Care Plans

Wound Care

Infection Management

Management of Tissue Load

Pain Management

Nutrition and Hydration

Surgical Intervention

Adjuvant Therapy

Reassessment and Ongoing Care

• To provide guidance and assistance in the decisions required to restore health, independence, control, and self-esteem to people with spinal cord injury
• To provide a conceptual framework within which to develop effective strategies for preventing and treating pressure ulcers

• To present nursing best practice guidelines on the assessment and management of stage I to IV pressure ulcers
• To identify nursing care related to assessment, management of tissue load, ulcer care, and the management of bacterial colonization and infection of pressure ulcers

• United States
• Adolescents and adults with spinal cord injury (SCI)

• Canada
• Patients in the adult population from all areas of clinical practice with or at risk for developing pressure ulcers

Advanced Practice Nurses
Allied Health Personnel
Health Plans
Hospitals
Managed Care Organizations
Nurses
Occupational Therapists
Patients
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers

Advanced Practice Nurses
Nurses

Assessment Following Onset of a Pressure Ulcer

Assessment of the Individual With a Pressure Ulcer

Perform an initial comprehensive assessment of the individual with a pressure ulcer, to include:

• Complete history
• Physical examination and laboratory tests
• Psychological health, behavior, cognitive status, and social and financial resources
• Availability and utilization of personal care assistance
• Positioning, posture, and related equipment

(Scientific evidence: I, II, III, V; Grade of recommendation: A, B, C; Strength of panel opinion: Strong)

Assessment of the Pressure Ulcer

Describe in detail an existing pressure ulcer. Include the following parameters:

• Anatomical location and general appearance
• Size (length width, depth, and wound area)
• Stage
• Exudate/odor
• Necrosis
• Undermining
• Sinus tracts
• Infection
• Healing (granulation and epithelialization)
• Wound margins/surrounding tissue

(Scientific evidence: I, II, V; Grade of recommendation: A, B, C; Strength of panel opinion: Strong)

Assessment

Recommendation 1.1

Conduct a history and focused physical assessment.

(Level of Evidence = IV)

Discussion of Evidence

Pressure ulcers should be assessed in the context of the patient's overall physical and psychological health. A focused physical assessment includes a risk assessment for pressure ulcer development - Appendix C in the original guideline document provides a description of the Braden Scale for Predicting Pressure Sore Risk. A French translation of this scale has recently been shown to be reliable and valid in clinical practice. The guideline development panel strongly supports consultation with interdisciplinary team members in the assessment process; in particular, the involvement of members who have wound care expertise.

Recommendation 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.

(Level of Evidence = IV)

Recommendation 1.3

Assess quality of life from the client's perspective.

(Level of Evidence = IV)

Recommendation 1.6

Assess all patients for pain related to the pressure ulcer or its treatment.

(Level of Evidence = IV)

Recommendation 1.7

Assess 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.

(Level of Evidence = IIb)

Recommendation 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.

(Level of Evidence = IV)

Recommendation 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.

(Level of Evidence = IV)

Discussion of Evidence

The guideline development panel recommends that vascular assessments, including Ankle/Brachial Pressure Index (ABPI) measurements, be used to rule out arterial disease and to determine appropriate therapy for those individuals with pressure ulcers on their lower extremities. It is cautioned, however, that ABPI readings may be unreliable and falsely elevated due to calcification of vessels in patients who have diabetes. Furthermore, research evidence indicates that Doppler ultrasound measurements of ABPI can be also unreliable if operators have not undergone training, adding that reliability can be considerably improved if operators have received appropriate education to undertake this measure.

A comprehensive treatment plan includes assessment of risk, health status of the individual, and status of the pressure ulcer. The elements of a treatment plan include cleansing, debridement, dressings, surgery, nutrition and management of tissue loads. These elements represent standard treatment procedures as reflected in current literature and practice. However, new research and innovative approaches are being developed in the areas of adaptive therapies.

Assessment

Recommendation 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.

(Level of Evidence = IV)

Discussion of Evidence

The goal of a psychosocial assessment is to collect the information necessary to develop a plan of care with the client that is consistent with individual and family preferences, goals and resources (personal, financial, etc.). The findings regarding an individual's psychological health and the impact on pressure ulcer development is mixed; however, it is evident that many of the recommendations for prevention and management of existing ulcers require the understanding, cooperation and initiative of clients and their caregivers. These complex behaviours suggest that a psychosocial assessment should be conducted to identify factors for consideration in developing prevention and management strategies.

A complete psychosocial assessment should include, but not be limited to, the following:

• Mental status, depression, client collaboration, learning ability
• Social support and social integration in the family
• Polypharmacy or overmedication; alcohol and/or drug abuse
• Goals, values and lifestyle
• Sexuality
• Culture and ethnicity
• Resources (e.g., availability, utilization and skill of caregivers; finances; positioning, posture and related equipment) of individuals being treated for pressure ulcers in the home
• Stressors, including pain as a symptom
• Quality of life

The treatment plan should include interventions to address identified psychosocial needs and goals. Follow-up should be planned in cooperation with the individual and caregiver, in consultation with appropriate interdisciplinary team members.

Cleansing

Cleanse pressure ulcers at each dressing change.

• Use minimum mechanical force when cleaning with gauze, cloth, or sponge.
• Use enough irrigation pressure to enhance cleansing without causing trauma to the wound.
• Use normal saline or wound cleansers.
• Avoid antiseptic agents.
• Consider hydrotherapy for ulcers containing large amounts of exudate and necrotic tissue.

(Scientific evidence: I, III, V; Grade of recommendation: A, C; Strength of panel opinion: Strong)

Debridement

Debride devitalized tissue from pressure ulcers using a method appropriate to the ulcer's status and the individual's condition and goals.

• Debride areas in which there is eschar and devitalized tissue

(Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong)

Refer to Table 7 in the original guideline document for a comparison of debridement methods.

Dressings

Use dressings that will keep the ulcer bed continuously moist and the surrounding intact skin dry.

• Use a dressing that controls exudate, but does not desiccate the ulcer bed or macerate surrounding tissue.
• Loosely fill pressure ulcer cavities with dressing material to avoid dead space; avoid overpacking the ulcer.
• Monitor the placement of all dressings, especially those in anatomical areas in which they are difficult to keep intact.
• Perform dressing changes on a specific schedule based on assessment of the individual, the ulcer, and the condition of the dressing. Consult the dressing manufacturer's package insert for general information and about the frequency of dressing changes.

(Scientific evidence: I, II; Grade of recommendation: A, B; Strength of panel opinion: Strong)

Refer to Table 8 in the original guideline document for a comparison of major dressing categories.

Local Wound Care

Assessment

Recommendation 3.1a

To plan treatment and evaluate its effectiveness, assess the pressure ulcer(s) initially for:

• Stage/Depth
• Location
• Surface Area (length x width) (mm², cm²)
• Odour
• Sinus tracts/Undermining/Tunneling
• Exudate
• Appearance of the wound bed
• Condition of the surrounding skin (periwound) and wound edges

(Level of Evidence = IV)

Discussion of Evidence

There are several classification systems to describe wound stages; however, the NPUAP system is the method most widely accepted. Refer to Appendix H in the original guideline document for a description of the NPUAP classification system.

Appendix I - Wound Measurement (see the original guideline document), provides a diagram of the recommended technique for measuring pressure ulcer surface area and undermining. Combining multiple measurement techniques may help to more accurately monitor and evaluate pressure ulcers. This clinical measurement can be achieved by using a ruler (width/length/depth), other measurement devices, transparency tracings or photography. Length is measured as the longest axis of the wound. Width is measured at 90 degrees to the length at the next longest axis.

Sibbald, Orsted et al. (2006) suggest that the MEASURE mnemonic can be used to guide a consistent approach to local wound assessment, though it is also emphasized that assessment must occur within the context of a global assessment of the particular client and environment. Refer to Appendix J in the original guideline document for a description of MEASURE.

Numerous tools have been developed for documenting wound assessment. These assessment tools include, but are not limited to: the Pressure Sore Status Tool (PSST); the NPUAP, Pressure Ulcer Scale for Healing (PUSH), the Wound Healing Scale (WHS), and the Sussman Wound Healing Tool (SWHT). Appendix K — Documentation: Wound Assessment Tools (see the original guideline document) provides examples of tools for systematic assessment and documentation.

A clean pressure ulcer with adequate vascular supply receiving adequate treatment should show signs of healing within two to four weeks. If the condition of the patient or of the wound deteriorates, or if the goal of care is healing and no progress can be demonstrated, re-evaluate the treatment plan and/or the presence of complications. Some wounds, however, will not heal. In this case, the goal of healing may be revised to prevent infection, to prevent further deterioration, and to provide comfort so that quality of life and dignity is maintained.

Recommendation 3.1b

Conduct a comprehensive reassessment weekly to determine wound progress and the effectiveness of the treatment plan. Monitor for variances from assessment with each dressing change. Identification of variances indicates need for reassessment.

(Level of Evidence = IV)

Debridement

Recommendation 3.2a

Lower extremity ulcers or wounds in patients who are gravely palliative with dry eschar need not be debrided if they do not have edema, erythema, fluctuance, or drainage. Assess these wounds daily to monitor for pressure ulcer complications that would require debridement.

(Level of Evidence = IV)

Recommendation 3.2b

Prior to debridement on ulcers on the lower extremities, complete a vascular assessment (e.g., clinical assessment, palpable pedal pulses, capillary refill, ankle/brachial pressure index, and toe pressure) to rule out vascular compromise.

(Level of Evidence = IV)

Recommendation 3.2c

Determine if debridement is appropriate for the patient and the wound.

(Level of Evidence = IV)

Discussion of Evidence

Given the risk and patient safety concerns associated with debridement procedures, the panel strongly emphasizes the need for caution in selecting debridement as an appropriate intervention.

In some instances debridement may not be appropriate. Situations of this nature would include a limb or digit that is ischemic, and amputation is not possible - these wounds will not heal. In these cases, the necrotic tissue should be kept as dry as possible to prevent odour and infection. The eschar provides a barrier to external contamination in a non-healing wound. The topical application of a drying, antimicrobial agent, such as betadine, may be beneficial. In addition, for some wounds the removal of eschar is not necessary (e.g., small areas on heels and toes).

Vascular assessment is essential to ensure patient safety and to determine appropriate treatment options. Although it is recognized that false positive results are possible with palpable pedal pulses and capillary refill assessment, in cases where diagnostic tests are unavailable, these assessments are recognized as useful to support decision making.

Recommendation 3.2d

If debridement is indicated, select the appropriate method of debridement considering:

• Goals of treatment (e.g., healability)
• Client's condition (e.g., end of life, pain, risk of bleeding, patient preference, etc.)
• Type, quantity, and location of necrotic tissue
• The depth and amount of drainage
• Availability of resources

(Level of Evidence = IV)

Recommendation 3.2e

Sharp debridement should be selected when the need is urgent, such as with advancing cellulitis or sepsis, increased pain, exudate, and odour. Sharp debridement must be conducted by a qualified person.

(Level of Evidence = IV)

Recommendation 3.2f

Use sterile instruments to debride pressure ulcers.

(Level of Evidence = IV)

Discussion of Evidence

The general categories of debridement are: sharp (or surgical), enzymatic, autolytic, biologic and mechanical. Refer to Appendix L in the original guideline document for a description of key factors in deciding on a method of debridement.

NGC Note: Refer to p. 36 of the original guideline document for additional discussion of the debridement methods mentioned above.

Wound Cleansing

Recommendation 3.4a

Do not use skin cleansers or antiseptic agents (e.g., povidone iodine, iodophor, sodium hypochlorite solution, hydrogen peroxide, acetic acid) to clean ulcer wounds.

(Level of Evidence = III)

Recommendation 3.4b

Use normal saline, Ringer's lactate, sterile water, or non-cytotoxic wound cleansers for wound cleansing.

(Level of Evidence = IV)

Recommendation 3.4c

Fluid used for cleansing should be warmed at least to room temperature.

(Level of Evidence = III)

Recommendation 3.4d

Cleanse wounds at each dressing change.

(Level of Evidence = IV)

Recommendation 3.4e

To reduce surface bacteria and tissue trauma, the wound should be gently irrigated with 100 to 150 milliliters of solution.

(Level of Evidence = IV)

Recommendation 3.4f

Use enough irrigation pressure to enhance wound cleansing without causing trauma to the wound bed. Safe and effective ulcer irrigation pressures range from 4 to 15 pounds per square inch (psi). Pressure of 4 to 15 psi is achieved by using:

• 35 milliliter syringe with a 19 gauge angiocath, or
• Single-use 100 milliliter saline squeeze bottle

(Level of Evidence = IIa)

Appendix P in the original guideline document provides a summary of the various wound care cleansers, indications and considerations.

Management Approaches

Recommendation 3.5a

For comprehensive wound management options, consider the following:

• Etiology of the wound
• Client's general health status, preference, goals of care, and environment
• Lifestyle
• Quality of life
• Location of the wound
• Site of the wound, including depth and undermining
• Pain
• A dressing that will loosely fill wound cavity
• Exudate: type and amount
• Risk of infection
• Risk of recurrence
• Type of tissue involved
• Phase of the wound healing process
• Frequency of the dressing change
• Comfort and cosmetic appearance
• Where and by whom the dressing will be changed
• Product availability
• Adjunctive therapies

(Level of Evidence = IV)

Recommendation 3.5b

Moisture-retentive dressings optimize the local wound environment and promote healing.

(Level of Evidence = Ia)

Recommendation 3.5c

Consider caregiver time when selecting a dressing.

(Level of Evidence = Ib)

Recommendation 3.5d

Consider the following criteria when selecting an interactive dressing:

• Maintains a moist environment (Level of Evidence = Ia)
• Controls wound exudate, keeping the wound bed moist and the surrounding intact skin dry (Level of Evidence = IV)
• Provides thermal insulation and wound temperature stability (Level of Evidence = IV)
• Protects from contamination of outside micro-organisms (Level of Evidence = IV)
• Maintains its integrity and does not leave fibres or foreign substances within the wound (Level of Evidence = IV)
• Does not cause trauma to wound bed on removal (Level of Evidence = IV)
• Client/patient preference (Level of Evidence = IV)
• Is simple to handle, and is economical in cost and time (Level of Evidence = IV)

Recommendation 3.5e

Monitor dressings applied near the anus, since they are difficult to keep intact. Consider use of special sacral-shaped dressings.

(Level of Evidence = Ib)

Appendix Q in the original guideline document provides a summary of various categories of wound dressings, indications and considerations.

Treatment

Nonsurgical

Topical antibiotics may be used if routine measures do not result in wound healing after several weeks. Broad spectrum agents, such as 1 percent silver sulfadiazine cream, may be used, although cross-sensitivity to other sulfonamides may occur. Mupirocin calcium cream 2 percent may be applied for pressure ulcers infected with Staphylococcus aureus and Streptococcus pyogenes. Prolonged use may result in overgrowth of nonsusceptible microorganisms, including fungi.

Preoperative Care

• Assess, treat, and optimize the following factors preoperatively:
  • Local wound infection
  • Osteomyelitis

(Scientific evidence: II, III, V; Grade of recommendation: C; Strength of panel opinion: Strong)

Complications of Pressure Ulcers

Nonsurgical

• Identify the presence of tissue and/or bone infection.
  • Obtain quantitative tissue and/or bone cultures in ulcers not responding to routine therapeutic measures.
  • Obtain a tissue and/or bone biopsy to confirm infection, if necessary.

(Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong)

• Management of cellulitis, osteomyelitis, and sepsis requires antibiotics.

Surgical

• Identify potential complications of surgical intervention, including:
  • Wound dehiscence/wound separation
  • Delayed infection and abscess
  • Hematoma and seroma

(Scientific evidence: None; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong)

Control Bacteria/Infection

Recommendation 3.3a

The treatment of infection is managed by wound cleansing, systemic antibiotics, and debridement, as needed.

(Level of Evidence = Ib)

Recommendation 3.3b

Protect pressure ulcers from sources of contamination, e.g., fecal matter

(Level of Evidence = IIa)

Recommendation 3.3c

Follow Body Substance Precautions (BSP) or an equivalent protocol appropriate for the healthcare setting and the client's condition when treating pressure ulcers.

(Level of Evidence = IV)

Recommendation 3.3d

Medical management may include initiating a two-week trial of topical antibiotics for clean pressure ulcers that are not healing or are continuing to produce exudate after two to four weeks of optimal patient care. The antibiotic should be effective against gram-negative, gram-positive and anaerobic organisms.

(Level of Evidence = Ib)

Recommendation 3.3e

Medical management may include appropriate systemic antibiotic therapy for patients with bacteremia, sepsis, advancing cellulitis or osteomyelitis.

(Level of Evidence = Ib)

Recommendation 3.3f

To obtain a wound culture, cleanse wound with normal saline first. Swab wound bed, not eschar, slough, exudate, or edges.

(Level of Evidence = IV)

Recommendation 3.3g

The use of cytotoxic antiseptics to reduce bacteria in wound tissue is not usually recommended.

(Level of Evidence = IIb)

Discussion of Evidence

Refer to Appendix M in the original guideline document for a description of the clinical signs and symptoms of wound infection.

Please refer to Appendix N in the original guideline document for a listing of commonly used topical antimicrobial agents.

The development panel supports the use of sterile dressings in all care settings, whenever possible, in order to decrease the bioburden within pressure ulcers.

Proper technique in obtaining a wound culture is critical, and a standardized quantitative swab technique can accurately document the bioburden in pressure ulcers. Though there remains much debate surrounding approaches to wound culture sampling, the panel supports the Levine method as it has recently emerged in the literature and current practice as the best approach for obtaining semi-quantitative wound culture swabs. This represents a change from the previously recommended zig-zag method. Most wounds need some form of preparation prior to the culture in order to reduce the risk of introducing extraneous microorganisms into the specimen. The exudate that accumulates on the surface of the wound and under dressings contains bacteria that are not the same as those causing infection in the wound. Irrigate wounds with normal saline until all visible debris has been washed away. Successful culturing also involves culturing viable tissue, therefore never swab eschar or yellow fibrous slough. Ensure that the swab is moist or alternatively, add normal saline to the wound bed and/or swab. Rotate the swab tip in a 1 cm² area of the cleanest and deepest part of the wound and/or area of granulation, using enough pressure to release tissue exudate for a period of five seconds. This may be painful so warn the patient of the possibility of pain. Ensure adequate pain management and pre-medicate (e.g., topical wound analgesia) if possible. For a diagram of swabbing technique for accurate wound culture results, refer to Appendix O — Wound Cultures: Swabbing Techniques (see the original guideline document).

Support Surfaces and Positioning for Managing Tissue Loads

Bed Positioning

Use bed-positioning devices and techniques to prevent and treat pressure ulcers. Use devices and techniques that are compatible with the bed type and the individual's health status.

• Avoid positioning individuals directly on a pressure ulcer.
• Avoid positioning individuals directly on the trochanter.
• Use cushions and positioning aids to relieve pressure on pressure ulcers or vulnerable skin areas by elevating them away from the support surface.
• Avoid close cutouts or donut-type cushions.
• Prevent contact between bony prominences.
• Limit the amount of time the head of the bed is elevated.
• Develop, display, and use an individualized positioning regimen and repositioning schedule.

(Scientific evidence: II, V; Grade of recommendation: B, C; Strength of panel opinion: Strong)

Bed Support Surfaces

Use pressure-reducing bed support surfaces for individuals who are at risk for or who have pressure ulcers.

• Select a static support surface for individuals who can be positioned without weight bearing on an ulcer and without bottoming out on the support surface.
• Select a dynamic support surface if the individual cannot be positioned without pressure on an ulcer, when a static support surface bottoms out, if there is no evidence of ulcer healing, or if new ulcers develop.
• Use low-air loss and air-fluidized beds in the treatment of pressure ulcers if one or more of the following conditions exist:
  • Pressure ulcers on multiple turning surfaces
  • Compromised skin temperature and moisture control in the presence of large stage III or IV pressure ulcers

(Scientific evidence: I, II, V; Grade of recommendation: A, B, C; Strength of panel opinion: Strong)

Wheelchair Positioning

Prescribe wheelchairs and seating systems according to individualized anthropometric, ergonomic, and functional principles.

• Obtain specific body measurements for optimal selection of seating system dimensions.
• Measure the effects of posture and deformity on interface pressure distribution.
• Prescribe a power weight-shifting wheelchair system for individuals who are unable to independently perform an effective weight shift.
• Use clinical judgment as well as objective data in determining the compatibility of the individual's shape with the seating system.

(Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong)

Evaluate the individual's postural alignment, weight distribution, balance, stability, and pressure reduction capabilities to establish a proper sitting schedule.

• Avoid positioning the wheelchair-seated individual directly on a pressure ulcer.
• Allow limited sitting in individuals capable of performing weight shifts every 15 minutes.
• Reposition the wheelchair-seated individual at least every hour; if this is not possible and the individual is unable to perform weight shifts, return the individual to bed.

(Scientific evidence: II, III; Grade of recommendation: B, C; Strength of panel opinion: Strong)

Wheelchair Support Surfaces

Use appropriate wheelchair cushions with all individuals with spinal cord injury.

• Inspect and maintain all wheelchair cushions at regularly scheduled intervals.

(Scientific evidence: II, V; Grade of recommendation: B, C; Strength of panel opinion: Strong)

Assessment

Recommendation 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.

(Level of Evidence = Ia)

Clients identified at risk of developing a pressure ulcer should receive care on a low interface pressure mattress.

Discussion of Evidence

Even when using a high specification foam mattress, other pressure management devices, such as overlays, can be used in combination as needed. Importantly, despite the use of any pressure management device, repositioning should also be used to prevent further pressure ulcers. Additional strategies, particularly for special needs pediatric and geriatric populations, can be designed in consultation with the interdisciplinary team.

For further discussion of prevention strategies, the reader is encouraged to consult the RNAO Nursing Best Practice Guideline Risk Assessment and Prevention of Pressure Ulcers (Revised) (2005) (See the NGC summary).

Management of Causative/Contributing Factors

Recommendation 2.1

Choose the support surface which best fits with the overall care plan for the client considering the goals of treatment, client bed mobility, transfers, caregiver impacts, ease of use, cost/benefit, etc. Ensure ongoing monitoring and evaluation to ensure that the support surface continues to meet the client's needs and that the surface is used appropriately and is properly maintained. If the wound is not healing, consider the total care plan for the client before replacing the surface.

(Level of Evidence = IV)

Recommendation 2.2

Pressure management of the heels while in bed should be considered independently of the support surface.

(Level of Evidence = III)

Recommendation 2.4

Obtain a seating assessment if a client has a pressure ulcer on a sitting surface.

(Level of Evidence = IV)

Recommendation 2.5

Refer patients at RISK to appropriate interdisciplinary team members (Occupational Therapist, Physiotherapist, Enterostomal Therapist, etc). Utilize those with expertise in seating, postural alignment, distribution of weight, balance, stability, and pressure management when determining positioning for sitting individuals. Ensure support surfaces are used appropriately and are properly maintained.

(Strength of Evidence = IV)

Recommendation 2.6

A client with a pressure ulcer on the buttocks and or trochanter should optimize mobilization. If pressure on the ulcer can be managed, encourage sitting as tolerated.

(Strength of Evidence = IV)

Discussion of Evidence

Pressure is the major causative factor in pressure ulcer formation. Therefore, pressure ulcers will not heal if the etiology of pressure, shearing and friction are not addressed. For clients at risk of developing pressure ulcers, or for those with existing pressure ulcers, institute the recommendations related to risk assessment and prevention described in the RNAO Nursing Best Practice Guideline Risk Assessment and Prevention of Pressure Ulcers (Revised) (2005), available at www.rnao.org/bestpractices. Appendix C in the original guideline document provides a sample of the Braden Scale for Predicting Pressure Sore Risk.

Importantly, the panel recognizes that the use of support surfaces may be limited by the availability of resources. As there are many factors which may result in the poor healing of pressure ulcers, the panel suggests an exploration of alternative measures to support healing prior to proceeding to a powered support surface (e.g., nutrition, transferring strategies).

All surfaces should be checked to ensure they are not "bottoming out". The condition of "bottoming out" occurs when a mattress overlay, support or wheelchair cushion is compressed by high pressure. A subjective estimate of the amount of compression can be achieved by palpation of the support thickness at the bony prominence. To determine if a patient has bottomed out, the caregiver should place an outstretched hand (palm up) under the mattress overlay below the part of the body at risk for ulcer formation. If the caregiver can feel that the support material is less than an inch thick at this site, the patient has bottomed out. Bottoming out should be checked at various anatomical sites and while the patient assumes various body positions.

No recommendations offered.

Recommendation 1.6

Assess all patients for pain related to the pressure ulcer or its treatment.

(Level of Evidence = IV)

Recommendation 1.7

Assess 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.

(Level of Evidence = IIb)

Discussion of Evidence

Pain should be assessed routinely and regularly using the same validated tool each time. Assessment tools should be appropriate for the cognitive ability of the patient, and should be easy to use. Although there are a number of validated tools, some of which are adapted for specific patient populations, there are no validated pain assessment tools for use specifically with clients experiencing pressure ulcer pain. However, recent studies have supported the use of the McGill Pain Questionnaire, the Modified Functional Independence Measure (FIM) in combination with the Visual Analogue scale, and the Faces Rating Scale, particularly with cognitively and sensory impaired elderly, to assess pain related to pressure ulcers or associated treatment. For sample assessment tools that have been tested for validity and reliability in adults, please refer to Appendix E in the original guideline document - Tools for Assessment of Pain.

The AHCPR (1994) recommends that the management of pressure ulcer pain should include eliminating or controlling the source of pain (i.e., covering wounds, adjusting support surfaces, and repositioning), as well as providing analgesia to treat procedure-related and wound pain. Case and pilot studies indicate topical analgesia may be useful in treating pressure ulcer pain. Overall, however, the successful management of pain is a complex interdisciplinary effort requiring a multifaceted treatment plan, the discussion of which is beyond the scope of this guideline.

Accurate assessment and diagnosis of the type of pain, its intensity and its effect on the person, are necessary to plan appropriate interventions or treatments and are an integral part of an overall clinical assessment. For comprehensive recommendations on the assessment and management of pain, and a discussion of the evidence, please refer to the RNAO Nursing Best Practice Guideline Assessment and Management of Pain (Revised) (2007) (see the NGC Summary).

Recommendation 3.2g

Prevent or manage pain associated with debridement. Consult with a member of the healthcare team with expertise in pain management. Refer to the Registered Nurses' Association of Ontario (RNAO) Best Practice Guideline Assessment and Management of Pain (Revised) (2007).

(Level of Evidence = IV)

Nutrition

• Assess nutritional status of all spinal-cord injury individuals on admission and as needed, based on medical status, including:
  • Dietary intake
  • Anthropometric measurements
  • Biochemical parameters (prealbumin, total protein, albumin, hemoglobin, hematocrit, transferrin, and total lymphocyte count)

(Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong)

• Provide adequate nutritional intake to meet individual needs, especially for:
  • Calories (or energy)
  • Protein
  • Micronutrients (zinc, vitamin C, vitamin A, and vitamin E)
  • Fluids

(Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong)

• Implement aggressive nutritional support measures if dietary intake is inadequate or if an individual is nutritionally compromised.

(Scientific evidence: II; Grade of recommendation: B; Strength of panel opinion: Strong)

Recommendation 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.

(Level of Evidence = III)

Recommendation 1.5

Prevent clinical nutrient deficiencies by ensuring that the patient is provided with optimal nutritional support through one or more of the following:

• Consultation with a Registered Dietitian for assessment (Level of Evidence = IV)
• Consultation with a speech language pathologist for swallowing assessment (Level of Evidence = IV)
• A varied, balanced diet to meet clinical requirements for healing and co-existing diseases (e.g., renal failure and diabetes) (Level of Evidence = IV)
• Nutritional supplements if needed (Level of Evidence = Ia)
• Multivitamin and mineral preparations (Level of Evidence = Ib)
• Enteral tube feeding (Level of Evidence = IV)
• Parenteral nutrition (Level of Evidence = IV)
• Ongoing monitoring of nutritional intake, laboratory data and anthropometric data (Level of Evidence = IV)

Discussion of Evidence

Nutritional management should address four rules: determine the nutritional status; ensure adequate nutritional intake; initiate additional nutrient intake and supplementation; and determine vitamin, mineral and trace element deficits and correct them.

A screening tool may be used by nurses to identify those at nutritional risk; however, referral to those with expertise in nutritional interventions is necessary to establish an appropriate treatment plan. For a sample tool focusing on nutritional screening and assessment, refer to Appendix D in the original guideline document which includes the Mini Nutritional Assessment (MNA). The Mini Nutritional Assessment has been validated for use with adults over the age of 55.

Body Mass Index (BMI) is another nutritional screening tool, which is a valid measurement of weight in relation to health. It is not recommended, however, for use as the sole measurement of either body composition or level of fitness. The BMI is available on the Health Canada Web site. Early identification and intervention to correct malnutrition can alter the healing trajectory in patients with wounds. A nutritional plan should be comprehensive and individualized, and therefore requires a multidisciplinary approach. The involvement of the interdisciplinary team and the patient in addressing nutritional goals is essential for successful outcomes.

Nutritional interventions should be staged to meet the nutritional needs of the individual and move from screening, monitoring of intake and supplementation (when necessary) to more intensive interventions, including enteral or parenteral feeding.

Reassessment

Surgical

Refer appropriate individuals with complex, deep stage III pressure ulcers (i.e., undermining, tracts) or stage IV pressure ulcers for surgical evaluation. When surgery is indicated, include the following tenets of surgical treatment:

• Excising of ulcer, surrounding scar, bursa, soft tissue calcification, and underlying necrotic or infected bone
• Filling dead space, enhancing vascularity of the healing wound, and distributing pressure off the bone
• Resurfacing with a large regional pedicle flap, with suture line away from the area of the direct pressure, and one that does not encroach on adjacent flap territories
• Preserving options for future potential breakdowns

(Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong)

Preoperative Care

Assess, treat and optimize the following factors preoperatively:

• Local wound infection
• Nutritional status
• Bowel regulation
• Severe spasm and contractures
• Comorbid conditions
• Previous ulcer surgery
• Smoking
• Osteomyelitis
• Urinary tract infection
• Heterotopic ossification

(Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong)

Postoperative Care

Be cognizant of postoperative care procedures.

• Position the individual in a manner that keeps pressure off a fresh surgical site.
• Use an air-fluidized bed when pressure on the surgical flap is unavoidable.
• Progressively mobilize the individual to a sitting position over at least 4 to 8 weeks to prevent reinjury of the ulcer or surgical site.
• Provide subsequent patient education on pressure management and skin inspection.

(Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong)

Complications of Pressure Ulcers

Surgical

Identify potential complications of surgical intervention, including:

• Wound dehiscence/wound separation
• Delayed infection and abscess
• Hematoma and seroma

(Scientific evidence: None; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong)

Surgical Intervention

Recommendation 3.7

Possible candidates for operative repair are medically stable, adequately nourished and are able to tolerate operative blood loss and postoperative immobility.

(Level of Evidence = IV)

Discussion of Evidence

Operative repair of pressure ulcers is an option for clean Stage III or Stage IV pressure ulcers that do not respond to optimal wound care. The high recurrence rate and long duration to achieve complete healing are often given as reasons for surgical closure as an appropriate option. Surgical procedures used to repair pressure ulcers include one or more of the following: direct closure, skin grafting, skin flaps, musculocutaneous flaps and free flaps.

The decision for surgery is determined in collaboration with the interdisciplinary team and the client. Factors to consider prior to operative repair include: the patient's medical stability, nutritional status, ability to tolerate the recovery period as well as the likelihood that surgery will improve the patient's functional status.

Treatment

Nonsurgical

Electrical Stimulation

Use electrical stimulation to promote closure of stage III or IV pressure ulcers combined with standard wound care interventions.

(Scientific evidence: I, II; Grade of recommendation: A; Strength of panel opinion: Strong)

Adjunctive Therapies

Literature reviews were done for several adjunctive wound therapies, including those that used physical forms of energy, such as ultraviolet radiation, low-energy laser radiation, normothermia, ultrasound, subatmospheric pressure therapy, hyperbaric oxygen, topical agents, cytokine growth factors, and nonantibiotic systemic drugs. These reviews did not provide sufficient supporting evidence to justify recommending them for the treatment of pressure ulcers in individuals with spinal cord injury.

Adjunctive Therapies

Recommendation 3.6a

Refer to physiotherapy for a course of treatment with electrotherapy for Stage III and IV pressure ulcers that have proved unresponsive to conventional therapy. Electrical stimulation may also be useful for recalcitrant Stage II ulcers.

(Level of Evidence = Ib)

Recommendation 3.6b

Chronic pressure ulcers may be treated by:

• Electrical stimulation (Level of Evidence = Ib)
• Ultraviolet light C (Level of Evidence = IIa)
• Warming therapy (Level of Evidence = Ib)
• Growth factors (Level of Evidence = Ib)
• Skin equivalents (Level of Evidence = IV)
• Negative pressure wound therapy (Level of Evidence = IV)
• Hyperbaric oxygen (Level of Evidence = IV)

Discussion of Evidence

Candidates for adjunctive therapies include individuals with chronic wounds who have failed to respond to optimal standard wound care, those with pre-existing medical conditions that delay wound healing and/or who prefer a non-surgical, conservative option to facilitate wound healing. Prior to initiating an adjunctive therapy, the health care provider must ensure that the patient does not have any contraindications for that treatment modality.

Reassessment

Monitor and assess the pressure ulcer on a consistent, ongoing basis to determine the adequacy of the plan of care.

• Monitor the pressure ulcer at each dressing change.
• Document ulcer assessment at least weekly and every time the condition of the pressure ulcer or the individual changes.

(Scientific evidence: None; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong)

Modify the treatment plan if the ulcer shows no evidence of healing within 2 to 4 weeks.

• Review individual risk factors when assessing the healing of pressure ulcers.
• Evaluate healing progress using an instrument or other quantitative measurements.

(Scientific evidence: I, V; Grade of recommendation: A, C; Strength of panel opinion: Strong)

Complications of Pressure Ulcers

Nonsurgical

• Identify the potential complications of immobility associated with pressure ulcer management and implement preventive and therapeutic measures for:
  • Nutritional deficiencies and dehydration
  • Decreased range of motion
  • Deconditioning (cardiopulmonary, cardiovascular, and musculoskeletal)

(Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong)

• Manage hypergranulation tissue that may impede ulcer healing.

(Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong)

• Identify the potential psychosocial impacts of pressure ulcers and immobility and provide referral for therapeutic interventions based upon the individual's characteristics and circumstances. Refer to appropriate resources for problem resolution, including:
  • Vocational rehabilitation services
  • Peer counseling and support groups
  • Formal psychotherapy and/or family therapy

(Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong)

Surgical

• Identify potential complications of surgical intervention, including:
  • Wound dehiscence/wound separation
  • Delayed infection and abscess
  • Hematoma and seroma

(Scientific evidence: None; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong)

A clean pressure ulcer with adequate vascular supply receiving adequate treatment should show signs of healing within two to four weeks. If the condition of the patient or of the wound deteriorates, or if the goal of care is healing and no progress can be demonstrated, re-evaluate the treatment plan and/or the presence of complications. Some wounds, however, will not heal. In this case, the goal of healing may be revised to prevent infection, to prevent further deterioration, and to provide comfort so that quality of life and dignity is maintained.

Management of Causative/Contributing Factors

Recommendation 2.1

Choose the support surface which best fits with the overall care plan for the client considering the goals of treatment, client bed mobility, transfers, caregiver impacts, ease of use, cost/benefit, etc. Ensure ongoing monitoring and evaluation to ensure that the support surface continues to meet the client's needs and that the surface is used appropriately and is properly maintained. If the wound is not healing, consider the total care plan for the client before replacing the surface.

(Level of Evidence = IV)

Recommendation 3.1b

Conduct a comprehensive reassessment weekly to determine wound progress and the effectiveness of the treatment plan. Monitor for variances from assessment with each dressing change. Identification of variances indicates need for reassessment.

(Level of Evidence = IV)

Discharge/Transfer of Care Arrangements

Recommendation 4.1

Clients moving between care settings should have the following information provided:

• Risk factors identified
• Details of pressure points and skin condition prior to transfer
• Need for pressure management/mobility equipment (e.g., support surfaces, seating, special transfer equipment, heel boots)
• Details of healed ulcers
• Stage, site and size of existing ulcers
• History of ulcers, previous treatments and dressings (generic) used
• Type of dressing currently used and frequency of change
• Any allergies to dressing products
• Need for on-going nutritional support

(Level of Evidence = IV)

Recommendation 4.2

Use the Registered Nurses' Association of Ontario Best Practice Guideline Risk Assessment and Prevention of Pressure Ulcers (Revised) (2005) (see the NGC summary).

(Level of Evidence = IV)

The benefits of clinical practice guidelines for the spinal cord medicine practice community are numerous. Among the more significant applications and results are the following:

• Clinical practice options and care standards
• Medical and health professional education and training
• Building blocks for pathways and algorithms
• Evaluation studies of clinical practice guidelines use and outcomes
• Research gap identification
• Cost and policy studies for improved quantification
• Primary source for consumer information and public education
• Knowledge base for improved professional consensus building

Additional benefits include:

• Reduced incidence and recurrence of pressure ulcer in patients with spinal cord injury

• Guideline implementation is intended to help nurses in a variety of health care settings with the assessment and management of stage I to stage IV pressure ulcers in Canadian clients.
• Appropriate evaluation and management of pressure ulcers may help promote wound healing, prevent further skin breakdown, and decrease the incidence and severity of pressure ulcers.
• Nurses, other health care professionals and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment and documentation tools, etc.

Mechanical debridement is slow, can be painful, and should be discontinued when necrotic tissue has been removed.

Bleeding, the need for anesthesia and its associated risks, and possible injury to nervous or other viable tissue are the main disadvantages of sharp or surgical debridement techniques.

• Debridement may not be appropriate for a limb or digit that is ischemic, and amputation is not possible.
• Debridement with a scalpel should be undertaken with caution and performed by specially trained and experienced health care professionals. It causes bleeding, may require anesthetic (for surgical debridement of Stage IV wounds), and has the potential to cause injury to nervous or other viable tissue.
• Mechanical debridement is a slow process, can be painful, and should be discontinued when necrotic tissue has been removed. Wet-to-dry dressings in particular are nonselective in that they remove both viable and necrotic tissue, and are potentially damaging to granulation and epithelial tissue. It is important to ensure that appropriate and adequate pain management is incorporated into the plan of care when this method is utilized.
• Autolytic debridement is slow and should not be utilized on infected ulcers. It may be prudent to avoid all occlusive dressings if anaerobic infection is suspected or cultured, as occlusive dressings are thought to promote an anaerobic environment.
• Prolonged use of topical antibiotics may facilitate the development of resistant organisms.
• Commercial wound cleansers (not skin cleaners) may be appropriate when the wound has adherent material; however, some have shown to be toxic to white blood cells.
• Irrigation pressures that exceed 15 pounds per square inch (psi) may cause wound trauma and force bacteria into the tissue.
• Avoid occlusive dressings if anaerobic infection is suspected or cultured, as occlusive dressings are thought to promote an anaerobic environment.
• The growth of fibroblasts and keratinocytes may be enhanced by pulsed low-intensity direct current due to changes in calcium homeostasis.

Hierarchy of the Levels of Scientific Evidence:

1. Large randomized trials with clear-cut results (and low risk of error)
2. Small randomized trials with uncertain results (and moderate to high risk of error
3. Nonrandomized trials with concurrent or contemporaneous controls
4. Nonrandomized trials with historical controls
5. Case series with no controls

Categories of the Strength of Evidence Associated With the Recommendations

1. The guideline recommendation is supported by one or more level I studies
2. The guideline recommendation is supported by one or more level II studies
3. The guideline recommendation is supported only by level III, IV, or V studies

Levels of Panel Agreement with the Recommendation

Based on a 5-point scale (1 corresponding to neutrality; 5 representing maximum agreement)

Low: Mean agreement score of 1.00 to 2.32

Moderate: Mean agreement score of 2.33 to 3.66

Strong: Mean agreement score of 3.67 to 5.00

Note: If the literature supporting a guideline recommendation came from two or more levels, the number and the level of evidence supporting the studies are reported (e.g., a guideline recommendation that is supported by two studies, one a level III and the other a level V, the scientific evidence would be indicated as III, V). Likewise, if a guideline recommendation is supported by literature that crossed two categories, both categories are reported (e.g., a recommendation that includes both level II and III studies would be classified as category B, C).

Levels of Evidence

Ia: Evidence obtained from meta-analysis or systematic review of randomized controlled trials.

Ib: Evidence obtained from at least one randomized controlled trial.

IIa: Evidence obtained from at least one well-designed controlled study without randomization.

IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization.

III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.

IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.