Prevention and Treatment of Pressure Ulcers/Injuries

Publication Date: November 1, 2019
Last Updated: March 14, 2022

Recommendations

Risk Factors and Risk Assessment

1.1 Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries. (A, ↑↑)
348298
1.2 Consider individuals with a Category/Stage I pressure injury to be at risk of developing a Category/Stage II or greater pressure injury. (A, ↑↑)
348298
1.3 Consider the potential impact of an existing pressure injury of any Category/Stage on development of additional pressure injuries. (C, ↑)
348298
1.4 Consider the potential impact of a previous pressure injury on additional pressure injury development. (GPS, )
348298
1.5 Consider the potential impact of alterations to skin status over pressure points on pressure injury risk. (GPS, )
348298
1.6 Consider the potential impact of pain at pressure points on pressure injury risk. (GPS, )
348298
1.7 Consider the impact of diabetes mellitus on the risk of pressure injuries. (A, ↑↑)
348298
1.8 Consider the impact of perfusion and circulation deficits on the risk of pressure injuries. (B1, ↑)
348298
1.9 Consider the impact of oxygenation deficits on the risk of pressure injuries. (C, ↑)
348298
1.10 Consider at the impact of impaired nutritional status on the risk of pressure injuries. (C, ↑)
348298
1.11 Consider the potential impact of moist skin on the risk of pressure injuries. (C, ↑)
348298
1.12 Consider the impact of increased body temperature on the risk of pressure injuries. (B1, ↑)
348298
1.13 Consider the potential impact of older age on the risk of pressure injuries. (C, ↑)
348298
1.14 Consider the potential impact of impaired sensory perception on the risk of pressure injuries. (C, ↑)
348298
1.15 Consider the potential impact of laboratory blood test results on the risk of pressure injuries. (C, ⟷)
348298
1.16 Consider the potential impact of general and mental health status on pressure injury risk. (GPS, )
348298
1.17 Consider the impact of time spent immobilized before surgery, the duration of surgery and the American Society of Anesthesiologists (ASA) Physical Status Classification on surgery-related pressure injury risk. (B2, ↑)
348298
1.18 Consider the following as additional risk factors for the development pressure injuries in critically ill individuals:
* Duration of critical care stay
* Mechanical ventilation
* Use of vasopressors
* Acute Physiology and Chronic Health Evaluation (APACHE II) score.
(GPS, )
348298
1.19 Consider the impact of skin maturity, perfusion and oxygenation, and presence of a medical device on pressure injury risk in neonates and children. (B1, ↑↑)
348298
1.20 Consider the impact of illness severity and the duration of critical care unit stay on pressure injury risk in neonates and children. (B2, ↑)
348298
1.21 Conduct a pressure injury risk screening as soon as possible after admission to the care service and periodically thereafter to identify individuals at risk of developing pressure injuries. (GPS, )
348298
1.22 Conduct a full pressure injury risk assessment as guided by the screening outcome after admission and after any change in status. (GPS, )
348298
1.23 Develop and implement a risk-based prevention plan for individuals identified as being at risk of developing pressure injuries (GPS, )
348298
1.24 When conducting a pressure injury risk assessment:
• Use a structured approach
• Include a comprehensive skin assessment
• Supplement use of a risk assessment tool with assessment of additional risk factors
• Interpret the assessment outcomes using clinical judgment.
(GPS, )
348298

Skin and Tissue Assessment

2.1 Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries:
• As soon as possible after admission/transfer to the healthcare service
• As a part of every risk assessment
• Periodically as indicated by the individual’s degree of pressure injury risk
• Prior to discharge from the care service.
(GPS, )
348298
2.2 Inspect the skin of individuals at risk of pressure injuries to identify presence of erythema. (A, ↑↑)
348298
2.3 Differentiate blanchable from non-blanchable erythema using either finger pressure or the transparent disk method and evaluate the extent of erythema. (B1, ↑↑)
348298
2.4 Assess the temperature of skin and soft tissue. (B1, ↑)
348298
2.5 Assess edema and assess for change in tissue consistency in relation to surrounding tissues. (GPS, )
348298
2.6 Consider using a sub-epidermal moisture/ edema measurement device as an adjunct to routine clinical skin assessment. (B2, ⟷)
348298
2.7 When assessing darkly pigmented skin, consider assessment of skin temperature and sub-epidermal moisture as important adjunct assessment strategies. (B2, ↑)
348298
2.8 Evaluate the relevance of performing an objective assessment of skin tone using a color chart when conducting a skin assessment. (B2, ⟷)
348298

Preventive Skin Care

3.1 Implement a skin care regimen that includes:
• Keeping the skin clean and appropriately hydrated
• Cleansing the skin promptly after episodes of incontinence
• Avoiding use of alkaline soaps and cleansers
• Protecting the skin from moisture with a barrier product.
(B2, ↑↑)
348298
3.2 Avoid vigorously rubbing skin that is at risk of pressure injuries. (GPS, )
348298
3.3 Use high absorbency incontinence products to protect the skin in individuals with or at risk of pressure injuries who have urinary incontinence. (B1, ↑)
348298
3.4 Consider using textiles with low friction coefficients for individuals with or at risk of pressure injuries. (B1, ↑)
348298
3.5 Use a soft silicone multi-layered foam dressing to protect the skin for individuals at risk of pressure injuries. (B1, ↑)
348298
4.6 Provide 30 to 35 kcalories/kg body weight/ day for adults with a pressure injury who are malnourished or at risk of malnutrition. (B1, ↑)
348298

Nutrition Assessment and Treatment

4.1 Conduct nutritional screening for individuals at risk of a pressure injury. (B1, ↑↑)
348298
4.2 Conduct a comprehensive nutrition assessment for adults at risk of a pressure injury who are screened to be at risk of malnutrition and for all adults with a pressure injury. (B2, ↑↑)
348298
4.3 Develop and implement an individualized nutrition care plan for individuals with, or at risk of, a pressure injury who are malnourished or who are at risk of malnutrition. (B2, ↑↑)
348298
4.4 Optimize energy intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition. (B2, ↑)
348298
4.5 Adjust protein intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition. (GPS, )
348298
4.7 Provide 1.2 to 1.5 g protein/kg body weight/ day for adults with a pressure injury who are malnourished or at risk of malnutrition. (B1, ↑↑)
348298
4.8 Offer high-calorie, high-protein fortified foods and/or nutritional supplements in addition to the usual diet for adults who are at risk of developing a pressure injury and who are also malnourished or at risk of malnutrition, if nutritional requirements cannot be achieved by normal dietary intake. (C, ↑)
348298
4.9 Offer high calorie, high protein nutritional supplements in addition to the usual diet for adults with a pressure injury who are malnourished or at risk of malnutrition, if nutritional requirements cannot be achieved by normal dietary intake. (B1, ↑↑)
348298
4.10 Provide high-calorie, high-protein, arginine, zinc and antioxidant oral nutritional supplements or enteral formula for adults with a Category/Stage II or greater pressure injury who are malnourished or at risk of malnutrition. (B1, ↑)
348298
4.11 Discuss the benefits and harms of enteral or parenteral feeding to support overall health in light of preferences and goals of care with individuals at risk of pressure injuries who cannot meet their nutritional requirements through oral intake despite nutritional interventions. (GPS, )
348298
4.12 Discuss the benefits and harms of enteral or parenteral feeding to support pressure injury treatment in light of preferences and goals of care for individuals with pressure injuries who cannot meet their nutritional requirements through oral intake despite nutritional interventions. (B1, ↑)
348298
4.13 Provide and encourage adequate water/fluid intake for hydration for an individual with or at risk of a pressure injury, when compatible with goals of care and clinical conditions. (GPS, )
348298
4.14 Conduct age appropriate nutritional screening and assessment for neonates and children at risk of pressure injuries. (GPS, )
348298
4.15 For neonates and children with or at risk of pressure injuries who have inadequate oral intake, consider fortified foods, age appropriate nutritional supplements, or enteral or parenteral nutritional support. (GPS, )
348298

Repositioning and Early Mobilization

5.1 Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. (B1, ↑↑)
348298
5.2 Determine repositioning frequency with consideration to the individual’s level of activity, mobility and ability to independently reposition. (B2, ↑↑)
348298
5.3 Determine repositioning frequency with consideration to the individual’s:
• Skin and tissue tolerance
• General medical condition
• Overall treatment objectives
• Comfort and pain.
(GPS, )
348298
5.4 Implement repositioning reminder strategies to promote adherence to repositioning regimens. (B1, ↑)
348298
5.5 Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved. (GPS, )
348298
5.6 Reposition the individual to relieve or redistribute pressure using manual handling techniques and equipment that reduce friction and shear. (B2, ↑)
348298
5.7 Consider using continuous bedside pressure mapping as a visual cue to guide repositioning. (C, ⟷)
348298
5.8 Use the 30° lateral side lying position in preference to the 90° side lying position when positioning. (C, ↑)
348298
5.9 Keep the head of bed as flat as possible. (B1, ⟷)
348298
5.10 Avoid extended use of prone positioning unless required for management of the individual’s medical condition. (B1, ⟷)
348298
5.11 Promote seating out of bed in an appropriate chair or wheelchair for limited periods of time. (B1, ↑)
348298
5.12 Select a reclined seated position with the individual’s legs elevated. If reclining is not appropriate or possible, ensure that the individual’s feet are well-supported on the floor or on footrests when sitting upright in a chair or wheelchair. (B2, ↑)
348298
5.13 Tilt the seat to prevent the individual sliding forward in the chair or wheelchair. (B2, ↑)
348298
5.14 Teach and encourage individuals who spend prolonged durations in a seated position to perform pressure relieving maneuvers. (C, ↑)
348298
5.15 Implement an early mobilization program that increases activity and mobility as rapidly as tolerated. (C, ↑)
348298
5.16 For individuals with an ischial or sacral pressure injury, evaluate the benefit of periods of bed rest in promoting healing versus the risk of new or worsening pressure injuries and the impact on lifestyle, physical and emotional health. (GPS, )
348298
5.17 Reposition unstable critically ill individuals who can be repositioned using slow, gradual turns to allow time for stabilization of hemodynamic and oxygenation status. (GPS, )
348298
5.18 Initiate frequent small shifts in body position for critically ill individuals who are too unstable to maintain a regular repositioning schedule, and to supplement regular repositioning. (C, ↑)
348298
5.19 Position the individual in such a way as to reduce the risk of pressure injury development during surgery by distributing pressure over a larger body surface area and offloading bony prominences. (GPS, )
348298

Heel Pressure Injuries

6.1 Assess the vascular/perfusion status of the lower limbs, heels and feet when performing a skin and tissue assessment, and as part of a risk assessment. (B2, ↑↑)
348298
6.2 For individuals at risk of heel pressure injuries and/or with Category/Stage I or II pressure injuries, elevate the heels using a specifically designed heel suspension device or a pillow/ foam cushion. Offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. (B1, ↑↑)
348298
6.3 For individuals with a Category/Stage III or greater heel pressure injury, elevate the heels using a specifically designed heel suspension device offloading the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. (GPS, )
348298
6.4 Use a prophylactic dressing as an adjunct to heel offloading and other strategies to prevent heel pressure injuries. (B1, ↑)
348298

Support Surfaces

7.1 Select a support surface that meets the individual’s need for pressure redistribution based on the following factors:
• Level of immobility and inactivity
• Need to influence microclimate control and shear reduction
• Size and weight of the individual
• Number, severity and location of existing pressure injuries
• Risk for developing new pressure injuries.
(GPS, )
348298
7.2 Ensure that the bed surface area is sufficiently wide to allow turning of the individual without contact with the bed rails. (C, ↑)
348298
7.3 For individuals with obesity, select a support surface with enhanced pressure redistribution, shear reduction and microclimate features. (GPS, )
348298
7.4 Use a high specification reactive single layer foam mattress or overlay in preference to a foam mattress without high specification qualities for individuals at risk of developing pressure injuries. (B1, ↑)
348298
7.5 Consider using a reactive air mattress or overlay for individuals at risk for developing pressure injuries. (C, ↑)
348298
7.6 Assess the relative benefits of using a medical grade sheepskin for individuals at risk of developing pressure injuries. (B1, ⟷)
348298
7.7 Assess the relative benefits of using an alternating pressure air mattress or overlay for individuals at risk of pressure injuries. (B1, ↑)
348298
7.8 Use a pressure redistribution support surface on the operating table for all individuals with or at risk of pressure injuries who are undergoing surgery. (B1, ↑)
348298
7.9 For individuals with a pressure injury, consider changing to a specialty support surface when the individual:
• Cannot be positioned off the existing pressure injury
• Has pressure injuries on two or more turning surfaces (e.g., the sacrum and trochanter) that limit repositioning options
• Has a pressure injury that fails to heal or the pressure injury deteriorates despite appropriate comprehensive care
• Is at high risk for additional pressure injuries
• Has undergone flap or graft surgery
• Is uncomfortable
• ‘Bottoms out’ on the current support surface.
(GPS, )
348298
7.10 Assess the relative benefits of using an air fluidized bed to facilitate healing while reducing skin temperature and excess hydration for individuals with Category/Stage III or IV pressure injuries. (B1, ↑)
348298
7.11 Select a seat and seating support surface that meets the individual’s need for pressure redistribution with consideration to:
• Body size and configuration
• Effects of posture and deformity on pressure distribution
• Mobility and lifestyle needs.
(GPS, )
348298
7.12 Use a pressure redistribution cushion for preventing pressure injuries in people at high risk who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. (B1, ↑)
348298
7.13 Assess the relative benefits of using an alternating pressure air cushion for supporting pressure injury healing in individuals who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. (B1, ↑)
348298
7.14 Use a bariatric pressure redistribution cushion designed for individuals with obesity on seated surfaces. (C, ↑)
348298
7.15 For individuals with or at risk for a pressure injury, consider using a pressure redistributing support surface during transit. (GPS, )
348298
7.16 Transfer the individual off a spinal hardboard/ backboard as soon as feasible after admission to an acute care facility in consultation with a qualified health professional. (C, ↑)
348298

Device Related Pressure Injuries

8.1 To reduce the risk of medical device related pressure injuries, review and select medical devices with consideration to:
• The device’s ability to minimize tissue damage
• Correct sizing/shape of the device for the individual
• Ability to correctly apply the device according to manufacturer’s instructions
• Ability to correctly secure the device.
(B2, ↑↑)
348298
8.2 Regularly monitor the tension of medical device securements and where possible seek the individual’s self-assessment of comfort. (C, ↑)
348298
8.3 Assess the skin under and around medical devices for signs of pressure related injury as part of routine skin assessment. (GPS, )
348298
8.4 Reduce and/or redistribute pressure at the skindevice interface by:
• Regularly rotating or repositioning the medical device and/or the individual
• Providing physical support for medical devices in order to minimize pressure and shear
• Removing medical devices as soon as medically feasible.
(GPS, )
348298
8.5 Use a prophylactic dressing beneath a medical device to reduce the risk of medical device related pressure injuries. (B1, ↑)
348298
8.6 If appropriate and safe, alternate the oxygen delivery device between correctly fitting mask and nasal prongs to reduce the severity of nasal and facial pressure injuries for neonates receiving oxygen therapy. (B1, ↑)
348298
8.7 If appropriate and safe, alternate the oxygen delivery between correctly-fitting mask(s) and nasal prongs to reduce the severity of nasal and facial pressure injuries for older children and adults receiving oxygen therapy. (GPS, )
348298
8.8 In consultation with a qualified health professional, replace an extrication cervical collar with an acute care rigid collar as soon as feasible and remove cervical collars as soon as possible as indicate by clinical condition. (C, ↑)
348298

Classification of Pressure Injuries

9.1 Differentiate pressure injuries from other types of wounds. (GPS, )
348298
9.2 Use a pressure injury classification system to classify and document the level of tissue loss. (GPS, )
348298
9.3 Verify that there is clinical agreement in pressure injury classification amongst the health professionals responsible for classifying pressure injuries. (GPS, )
348298

Assessment of Pressure Injuries and Monitoring of Healing

10.1 Conduct a comprehensive initial assessment of the individual with a pressure injury. (GPS, )
348298
10.2 Set treatment goals consistent with the value and goals of the individual, with input from the individual’s informal caregivers, and develop a treatment plan that supports these values and goals. (GPS, )
348298
10.3 Conduct a comprehensive reassessment of the individual if the pressure injury does not show some signs of healing within two weeks despite appropriate local wound care, pressure redistribution, and nutrition. (B2, ↑↑)
348298
10.4 Assess the pressure injury initially and re-assess at least weekly to monitor progress toward healing. (GPS, )
348298
10.5 Select a uniform, consistent method for measuring pressure injury size and surface area to facilitate meaningful comparisons of wound measurements across time. (B2, ↑↑)
348298
10.6 Assess the physical characteristics of the wound bed and the surrounding skin and soft tissue at each pressure injury assessment. (GPS, )
348298
10.7 Monitor the pressure injury healing progress. (GPS, )
348298
10.8 Consider using a validated tool to monitor pressure injury healing. (B2, ↑)
348298

Pain Assessment and Treatment

11.1 Conduct a comprehensive pain assessment for individuals with a pressure injury. (B1, ↑↑)
348298
11.2 Use non-pharmacological pain management strategies as a first line strategy and adjuvant therapy to reduce pain associated with pressure injuries. (GPS, )
348298
11.3 Use repositioning techniques and equipment with consideration to preventing and managing pressure injury pain. (GPS, )
348298
11.4 Use the principles of moist wound healing to reduce pressure injury pain. (GPS, )
348298
11.5 Consider applying a topical opioid to manage acute pressure injury pain, if required and when there are no contraindications. (B1, ⟷)
348298
11.6 Administer analgesia regularly to control pressure injury pain. (GPS, )
348298

Cleansing and Debridement

12.1 Cleanse the pressure injury. (B1, ↑)
348298
12.2 Use cleansing solutions with antimicrobials to clean pressure injuries with suspected or confirmed infection. (GPS, )
348298
12.3 Cleanse the skin surrounding the pressure injury. (B2, ↑)
348298
12.4 Avoid disturbing stable, hard, dry eschar in ischemic limbs and heels, unless infection is suspected. (B2, ↑↑)
348298
12.5 Debride the pressure injury of devitalized tissue and suspected or confirmed biofilm and perform maintenance debridement until the wound bed is free of devitalized tissue and covered with granulation tissue. (B2, ↑↑)
348298

Infection and Biofilms

13.1 Have a high index of suspicion of local infection in a pressure injury in the presence of:
• Delayed healing
​​​​​​​• Lack of signs of healing in the preceding two weeks despite appropriate treatment
• Larger size and/or depth
• Wound breakdown/dehiscence
• Necrotic tissue
• Friable granulation tissue
• Pocketing or bridging in the wound bed
• Increased exudate, or change in the nature of the exudate
• Increased warmth in the surrounding tissue
• Increased pain
• Malodor
(B1, ⟷)
348298
13.2 Have a high index of suspicion of biofilm in a pressure injury in the presence of:
• Failure to heal despite appropriate antibiotic therapy
• Recalcitrance to appropriate antimicrobial therapy
• Delayed healing despite optimal treatment
• Increased exudate
• Increased poor granulation or friable hypergranulation
• Low level erythema and/or low level chronic inflammation
•Secondary signs of infection.
(GPS, )
348298
13.3 Consider a diagnosis of spreading infection if the individual with a pressure injury has local and/or systemic signs of acute infection including but not limited to:
• Delay in healing
• Erythema extending from the ulcer edge
• Wound breakdown/dehiscence
• Induration
• Crepitus, fluctuance or discoloration of the surrounding skin
• Lymphangitis
• Malaise/lethargy
• Confusion/delirium and anorexia (particularly in older adults).
(GPS, )
348298
13.4 Determine presence of microbial bioburden in the pressure injury by tissue biopsy or semiquantitative swab technique and microscopy. (GPS, )
348298
13.5 Determine presence of biofilm in the pressure injury by tissue biopsy and high resolution microscopy. (GPS, )
348298
13.6 Evaluate the pressure injury for presence of osteomyelitis in the presence of exposed bone and/or if the bone feels rough or soft, or if the pressure injury has failed to heal with appropriate treatment. (B2, ↑)
348298
13.7 Optimize potential for healing by:
• Evaluating the individual’s nutritional status and addressing deficits
• Evaluating the individual’s comorbidities and promoting disease control
• Reducing the individual’s immunosuppressant therapy if possible
• Preventing contamination of the pressure injury
• Preparing the wound bed through cleansing and debridement.
(GPS, )
348298
13.8 Use topical antiseptics in tissue-appropriate strengths to control microbial burden and to promote healing in pressure injuries that have delayed healing. (B1, ↑)
348298
13.9 Use topical antiseptics that are active against biofilm in tissue-appropriate strengths in conjunction with regular debridement to control and eradicate suspected (or confirmed) biofilm in pressure injuries with delayed healing. (C, ↑)
348298
13.10 Use systemic antibiotics to control and eradicate infection in individuals with pressure injuries and clinical evidence of systemic infection. (GPS, )
348298

Wound Dressings

14.1 For all pressure injuries, select the most appropriate wound dressing based on goals and self-care abilities of the individual and/or their informal caregiver and based on clinical assessment, including:
• Diameter, shape and depth of the pressure injury
• Need to address bacterial bioburden
• Ability to keep the wound bed moist
• Nature and volume of wound exudate
• Condition of the tissue in the wound bed
• Condition of the peri-wound skin
• Presence of tunneling and/or undermining
• Pain
(GPS, )
348298
14.2 Evaluate the cost effectiveness of wound dressings at a local level, with consideration to direct and indirect costs to the health care system and to the individual with a pressure injury. Advanced wound dressings that promote moist wound healing are more likely to be cost-effective due to faster healing times and less frequent dressing changes. (GPS, )
348298
14.3 Use hydrocolloid dressings for non-infected Category/Stage II pressure injuries as indicated by the clinical condition of the pressure injury. (B1, ↑)
348298
14.4 Use hydrogel dressings for non-infected Category/Stage II pressure injuries as indicated by the clinical condition of the pressure injury. (B1, ↑)
348298
14.5 Use polymeric dressings for non-infected Category/Stage II pressure injuries as indicated by the clinical condition of the pressure injury. (B1, ↑)
348298
14.6 Use a hydrogel dressing for non-infected Category/Stage III and IV pressure injuries with minimal exudate. (B1, ↑)
348298
14.7 Use calcium alginate dressings for Category/ Stage III and IV pressure injuries with moderate exudate. (B1, ↑)
348298
14.8 Use foam dressings (including hydropolymers) for Category/Stage II and greater pressure injuries with moderate/heavy exudate. (B1, ↑)
348298
14.9 Use super-absorbent wound dressings with a high capacity for absorption to manage heavily exuding pressure injuries. (B2, ↑)
348298
14.10 Use moist gauze dressings to maintain an appropriately moist wound environment when advanced wound dressings are not an option. (B1, ⟷)
348298
14.11 Use a transparent film dressing as a secondary dressing when advanced wound dressings are not an option. (B1, ⟷)
348298
14.12 Consider the available evidence and guidance on using local resource wound dressings when selecting dressings in geographic regions with limited access to resources. (GPS, )
348298

Biological Dressings

15.1 Consider applying collagen dressings to nonhealing pressure injuries to improve rate of healing and decrease signs and symptoms of wound inflammation. (B1, ↑)
348298

Growth Factors

16.1 Consider applying platelet-rich plasma for promoting healing in pressure injuries. (B1, ⟷)
348298
16.2 Consider applying platelet-derived growth factor for promoting healing in Category/Stage III and IV pressure injuries. (B1, ⟷)
348298

Biophysical Agents

17.1 Administer pulsed current electrical stimulation to facilitate wound healing in recalcitrant Category/Stage II pressure injuries and Category/Stage III or IV pressure injuries. (A, ↑)
348298
17.2 Consider using non-contact low frequency ultrasound therapy as an adjunct therapy to facilitate healing in Category/Stage III and IV pressure injuries and suspected deep tissue injuries. (B2, ⟷)
348298
17.3 Consider using high frequency ultrasound therapy at 1MHz as an adjunct therapy to facilitate healing in Category/Stage III and IV pressure injuries. (B1, ⟷)
348298
17.4 Consider negative pressure wound therapy as an early adjunct therapy for reducing the size and depth of Category/Stage III and IV pressure injuries. (B1, ↑)
348298

Pressure Injury Surgery

18.1 Obtain a surgical consultation for an individual with a pressure injury that:
• Has advancing cellulitis or is a suspected source of sepsis
• Has undermining, tunneling, sinus tracts and/or extensive necrotic tissue not easily removed by conservative debridement
• Is Category/Stage III or IV and not closing with conservative treatment.
(GPS, )
348298
18.2 Consider the following factors when assessing eligibility for pressure injury surgery:
• Likelihood of healing with non-surgical treatment versus surgical intervention
• The individual’s goals of care
• The individual’s clinical condition
• Motivation and ability of the individual to comply with the treatment regimen
• Risk of surgery for the individual.
(GPS, )
348298
18.3 Evaluate and mitigate physical and psychosocial factors that may impair surgical wound healing or influence recurrence of a pressure injury. (B2, ↑)
348298
18.4 Fully excise the pressure injury, including abnormal skin, granulation and necrotic tissue, sinus tracts, bursa and involved bone to the extent possible. (B2, ↑)
348298
18.5 When designing a flap:
• Select tissue with a good quality blood supply
• Use composite tissues to increase durability
• Use a flap as large as possible
• Minimize violation of adjacent skin and tissue
• Locate the suture line away from areas of direct pressure
• Minimize tension on the incision at closure.
(GPS, )
348298
18.6 Regularly monitor the wound and immediately report signs of flap failure. (GPS, )
348298
18.7 Use a speciality support surface in the immediate post-operative period. (B2, ↑)
348298
18.8 Position and transfer the individual in such a way as to avoid pressure on, and disruption to, the surgical site. (GPS, )
348298
18.9 When the surgical site is sufficiently healed commence a progressive sitting protocol. (B2, ↑)
348298

Measuring Pressure Injury Prevalence and Incidence

19.1 Use a rigorous methodological design and consistent measurement variables when conducting and reporting pressure injury prevalence and incidence studies. (GPS, )
348298

Implementing Best Practice in Clinical Settings

20.1 At an organizational level, assess and maximize workforce characteristics as part of a quality improvement plan to reduce pressure injury incidence. (C, ↑)
348298
20.2 At the organizational level, assess the knowledge health professionals have about pressure injuries to facilitate implementation of education and quality improvement programs. (B1, ↑)
348298
20.3 At an organizational level, assess and maximize workforce attitudes and cohesion to facilitate implementation of a quality improvement program. (GPS, )
348298
20.4 At an organizational level, assess and maximize the availability and quality of equipment and standards for its use as part of a quality improvement plan to reduce the incidence of pressure injuries. (B1, ↑↑)
348298
20.5 At an organizational level, develop and implement a structured, tailored and multifaceted quality improvement program to reduce the incidence of pressure injuries. (A, ↑↑)
348298
20.6 At an organizational level, engage all key stakeholders in oversight and implementation of the quality improvement program to reduce the incidence of pressure injuries. (B1, ↑↑)
348298
20.7 At an organizational level, include evidencebased policies, procedures and protocols and standardized documentation systems as part of a quality improvement plan to reduce the incidence of pressure injuries. (B1, ↑↑)
348298
20.8 At an organizational level, provide clinical decision support tools as part of a quality improvement plan to reduce the incidence of pressure injuries. (B1, ↑↑)
348298
20.9 Provide clinical leadership in pressure injury prevention and treatment as part of a quality improvement plan to reduce pressure injuries. (B1, ↑↑)
348298
20.10 At a professional level, provide education in pressure injury prevention and treatment as part of a quality improvement plan to reduce the incidence of pressure injuries. (A, ↑↑)
348298
20.11 At an organizational level, regularly monitor, analyze and evaluate performance against quality indicators for pressure injury prevention and treatment. (B1, ↑↑)
348298
20.12 At an organizational level, use feedback and reminder systems to promote the quality improvement program and its outcomes to stakeholders. (B2, ↑)
348298

Health Professional Education

21.1 At the organizational level, assess the knowledge health professionals have about pressure injuries to facilitate implementation of education and quality improvement programs. (B1, ↑↑)
348298
21.2 At an organizational level, develop and implement a multi-faceted education program for pressure injury prevention and treatment. (B2, ↑↑)
348298

Quality of Life, Self-Care and Education

22.1 Assess the health-related quality of life, knowledge and self-care skills of individuals with or at risk of pressure injuries to facilitate the development of a pressure injury care plan and education program. (GPS, )
348298
22.2 Provide pressure injury education, skills training and psychosocial support to individuals with or at risk of pressure injuries. (C, ↑)
348298

Recommendation Grading

Overview

Title

Prevention and Treatment of Pressure Ulcers/Injuries

Authoring Organization

Publication Month/Year

November 1, 2019

Last Updated Month/Year

July 3, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

It includes the evidence-based recommendations and good practice statements, together with implementation considerations, evidence summaries and evidence discussion on Prevention and Treatment of Pressure Ulcers/Injuries

Target Patient Population

Patients with pressure ulcers/injuries

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Home health, Hospital, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D051346 - Mobility Limitation, D008134 - Long-Term Care, D003668 - Pressure Ulcer, D011312 - Pressure

Keywords

long-term care, pressure ulcer, long term care, pressure injury