Standardized Pressure Injury Prevention Protocol 2.0

Standardized Pressure Injury Prevention Protocol 2.0 (SPIPP 2.0)

Assessment Items

Status

Evaluation

Assess pressure injury (PI) risk factors to guide prevention

Current or anticipated mobility issues

Use structured risk assessment methods (such as Braden or other validated risk assessment tools) upon admission

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

Explain the risks of pressure injuries (PI) and the prevention plan to patients/families

Other risk factors to consider: history of previous pressure injuries (PI), localized pain, diabetes, poor perfusion, vasopressors, hypoxia, increased temperature, advanced age, spinal cord injury, neuropathy, duration of surgery/treatment >2hrs, critical illness, organ failure, sepsis, mechanical ventilation, medical devices, sedation, darker skin tones

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

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

Assess skin under medical devices at every shift

Check heels at every shift

For individuals with darker skin tones, ensure adequate lighting and moisturize the skin to enhance visual inspection

Consider enhanced skin assessment methods – thermography, SEM skin color charts

Preventive skin care – manage moisture/incontinence

Clean after each incontinence event and use appropriate moisture barriers

Avoid using 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 fabrics

Use soft absorbent materials in skin folds when appropriate

Pressure redistribution

For individuals who cannot move independently in bed, turn/reposition every 2-3 hours, and also consider frequent micro-adjustments unless contraindicated (Braden activity/mobility score ≤2)

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

Use positioning aids to minimize friction/shear (pillows, wedges). Use turning/lifting devices (if available). Proper side-lying position, with the upper leg in front of the lower leg

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

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

Ensure adequate position changes (30 degrees) when side-lying. Position the upper leg forward and use a pillow to support the upper leg between both legs

When the overall condition of the patient is unstable, perform position changes slowly, progressively, frequently, and in small increments

For individuals who cannot adequately change positions themselves, use pressure redistribution cushions when sitting

Patients in a sitting position should change positions at least once an hour, and also vary the direction of weight bearing to relieve pressure

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

Consider reminder systems, pressure monitoring, motion sensors

Implement early mobilization plans

Nutrition

Use validated tools for malnutrition screening upon admission

For individuals with existing malnutrition or at risk of malnutrition, decreased nutrient intake, NPO >48hrs, or with stage 2 or higher pressure injuries (PI) (Braden nutrition score ≤2), consult a dietitian

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

Continuously evaluate goals and consult a dietitian as needed