New Guide SPIPP 2.0: Standardized Pressure Injury Prevention Protocol

Standardized Pressure Injury Prevention Protocol Version 2.0 (SPIPP 2.0：Standardized Pressure Injury Prevention Protocol）

Assessment Items

Completion Status

Evaluation

Assess pressure injury (PI) risk factors to guide prevention

Significant current or anticipated mobility issues

Use structured risk assessment methods upon admission (e.g., Braden or other validated risk assessment tools)

Reassess risk factors at each shift and when there are significant changes in condition

Explain pressure injury (PI) risks and prevention plans to patients/families

Other risk factors to consider: history of previous pressure injuries (PI), local pain_, diabetes____, poor perfusion__, vasopressors__, hypoxia__, increased temperature__, advanced age___, spinal cord injury, neuropathy___, surgery/treatment duration>2hrs___, severe illness_, organ failure_, sepsis_, mechanical ventilation___, medical devices____, sedation_, darker skin tones__

Assess skin/tissue for signs of skin damage and pressure injury (PI)

Assess skin upon admission and at each shift (comprehensive, visual, palpation) for redness, color changes, edema, and temperature changes

Assess skin under medical devices at each shift

Check heels at each shift

For individuals with darker skin tones, ensure adequate lighting and moisture/to enhance visual assessments

Consider enhanced skin assessment methods –thermographic imaging, SEM skin color charts

Preventive skin care –manage moisture/incontinence

Clean and apply appropriate moisture barriers after each incontinence episode

Avoid alkaline soaps/cleansers

For high-risk individuals, consider urine/fecal management systems

Use single-layer, breathable, and highly absorbent pads for incontinence

Consider using low-friction textiles

When appropriate, use soft absorbent materials in skin folds

Pressure Redistribution

For individuals unable to move in bed independently, turn/reposition every 2-3 hours, and may also include frequent micro-adjustments unless contraindicated (Braden activity/mobility score ≤2)

For immobile individuals, use high-specification pressure-reducing mattresses (Braden activity/mobility score ≤2)

Use positioning aids to minimize friction/shear (e.g., pillows, wedges). Use turning/lifting equipment (if available). Correct side-lying position, upper leg in front of lower leg

Add local pressure-reducing protective pads or multilayer protective dressings at high-risk sites (e.g., sacrum, lower buttocks, or heels) (Braden activity/mobility score ≤2)

Use pressure-reducing soft pillows, heel pressure-reducing pads, or specialized heel boots to elevate heels (Braden sensory perception score ≤3)

Ensure adequate repositioning when side-lying (30 degrees). Place the upper leg forward and use a pillow between the legs to support the upper leg

When the overall condition of the patient is unstable, reposition slowly, gradually, frequently, and in small increments

For individuals unable to sufficiently change positions on their own, use pressure redistribution cushions when sitting

Sitting patients should change positions at least once an hour, and may also change the direction of weight bearing to achieve pressure relief

Consult a physical therapist for activity plans as appropriate (Braden activity/mobility score ≤2)

Consider prompting systems, pressure monitoring, movement sensors

Implement early activity plans

Nutrition

Use validated tools for malnutrition screening upon admission

For individuals with existing malnutrition or at risk of malnutrition, reduced nutritional intake,NPO>48hrs or with 2 or more stage pressure injuries (PI) (Braden nutrition score ≤2), consult a nutritionist

Provide additional calories, protein, fluids, and nutritional supplements as per nutritional care plans or as needed (e.g., multivitamins, arginine, glutamine, HMB)

Continuously evaluate goals and consult a nutritionist as needed