite convincing but without support by adequate human experience. Level III: Suggestive data of proof-of-principle, but lacking sufficient data such as meta-analysis, RCT, or multiple clinical series. 1. Pressure Ulcer Risk Screening (PURS) Preamble: Pressure ulcer prevention is an important issue in every health care setting. Pressure ulcers are areas of localized tissue destruction caused by unrelieved pressure, shear, and friction to the skin. Contributing risk factors increase the person's susceptibility to a complex etiology that causes pressure ulcers. Common risk factors have been identified: immobility, friction and shear, moisture, incontinence, poor nutrition, perfusion, age, skin condition, and altered level of consciousness. Individuals at high risk should be screened and assessed and efforts can be focused with interdisciplinary plans of care for preventing pressure ulcers in these patients. Patients who are at risk should be identified by PURS shortly after admission to a health care setting. While there are limited definitive studies, the best current evidence and expert opinion suggest the following guidelines. Guideline #1.1: All patients admitted to the health care setting shall undergo a PURS by or under the supervision of a registered nurse or health care professional with training and expertise in wound care within the time frame specified by organization policy or as required by regulation within 12 hours of admission. In nursing home settings, the window for screening is the MDS, which should be completed in 7 days. (Examples of "training and expertise" in wound care include academic course work, continuing education hours, or contact hours on basic and advanced wound care and wound bed preparation or national certification in wound care through organizations such as the Wound, Ostomy and Continence Nurses Society [WOCN] or the American Academy of Wound Management). Level of evidence: II Principle: The best-practice process of pressure ulcer prevention requires a series of steps with feedback loops. These steps include PURS, pressure ulcer risk assessment (PURA), formulation of a pressure ulcer prevention care plan (PUPCP), implementation of the plan, monitoring, reassessment of the care plan, reevaluation of the health care setting, and then either reformulation of the care plan or termination of therapy. Reported time of pressure ulcer development after admission ranged from 1 to 59 days. Acute care: Pressure ulcers usually develop within the first 2 weeks of hospitalization. ICU patients who developed pressure ulcers did so within the first 72 hours of admission to the ICU. Fifteen percent of elderly patients will develop pressure ulcers within the first week of hospitalization. Long-term care residents usually develop pressure ulcers within the first 4 weeks of admission. Risk assessment screening tools may be helpful to identify patients at risk for pressure ulcer development. Several risk-screening assessment tools are available that consist of subscales for determining risk score. A tool may be used to classify pressure ulcer risk. The Braden scale is the only scale that has been extensively tested in adults across health care settings. Predictive ability of pressure ulcer risk scales is not yet determined; there are not high levels of reliability and validity reported with their use. PURS recommendations: The Braden scale has been the most extensively studied. The Braden scale consists of six parameters (sensory perception, mobility, activity, moisture, nutrition, and friction and shear) with potential scores from 6 to 23. Lower total scores indicate greater risk of developing pressure ulcers. If other major risk factors are present (e.g., age, fever, poor dietary intake of protein, diastolic pressure <60, and/or hemodynamic instability), advance to next level of risk. Mild risk=15–18; moderate risk=13–14; high risk=10–12; very high risk=9 or below. The Norton scale is a PURA scale that consists of five parameters (general physical condition, mental condition, activity, mobility, and incontinence) each rated on a scale of 1–4, with lower numbers associated with greater impairment and potential total scores ranging from 5 to 20. Mild risk=14; moderate risk=13; high risk=12. The reliability and validity of the tool has not been established. Braden Q scores: This scale was adapted from the Braden scale for use in the pediatric population. Mild risk=25; moderate risk=21; high risk=16. Level of evidence: II, III Resident Assessment Protocol for nursing homes: This is the only assessment tool recognized by CMS for PURA in nursing homes. The Braden scale does not perform well in settings outside the hospital. Both the Norton Score and the Braden scale have good sensitivity (73–92% and 83–100%, respectively) and specificity (61–94% and 64–77%, respectively), but have poor positive predictive value in nursing home residents (around 37% at a pressure ulcer incidence of 20%). In populations with a lower incidence of pressure ulcers, such as nursing home residents, the same sensitivity and specificity would produce a positive predictive value of 2%. The Norton and Braden scales show a 0.73 kappa statistic agreement among at-risk patients, with the Norton Score tending to classify patients at risk when the Braden scale classified them as not at risk. The net effect of poor positive predictive value means that many patients who will not develop pressure ulcers will receive expensive and unnecessary treatment. Level of evidence: II, III Evidence: Agency for Healthcare Research and Quality. Clinical practice guidelines online. Available at: http://www.ahrq.gov/clinic/cpgonline.htm. Accessed December 2, 2002 [STAT]. Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995; 273: 865–70 [CLIN S]. Ayello EA, Braden BJ. How and why to do pressure ulcer risk assessment. Adv Wound Care 2002; 15: 125–31 [LIT REV]. Bergstrom N, Braden B, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nurs Res 1987; 36: 205–10 [LIT REV]. Bergstrom N, Braden B, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nurs Res 1987; 36: 205–10 [CLIN S]. Bergstrom N, Demuth PJ, Braden B. A clinical trial of the Braden Scale for predicting pressure sore risk. Nurs Clin North Am 1987; 22: 417–28 [CLIN S]. Braden BJ, Bergstrom N. Predictive validity of the Braden Scale for pressure sore risk in a nursing home population. Res Nurs Health 1994; 17: 459–70 [CLIN S]. Braden BJ, Bergstrom NA. Clinical utility of the Braden scale for predicting pressure sore risk. Decubitus 1989; 2: 44–51 [TECH]. Deeks JJ. Pressure sore prevention using and evaluating risk assessment tools. Br J Nurs 1996; 5: 313–4, 316–20 [LIT REV]. Edwards M. Pressure sore risk calculators: some methodological issues. J Clin Nurs 1996; 5: 307–12 [TECH] [LIT REV]. Flanagan M. Pressure Sore Risk Assessment Scales. J Wound Care 1993; 2: 162–7 [LIT REV]. Flanagan M. Who is at risk of a pressure sore? A practical review of risk assessment systems. Prof Nurse 1995; 10: 305–8. Gordon MD, Gottschlich MM, Helvig EI, Marvin JA, Richard RL. Review of evidenced-based practice for the prevention of pressure sores in burn patients. J Burn Care Rehabil 2004; 25: 388–410 [LIT REV]. Hagisawa S, Barbenel J. The limits of pressure sore prevention. J R Soc Med 1999; 92: 576–8 [CLIN S]. Langemo DK, Olson B, Hunter S, Burd C, Hansen D. Incidence of pressure sores in acute care, rehabilitation, extended care, home health, and hospice in one locale. Decubitus 1989; 2: 42 [CLIN S]. Lyder CH. Pressure ulcer prevention and management. JAMA 2003; 289: 223–6 [LIT REV]. Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med 2001; 161: 1549–54 [RETRO S]. National Pressure Ulcer Advisory Panel. Available at: http://www.npuap.org. Accessed December 2, 2002 [STAT]. National Pressure Ulcer Advisory Panel. Pressure ulcers: incidence, economics, risk assessment. West Dundee, IL: Consensus Development Conference Statement, S-N Publications, 1989:3–4. Available at: http://www.npuap.org/positn2.htm. Accessed December 11, 2002 [STAT]. Norton D. Calculating the risk: reflections on the Norton Scale. Decubitus 1989; 2: 24–31 [LIT REV]. Quigley SM, Curley MA. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Soc Pediatri Nurs 1996; 1: 7–18 [CLIN S]. Smith DM, Winsemius DK, Besdine RW. Pressure sores in the elderly: can this outcome be improved? J Gen Intern Med 1991; 6: 81–93 [CLIN S]. Stotts N. Risk factors associated with pressure ulcer development in surgical patients. Decubitus 1989; 2: 59 [CLIN S]. Thomas DR. Issues and dilemmas in managing pressure ulcers. J Gerontol: Med Sci 2001; 56: M238–340 [LIT REV]. Thomas DR. Are all pressure ulcers avoidable? J Am Med Dir Assoc 2001; 2: 297–301 [LIT REV]. Towey AP, Erland SM. Validity and reliability of an assessment tool for pressure ulcer risk. Decubitus 1988; 1: 40–8 [CLIN S]. van Marum RJ, Ooms ME, Ribbe MW, van Eijk JT. The Dutch pressure sore assessment score or the Norton scale for identifying at-risk nursing home patients? Age Ageing 2000; 29: 63–8 [CLIN S]. Whitfield MD, Kaltenthaler EC, Akehurst RL, Walters SJ, Paisley S. How effective are prevention strategies in reducing the prevalence of pressure ulcers? J Wound Care 2000; 9: 261–6 [LIT REV]. Wound Ostomy Continence Nurses Society. Guideline for prevention and management of pressure ulcers. WOCN clinical practice guideline series. Glenview, IL: WOCN, 2003 [STAT]. Xakellis GC, Frantz RA, Arteaga M, Nguyen M, Lewis A. A comparison of patient risk for pressure ulcer development with nursing use of preventive interventions. J Am Geriatr Soc 1992; 40: 1250–4 [CLIN S]. Guideline #1.2: The result of the PURS shall be documented and appropriate assessment and intervention initiated within 24 hours of admission. In nursing home settings, the window for screening and appropriate assessment and intervention is the MDS, which should be completed in 7 days. Level of evidence: II Principle: A skin risk screening assessment tool may be most helpful when used in combination of strategies including additional skin assessment policies and procedures, skin care teams, and educational programs. Evidence: Bennett RG, O'Sullivan J, DeVito EM, Remsberg R. The increasing medical malpractice risk related to pressure ulcers in the United States. J Am Geriatr Soc 2000; 48: 73–81 [CLIN S]. Bergstrom NA, Braden BJ. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992; 40: 747–58 [CLIN S]. Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med 2001; 161: 1549–54 [RETRO S]. McGough A. Epidemiological issues in monitoring pressure damage. J Wound Care 1998; 7: 214–5 [LIT REV]. Staas WE Jr., Cioschi HM. Pressure sores—a multifaceted approach to prevention and treatment. West J Med 1991; 154: 539–44 [CLIN S]. Guideline #1.3: A procedure for pressure ulcer rescreening should be implemented within 48 hours or when there is a significant change in the individual's condition; transfer to ICU, system or organ failure, septicemia, chronic ICU status with prolonged ventilator support, fever, hemodynamic instability, urinary tract infection in nursing home residents, etc. Level of evidence: II Principle: The best practice process of pressure ulcer prevention requires a series of steps with feedback loops. These steps include PURS, PURA, formulation of a PUPCP, implementation of the plan, monitoring, reassessment of the care plan, reevaluation of the health care setting, and then either reformulation of the care plan or termination of therapy. Evidence: Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995; 273: 865–70 [CLIN S]. Carlson EV, Kemp MG, Shott S. Predicting the risk of pressure ulcers in critically ill patients. Am J Crit Care 1999; 8: 262–9 [CLIN S]. Fogerty M, Abumrad N, Nanney L, Arbogast P, Poulose B, Barbul A. Risk factors for pressure ulcers in acute care hospitals. Wound Rep Regen 2008; 16: 11–8 [RETRO S]. Versluysen M. Pressure sores in elderly patients: the epidemiology related to hip operations. J Bone Joint Surg Br 1985; 7: 10 [CLIN S]. Guideline #1.4: A schedule for reassessing risk should be based on the acuity of the individual and awareness of when pressure ulcers occur in a particular clinical setting. Level of evidence: II, III Principle: Note that there is limited evidence that risk assessment leads to a reduction in frequency of pressure ulcers. The data show that risk assessment did not prevent development of pressure ulcers. In fact, at-risk patients who received proper interventions had a higher incidence of pressure ulcers. Other studies demonstrate similar findings. There are limits of risk factor identification; a number of risk factors are not modifiable, such as fecal incontinence, mobility, level of consciousness, or even nutrition. Evidence: Bliss M, Simini B. When are the seeds of postoperative pressure sores sown: often during surgery. BMJ 1999; 319: 863–4 [LIT REV]. Hagisawa S, Barbenel J. The limits of pressure sore prevention. J R Soc Med 1999; 92: 576–8 [CLIN S]. McGough A. Epidemiological issues in monitoring pressure damage. J Wound Care 1998; 7: 214–5 [LIT REV]. Schoonhoven L, Defloor T, van der Tweel I, Buskens E, Grypdonck MH. Risk indicators for pressure ulcers during surgery. Appl Nurs Res 2002; 16: 163–73 [CLIN S]. Thomas DR. Are all pressure ulcers avoidable? J Am Med Dir Assoc 2001; 2: 297–301 [LIT REV]. 2. Pressure Ulcer Risk Assessment (PURA): It plays a significant role in the prevention of pressure ulcers. Patients who are at risk should be identified by PURA shortly after admission to a health care setting. While there are limited definitive studies, the best current evidence and expert opinion suggest the following guidelines. Guideline #2.1: The PURA shall be performed by or under the supervision of a registered nurse or health care professional with training and expertise in wound care within the time frame specified by organization policy or as required by regulation. (Examples of "training and expertise" in wound care include academic course work, continuing education hours, or contact hours on basic and advanced wound care and wound bed preparation or national certification in wound care through Wound Ostomy and Continence Nurses Society.) Level of evidence: II Principle: Each patient shall undergo a thorough PURA by or under the supervision of a registered nurse or health care professional with training and expertise in wound care to determine and assess the risk factors and care needs and the type of preventive care to be provided. Evidence: Allman RM. Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med 1997; 13: 421–36 [LIT REV]. Ayello EA, Lyder CH. Pressure ulcers in persons of color, race, and ethnicity. In: Cuddigan J, editor. Pressure ulcers in America: prevalence, incidence and implications for the future. Washington, DC: National Pressure Ulcer Advisory Panel, 2001: 153–62 [LIT REV]. Brandeis GH, Morris JN, Nash DJ. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990; 264: 2905–9 [CLIN S]. Bergstrom NA, Braden BJ. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992; 40: 747–58 [CLIN S]. Bergstrom N. Lack of nutrition in AHCPR prevention guideline. Decubitus 1993; 6: 4,6 Level [LIT REV]. Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Predicting pressure ulcer risk: a multisite study of the predictive ability of the Braden scale. Nurs Res 1998; 47: 261–9 [CLIN S]. Bergstrom N, Bennett MA, Carlson CE, Alvarez OM, Frantz RA, Garber SL, Jackson BS, Kaminski MV, Kemp MG, Krouskop TA, Lewis VL, Jr., Maklebust J, Margolis DJ, Marvel EM, Reger SI, Rodeheaver GT, Salcido R, Xakellis GC, Yarkony GM. Treatment of pressure ulcers. Clinical practice guideline no. 15. AHCPR publication no. 95-0652. Rockville, MD: US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research, 1994 [STAT]. Berlowitz DR, Brandeis GH, Morris JN, Ash AS, Anderson JJ, Kader B, Moskowitz MA. Deriving a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Geriatr Soc 2001; 49: 866–71 [CLIN S]. Berlowitz DR, Brandeis GH, Anderson JJ, Ash AS, Kader B, Morris JN, Moskowitz MA. Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Geriatr Soc 2001; 49: 872–6 [CLIN S]. Bourdel-Marchasson I, Barateau M, Rondeau V, Dequae-Merchadou L, Salles-Montaudon N, Emeriau JP, Manciet G, Dartigues JF. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. Nutrition 2000; 16: 1–5 [RCT]. Brandeis GH, Ooi WL, Hossain M, Morris JN, Lipsitz LA. A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes. J Am Geriatr Soc 1994; 42: 388–93 [CLIN S]. Delmi M, Rapin CH, Bengoa M, Delmas PD, Vasey H, Bonjour JP. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990; 335: 1013–6 [RCT]. Ek AC, Unosson M, Larsson J, Von Schenck H, Bjurulf P. The development and healing of pressure sores related to the nutritional state. Clin Nutr 1991; 10: 245–50 [CLIN S]. Fogerty M, Abumrad N, Nanney L, Arbogast P, Poulose B, Barbul A. Risk factors for pressure ulcers in acute care hospitals. Wound Repair Regen 2008; 16: 11–8 [RETRO S]. Fritsch DE, Coffee TL, Yowler CJ. Characteristics of burn patients developing pressure ulcers. J Burn Care Rehabil 2001; 22: 293–9 [CLIN S]. Green MF, Exton-Smith AN, Helps EP, et al. Prophylaxis of pressure sores using a new lotion. Modern Geriatr 1974; 4: 376–82 [CLIN S]. Gordon M, Hockless R, Jecker G, Duval K, Owen S, Marvin J. Use of the Braden scale to predict occurrence of pressure sores in the pediatric burn population. J Burn Care Rehabil 2002; 23 (Suppl.): S84 [CLIN S]. Hartgrink HH, WillejKoing P, Hermans J, Breslau PJ. Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial. Clin Nutr 1998; 17: 287–92 [RCT]. Houwing RH, Rozendaal M, Wouters-Wesseling W, Beulens JW, Buskens E, Haalboom JR. A randomized, double-blind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip-fracture patients. Clin Nutr 2003; 22: 401–5 [RCT]. Hill-Rom Inc. National Pressure Ulcer Prevalence Survey. Company Report. Charleston, SC: Hill-Rom Inc., 1999 [CLIN S]. Jiricka MJ, Ryan P, Carvalho MA, Bukvich J. Pressure ulcer risk factors in an ICU population. Am J Crit Care 1995; 4: 361–7 [CLIN S]. Krause JS, Vines CL, Farley TL, Sniezek J, Coker J. An exploratory study of pressure ulcers after spinal cord injury; relationship to protective behaviors and risk factors. Arch Phys Rehabil 2001; 82: 107–13 [CLIN S]. Makelbust J, Sieggreen M. Etiology and pathophysiology. In: Maklebust J, Fieggreen M, editors. Pressure ulcers: guidelines for prevention and Management, 3rd ed. Springhouse, PA; Springhouse Corp, 2001: 24 [LIT REV]. Meehan M. National Pressure Ulcer prevalence survey. Adv Wound Care 1994; 7: 27–30 [CLIN S]. Nixon J, McElvenny D, Mason S, Brown J, Bond S. A sequential randomized controlled trial comparing a dry visco-elastic polymer pad and guideline operating table mattress in the prevention of post-operative pressure sores. Int J Nurs Stud 1998; 35: 193–203 [RCT]. Ooka M, Kemp MG, McMyn R, Shott S. Evaluation of three types of support surfaces for preventing pressure ulcers in patients in a surgical intensive care unit. J Wound Ostomy Continence Nurs 1995; 22: 271–9 [CLIN S]. Peerless JR, Davies A, Klein D, Yu D. Skin complications in the intensive care unit. Clin Chest Med 1999; 20: 453–67 [CLIN S]. Quigley SM, Curley MA. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Soc Pediatr Nurs 1996; 1: 7–18 [CLIN S]. Reddy M, Gill S, Rochon P. Preventing pressure ulcers: a systematic review. JAMA 2006; 296: 974–84 [LIT REV]. Scott EM, Leaper DJ, Clark M, Kelly PJ. Effects of warming therapy on pressure ulcers—a randomized trial [review]. AORN J 2001; 73: 921–33, 37–8 [RCT]. Theaker C, Mannan M, Ives N, Soni N. Risk factors for pressure sores in the critically ill. Anaesthesia 2000; 55: 221–4 [CLIN S]. Thomas DR. The role of nutrition in prevention and healing of pressure ulcers. Clin Geriatr Med 1997; 13: 497–511 [LIT REV]. Thomas DR. Issues and dilemmas in managing pressure ulcers. J Gerontol A Biol Sci Med Sci 2001; 56: M238–340 [LIT REV]. Torra i Bou JE, Segovia Gómez T, Verdú Soriano J, Nolasco Bonmatí A, Rueda López J, Arboix i Perejamo M. The effectiveness of a hyperoxygentated fatty acid compound preventing pressure ulcers. J Wound Care 2005; 14: 117–21 [RCT]. Van der Cammen TJ, O'Callaghan U, Whitefield M. Prevention of pressure sores: a comparison of new and old pressure sore treatments. Br J Clin Pract 1987; 41: 1009–11 [RCT]. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs 2000; 27: 209–15 [CLIN S]. Guideline #2.2: The PURA shall include identification of subjective, objective, and psychosocial factors to determine and assess the risk factors and care needs and the type of preventative care to be provided. The following key points are recommended for documentation and shall be addressed when appropriate: The subjective/objective assessment of skin status and bony prominences and risk for pressure ulcers should include information from the patient and his/her medical record. Elements that should be documented as part of the subjective assessment of skin status and bony prominences include: Description of skin changes as well as any actions taken, recent trauma, friction, shear, or immobility. Use of special garments, shoes, heel, and elbow protectors, orthotic or orthopedic devices. History of pressure ulcers and presence of current ulcer. Previous treatments or surgical interventions that increase risk for pressure ulcers. Factors that impede healing status, such as comorbid conditions or medications. Medical history (history of stroke). Reported usual body weight; desirable body weight, recent change in body weight (quantified) and a decrease in subcutaneous tissue, appetite, dental health, oral and gastrointestinal history, including chewing and swallowing difficulties and a person's ability to feed himself or herself, drug/nutrient interactions, medical/surgical history or interventions that influence nutritional intake or absorption of nutrients; recent changes in dietary intake (quantitative and qualitative). Alcohol and substance abuse, use of tobacco. Gastrointestinal and elimination symptoms (including normal bowel/bladder habits, incontinence, and diarrhea; describe onset, duration, and aggravating and relieving factors of incontinence). Recent changes in functional capacities (e.g., activities of daily living, immobility, ability to move, reposition and turn, level of consciousness, ability and willingness to follow instruction, employment, recreation). Level of evidence: II, III Elements that should be documented as part of the objective assessment for risk of pressure ulcers include: Advanced age (>75 years of age having an odds ratio of >12.6). African-American race. Female gender. Disorders of skin integrity. Daily inspection of skin (dryness and/moisture/shear and friction) and bony prominences and specific vulnerable pressure points for bed- or chair-bound individuals in acute care settings (supine position: occiput, sacrum, heels, spine, elbows, ankles; sitting position: ischial tuberosities, coccyx; side-lying position: trochanters); in long-term care and nursing home settings, inspection may be less frequent—occurring when bathing or providing skin care, yet should still be assessed head to toe and documented on a regular basis as determined by initial risk assessment, changes in risk status, and facility protocol. Assessment for immobility (confined to bed, chairs, wheelchairs, recliners, and couches); individuals who have contractures; who have limited range of motion and limited function; or those who may require assistance in ambulating, moving, turning, repositioning, or getting out of bed or chairs should be carefully monitored for pressure ulcer development; assessment for friction and shearing (individuals who cannot lift themselves during repositioning and transferring at risk for friction injuries; shear injuries commonly occur when the head of the bed is elevated and the individual slides downward). Assessment for incontinence. Admitting diagnosis that may affect skin integrity (gangrene, burns, osteomyelitis, edema, and infections) and wound healing (including immune status and diabetes). Concurrent medical and surgical problems that may affect skin integrity (burns, edema, organ system failure, septicemia, ICU length of stay, ventilator days, advanced cancer, terminal illness, and diabetes) and wound healing (including infections, e.g., urinary tract infections, bacterial infections, pneumonia, anemia, and immune status). Assessment of nutrition status data obtained from the physical examination includes weight, BMI, and anthropometric and laboratory evaluations. Other elements of an objective assessment of nutrition status that may be helpful include lab values listed below such as serum transferrin, prealbumin, and resting energy expenditure. Nutritional requirements and nutrition support options should be determined as an integral part of the initial risk assessment for each individual. Laboratory data as available which may include but are not limited to complete blood count with red cell indices, total lymphocyte count, serum electrolytes, blood urea nitrogen, creatinine, serum glucose, serum albumin, prealbumin, C-reactive protein, transferrin, serum cholesterol, serum triglycerides, and liver function studies. Level of evidence: II Principle: Each patient shall undergo a thorough PURA to assess the risk factors and care needs and the type of preventative care to be provided. Additional considerations, which impact pressure ulcer prevention measures, and should be addressed on an individual basis include: Age differences: Seniors and children are at high risk. Individuals over 65 years of age are at high risk for developing pressure ulcers, neonates and children younger than 5 years old are at high risk, with the head (occiput) being the most common site of pressure ulcer occurrence. Level of evidence: II Gender and racial differences: Female gender, African-American race, and advanced age are identified as risk factors for pressure ulcer diagnosis in acute care hospitals. Spinal cord injury (SCI): Patients with SCI are at high risk of developing pressure ulcers with high rates of recurrence. Level of evidence: II The following are associated with increased risk: history of ulcers, younger age at onset and duration of SCI, greater disability and difficulty with practicing good skin care, and extent of paralysis. Pressure ulcers are least likely to occur among individuals with SCI who maintain a normal weight, return to work and family roles, do not have a history of tobacco u