Pressure Ulcer Treatment:
The Clinical Practice Guideline for Prevention and Treatment

This quick reference guide contains highlights from the Clinical Practice Guideline version of Treatment of Pressure Ulcers, which was developed by an independent panel of health care providers and a consumer. The following selected aspects of pressure ulcer identification, assessment and treatment are presented.

PURPOSE AND SCOPE

The purpose of this guideline is to help identify adults at risk of pressure ulcers and to define early interventions for prevention; it may also be used to treat Stage I pressure ulcers. This guideline is not intended as a basis for care of infants and children. The guideline does not apply to individuals with existing Stage II or greater pressure ulcers or to individuals who are fully mobile.

Recommendations target four goals: (1) identifying at-risk individuals who need prevention and the specific factors placing them at risk; (2) maintaining and improving tissue tolerance to pressure in order to prevent injury; (3) protecting against the adverse effects of pressure, friction, and shear; and (4) reducing the incidence of pressure ulcers through educational programs.

What is a Pressure Sore?

Pressure sores, often referred to as pressure ulcer, are defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue. Pressure ulcers usually occur over bony areas such as the heel, hip bone or coccyx region and are described in different stages to indicate the extent of the tissue damage observed. The staging of pressure sores is recommended by this panel is consistent with the recommendations of the National Pressure Ulcer Advisory Panel (NPUAP):

When should a Pressure Sore be Staged?

According to the Federal Guidelines created for Long-term care facilities, pressure sores cannot be adequately staged when covered with a scab or until all black surrounding dead tissue is removed. Staging should be done after the wound has been cleaned or surgically debrided.

What does a Pressure Sores look like?

• Stage I: Nonblanchable erythema of intact skin; the heralding lesion of skin ulceration. Note: Reactive hyperemia can normally be expected to be present for one-half to three-fourths as long as the pressure occluded blood flow to the area; it should not be confused with a Stage I pressure ulcer.
• Stage II: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
• Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
• Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structure (for example, tendon or joint capsule). Note: Undermining and sinus tracts may also be associated with Stage IV pressure ulcers.

Staging definitions recognized these limitations:

• Assessment of Stage I pressure ulcers may be difficult in patients with darkly pigmented skin.
• When eschar is present, accurate staging of the pressure ulcer is not possible until the eschar has sloughed or the wound has been debrided.

The guideline is intended for clinicians who examine and treat persons at risk of developing pressure ulcers. These clinicians include family physicians, internists, geriatricians, dieticians, occupational and physical therapists, nurses, and nurse practitioners working in a variety of health care settings such as acute care, rehabilitation, geriatric care, and home and community based settings.

After an extensive review of the scientific literature, the panel used the following criteria to grade the evidence supporting each recommendation:

1. There is a good research-based evidence to support the recommendation.
2. There is a fair research-based evidence to support the recommendation.
3. The recommendation is based on expert opinion and panel consensus.

Skin Care and Early Treatment

Goal: Maintain and improve tissue tolerance to pressure in order to prevent injury.

1. All individuals at risk should have a systematic skin inspection at least once a day, paying particular attention to the bony prominences. Results of skin inspection should be documented.
2. Skin should be cleansed at the time of soiling and at routine intervals. The frequency of skin cleansing should be individualized according to need and/or patient preference. Avoid hot water and use a mild cleansing agent that minimizes irritation and dryness of the skin. During the cleansing process, care should be used to minimize the force and friction applied to the skin.
3. Minimize environmental factors leading to skin drying, such as low humidity (less than 40 percent) and exposure to cold. Dry skin should be treated with moisturizers.
4. Avoid massage over bony prominences. Current evidence suggests that massage over bony prominences may be harmful.
5. Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. When these sources of moisture cannot be controlled, underpads or briefs can be used that are made of materials that absorb moisture and present a quick-drying surface to the skin. For information about assessing and managing urinary incontinence, refer to Urinary Incontinence in Adults: Clinical Practice Guideline (available from AHCPR). Topical agents that act as barriers to moisture can also be used.
6. Skin injury due to fraction and shear forces should be minimized through proper positioning, transferring, and turning techniques. In addition, friction injuries may be reduced by the use of lubricants (such as cornstarch and creams), protective films (such as transparent film dressings and skin sealants), protective dressings (such as hydrocolloids), and protective padding.
7. When apparently well-nourished individuals develop an inadequate dietary intake of protein or calories, caregivers should first attempt discover the factors compromising intake and offer support with eating. Other nutritional supplements or support may be needed. If dietary intake remains inadequate and if consistent with overall goals of therapy, more aggressive nutritional intervention should be considered.

Nutritionally Compromised Individuals

For nutritionally compromised individuals, a plan of nutritional support and/or supplementation should be implemented that meets individual needs and is consistent with the overall goals of therapy.

8. If the potential exists for improving the individual’s mobility and activity status, rehabilitation efforts should be instituted if consistent with the overall goals of therapy. Maintaining current activity level, mobility, and range of motion is an appropriate goal for most individuals.
9. Interventions and outcomes should be monitored and documented.

Mechanical Loading and Support Surfaces

Goal: Protect against the adverse effects of external mechanical forces: pressure, friction, and shear.

1. Any individual in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every 2 hours if consistent with overall patient goals. A written schedule for systematically turning and repositioning the individual should be used.
2. For individuals in bed, repositioning devices such as pillows or foam wedges should be used to keep bony prominences (such as knees or ankles) from direct contact with one another, according to a written plan.
3. Individuals in bed who are completely immobile should have a care plan that includes the use of devices that totally relieve pressure on the heels, most commonly by raising the heels off the bed. Do not use donut-type devices.
4. When the side-lying position is used in bed, avoid positioning directly on the trochanter.
5. Maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. Limit the amount of time the head of the bed is elevated.
6. Using lifting devices such as a trapeze or bed linen to move (rather than drag) individuals in bed who cannot assist during transfer and position changes.
7. Any individual assessed to be at risk for developing pressure ulcers should be placed when lying in bed on a pressure-reducing device, such as foam, static air, alternating air, gel, or water mattresses.
8. Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every hours or be put back to bed if consistent wit overall patient management goals. Individuals who are able should be taught to shift weight every 15 minutes.
9. For chair-bound individuals, the use of pressure-reducing device such as those made of foam, gel, air, or a combination is indicated. Do not use donut-type devices.
10. Positioning of chair-bound individuals should include consideration of postural alignment, distribution of weight, balance and stability, and pressure relief.
11. A written plan for the use of positioning devices and schedules may be helpful for chair-bound individual.

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