The levels of evidence (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.

Assessment

Recommendation 1.1

Conduct a history and focused physical assessment.

(Level of Evidence = IV)

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 1.4

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)

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 1.9

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)

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)

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 2.3

Use pressure management for clients in the Operating Room to reduce the incidence of pressure ulcers post operatively.

(Level of Evidence = Ia)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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

The following are available:

The following is available:

• Health education fact sheet. Taking the pressure off: preventing pressure ulcers. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2003 Nov. 2 p.

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