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Guideline Summary
Guideline Title
Association for the Advancement of Wound Care guideline of pressure ulcer guidelines.
Bibliographic Source(s)
Association for the Advancement of Wound Care (AAWC). Association for the Advancement of Wound Care guideline of pressure ulcer guidelines. Malvern (PA): Association for the Advancement of Wound Care (AAWC); 2010. 14 p.
Guideline Status

This is the current release of the guideline.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • November 13, 2013 – Over-the-Counter Topical Antiseptic Products External Web Site Policy: The U.S. Food and Drug Administration (FDA) is requesting label and packaging changes to enhance the safe use of certain over-the-counter (OTC) topical antiseptic products. This request is the result of their ongoing evaluation of infrequent but continuing reports of infections resulting from antiseptic products labeled for preoperative or preinjection skin preparation. When used properly, topical antiseptics are safe and effective products to reduce the number of bacteria on patients' skin prior to surgery or injections. However, most often, contamination of topical antiseptics occurs when organisms are introduced into the product by users. Therefore, health care professionals and patients should follow all label directions to decrease the chances of infection.

Scope

Disease/Condition(s)

Pressure ulcers

Guideline Category
Evaluation
Management
Prevention
Rehabilitation
Risk Assessment
Screening
Treatment
Clinical Specialty
Critical Care
Dermatology
Emergency Medicine
Family Practice
Geriatrics
Nursing
Nutrition
Orthopedic Surgery
Pediatrics
Physical Medicine and Rehabilitation
Plastic Surgery
Podiatry
Preventive Medicine
Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Physical Therapists
Physician Assistants
Physicians
Podiatrists
Public Health Departments
Students
Utilization Management
Guideline Objective(s)

To support evidence-based pressure ulcer management by all levels of professionals, patients, and non-professional caregivers involved in pressure ulcer care by summarizing evidence that promotes:

  • Consistent, high quality of pressure ulcer prevention and treatment interventions
  • Reliable, valid pressure ulcer assessment and outcomes measurement
  • Accurate pressure ulcer risk assessment for screening, diagnosis, and triage
Target Population

Individuals at risk of developing a pressure ulcer or who have one or more existing or prior pressure ulcers

Interventions and Practices Considered

Evaluation/Risk Assessment/Screening

  1. Initial and continuous pressure ulcer risk assessment using valid, reliable scales (including Braden scale)
  2. Nutritional assessment with a validated measure
  3. Document medical and surgical history
  4. Assessment of psychosocial conditions and quality of life
  5. Environmental assessment
  6. Physical examination including wound assessment
  7. Diagnostic tests

Prevention/Rehabilitation

  1. Skin inspection and maintenance
  2. Hydration and nutrition plan of care
  3. Rehabilitative and restorative programs
  4. Positioning standards of care to manage pressure ulcers
  5. Off-loading equipment including chairs, intensive care, and operating rooms
  6. Interdisciplinary team approach
  7. Education

Management/Treatment

  1. Remove/alleviate all causes of pressure ulcer damage
  2. Debride, cleanse, and dress the wound
  3. Advanced or adjuvant interventions
  4. Surgical interventions
  5. Documentation of response
  6. Palliative care
Major Outcomes Considered
  • Risk-adjusted pressure ulcer prevalence and incidence
  • Risk-adjusted pressure ulcer healing time, pain, odor, and infections
  • Risk-adjusted percent of pressure ulcers healed by 4 to 20 weeks of care
  • Risk-adjusted pressure ulcer recurrence
  • Patient and professional satisfaction with pressure ulcer care and outcomes
  • Cost-effectiveness of healing (e.g., per pressure ulcer healed)
  • Cost-effectiveness of prevention (e.g., per 100 pressure-ulcer-free days)

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

The all-volunteer Association for the Advancement of Wound Care Guideline Department (AAWCGD) engaged in the following steps using Total Quality Management principles to develop a quality, comprehensive "guideline of pressure ulcer guidelines." They resolved discrepancies among existing pressure ulcer guidelines by adapting recommendations to meet best available evidence and/or formally content validated professional opinion. The Guideline development process used applicable Appraisal of Guidelines Research and Evaluation (AGREE) principles, except that they used more stringent criteria for acceptance of opinion-based care including only recommendations with a content validity index ≥0.75.

Step 1. Jan-Oct, 2008. All relevant recommendations for assessing patient pressure ulcer risk, screening and diagnosis of patients developing pressure ulcer(s), pressure ulcer assessment, healing prognosis, prevention and treatment were compiled from a MEDLINE search and from pressure ulcer guidelines on the National Guideline Clearinghouse Web site as of June 1, 2008, plus those of the Wound Healing Society, the European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) draft guidelines.

Step 2. Feb-Nov, 2008. Redundant recommendations were combined. Language was simplified and clarified.

Step 3. Nov, 2008-Feb, 2009. The resulting 368 recommendations were prepared for a content-validation survey accessed online at aawconline.org and completed by 31 multidisciplinary volunteer respondents, then analyzed using Microsoft EXCEL©. Content Validity Index was calculated as the percent of respondents rating the recommendation as clinically relevant and succinct or clinically relevant with recommended minor change.

Step 4. Feb, 2009-June, 2010. MEDLINE and/or CINAHL searches were conducted for each content validated recommendation. Up to 5 of the best available references in terms of highest level of evidence quality were used to support each recommendation.

Step 5. March-July, 2010. Colleagues from four additional societies working with the AAWC to publish a unified initiative to analyze education (A-Level Evidence, content validity index [CVI] <0.75) and research (B- or C-Level Evidence, CVI ≥0.75) opportunities reviewed the recommendations and provided references to strengthen some evidence levels. This work was presented as a poster at the Symposium for Advanced Wound Care, the American Professional Wound Care Association and the Wound Ostomy Continence Nurses Conference April-June, 2010. The four societies are the:

  • Canadian Association for Enterostomal Therapy
  • Canadian Association of Wound Care
  • National Pressure Ulcer Advisory Panel
  • Wound Healing Society
Number of Source Documents

This guideline is a compilation of recommendations from 11 source documents.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Strength of Evidence Level

  1. Results of a meta-analysis or two or more pressure (PU)-related randomized controlled trials (RCTs) on humans provide support (or for diagnostics or risk assessment: prospective cohort [CO] studies and/or controlled studies reporting recognized diagnostic or predictive validity measures).
  2. Results of one PU-related RCT in humans plus two or more similar historically controlled trials (HCTs) or convenience controlled trials (CCTs) or one HCT and one CCT provide support or when appropriate, results of two or more RCTs in animal model validated as clinically relevant to PU provide indirect support. For diagnostics or risk assessment one PU-related prospective CO study and/or a controlled study reporting recognized diagnostic or predictive validity measures.
  3. This rating requires one or more of the following:

    C1: Results of one controlled trial, e.g., RCT, CCT or HCT (or for diagnostics or risk prediction one prospective CO study may be substituted for a controlled trial)

    C2: Results of at least two case series (CS) or descriptive studies or a cohort study in humans

    C3: Expert opinion (EO)

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
  1. Evidence was summarized in a WORD© Evidence Table (accessible from the Association for the Advancement of Wound Care [AAWC] Web site) with references in alphabetic order and brief description of subjects, study design, methods, and results.
  2. A similar WORD table (accessible from the AAWC Web site External Web Site Policy) listed the 368 recommendations, with corresponding best available evidence references, evidence level, mean content validity and content validity index (CVI).
  3. Items with A-Level Evidence and /or CVI ≥0.75 were included in the final guideline, which was summarized in outline format in a WORD© document (accessible from the AAWC Web site External Web Site Policy).
Methods Used to Formulate the Recommendations
Informal Consensus
Other
Description of Methods Used to Formulate the Recommendations

Informal Consensus

The Association for the Advancement of Wound Care Guideline Development (AAWCGD) compiled, condensed, and simplified the 368 recommendations from the 11 published guidelines identified.

Formal Content Validation

Formal content validation was performed by 31 multidisciplinary respondents to a survey accessible to all AAWC members. Respondents rated clinical relevance of each recommendation on the scale below and added open-ended comments for improving each recommendation with a corresponding rationale. Content validity index (CVI) was the percent of respondents rating the recommendation 3 or 4. A CVI ≥0.75 was the criterion for acceptable recommendation content validity:

  1. A rating of 1 means the item is not clinically relevant to best pressure ulcer patient or wound care practice and should be deleted from the final guideline.
  2. A rating of 2 means that the wording or content of the item was confusing and you are unable to assess its relevance without further information.
  3. A rating of 3 means that the item is clinically relevant to best practice for pressure ulcer patient or wound care, but needs minor improvements to make it very relevant and succinct. Please list the improvements needed for that item in the box below the item. 
  4. A 4 rating means the item is very relevant to best practice for pressure ulcer patient or wound care.
Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

The developers reviewed published cost-analyses.

Method of Guideline Validation
Comparison with Guidelines from Other Groups
Peer Review
Description of Method of Guideline Validation

After the inclusive list of recommendations was developed and simplified by the Association for the Advancement of Wound Care (AAWC) Guideline Committee, each recommendation was independently content validated by 31 multidisciplinary wound care professionals (physicians of varying specialties, nurses, physical therapists and other wound care specialists) from November 2008-Feburary 2009. The Content Validity Index was calculated as the percent of respondents rating the recommendation as clinically relevant and succinct or clinically relevant with recommended minor change. The criterion for inclusion of a recommendation in the final content validated guideline was a Content Validity Index of at least 75 percent.

Recommendations

Major Recommendations

Definitions for the strength of evidence level (A, B, C) are provided at the end of the "Major Recommendations" field.

I.   Patient and Pressure Ulcer Assessment

  1. Patient Pressure Ulcer (PU) Risk Assessment for all Settings (Evidence Level = A)
    1. For all settings, a trained professional should assess and document PU risk within 72 hours (h) of admission or on change of any PU risk factor, using a valid, reliable scale with good predictive validity for the setting and for patient age and cognition (Comfort, 2008; Magnan & Maklebust, 2008; Maklebust & Magnan, 2009). (Evidence Level = A)
      1. Assess environmental/physical/medical/psychosocial factors, patient end-of-life goals (Brink, Smith, & Linkewich, 2006; Baharestani, 1994), e.g., body mass index (BMI), skin, friction/shear potential, note surgical procedures (Compton et al., 2008; Fowler, Scott-Williams, & McGuire, 2008; Schoonhoven et al., 2006). (Evidence Level = A)
      2. Extremes of age increase PU risk, especially for those over 62 years of age and neonates (Fowler, Scott-Williams, & McGuire, 2008; Bergstrom & Braden, 1992; Bergstrom et al, 1996; Quigley & Curley, 1996). (Evidence Level = A)
      3. Previous or current ulcer increases PU risk (Guihan et al., 2008). (Evidence Level = C)
    1. Braden scale has highest inter-rater reliability (Kottner & Dassen, 2008) and percent correct predictions (Ayello & Braden, 2002; Pancorbo-Hidalgo et al., 2006; Bolton, 2007). Norton & Warterlow Scales are also valid. See Table 1 in the original guideline document for published scores for some validated scales corresponding to levels of PU risk. (Evidence Level = A)
    2. Continue risk assessments routinely according to setting protocols and changes in patient PU risk (Brandeis et al., 1995; Berlowitz et al., 1997; Ayello & Braden, 2002). (Evidence Level = A)
    3. If PU risk assessment is inappropriate for a patient, document why (Brandeis et al., 1995; Berlowitz et al., 1997; Ayello & Braden, 2002). (Evidence Level = A)
    4. Use clinical judgment and institutional protocols to implement patient-appropriate interventions indicated by risk scores. (Comfort, 2008; Magnan & Maklebust, 2008; Maklebust & Magnan, 2009) and to identify factors affecting PU risk (Wound Ostomy and Continence Nurses [WOCN], 2010; Royal College of Nursing & National Institute for Health and Clinical Excellence [NICE], 2005) in each of the following settings (Evidence Level = A):
      1. Acute Care: Reassess every 48 h and on transfer to higher care level (Fowler, Scott-Williams, & McGuire, 2008) (Evidence Level = B)
      2. Long Term Care: Reassess weekly or on status change (WOCN, 2010) (Evidence Level = C)
      3. Home Care: Reassess at each visit, weekly and on resumed care or recertification (Ayello & Braden, 2002) (Evidence Level = C)
      4. Hospice Care: Reassess weekly for 4 weeks, then monthly (Henoch & Gustaffson, 2003; Seaman & Shively, 2000) (Evidence Level = A)
  1. Patient Nutritional Assessment (Evidence Level = A)
    1. Properly trained staff should assess nutritional parameters with a validated measure (Hengstermann et al., 2007; Lindgren et al., 2005; Pinchcofsky-Devin & Kaminski, 1986; Scott et al., 1999; Uzun & Tan, 2007) on admission, at change in condition, and as needed based on medical status or if ulcer is not decreasing in size. Inform appropriate dietary professional of results (Guenter et al., 2000; Langer et al., 2003; Reed et al., 2003; Pinchcofsky-Devin & Kaminski, 1986). (Evidence Level = A)
      1. Document adequate protein, calorie & fluid intake as well as feasible, e.g., 3-day calorie count, intake record (Guenter et al., 2000; Langer et al., 2003; Pinchcofsky-Devin & Kaminski, 1986). (Evidence Level = A)
      2. Record current and usual weight, height as baseline to set goals or estimate body mass index (kg/m2) as weight (kg) divided by square of height (m2) (Guenter et al., 2000; Kernozek et al., 2002; Uzun & Tan, 2007). See Table 2 in the original guideline document for standard BMI adult values. (Evidence Level = A)
      3. Other factors for nutritional risk may include history of involuntary weight loss; compromised oral, dental, gastro-intestinal and/or swallowing status; medical/surgical history or interventions influencing intake or absorption of nutrients; drug-nutrient interactions, e.g., chemotherapy agents causing nausea, agents to correct hyperkalemia causing diarrhea or other related conditions or medications (Pinchcofsky-Devin & Kaminski, 1986). (Evidence Level = C)
    1. Assess nutritional laboratory parameters regularly for patients with documented deficiencies or in those at high PU risk (Posthauer & Thomas, 2004; "NPUAP draft," 2009; WOCN, 2010). Example values are presented in Table 3 in the original guideline document. (Evidence Level = C)
  1. Medical/Surgical History (Evidence Level = A)
    1. Document unstable or significant intrinsic risk factors and comorbidities that impede healing or contribute to altered tissue tolerance or integrity (Fowler, Scott-Williams, & McGuire, 2008; Milne et al., 2009). (Evidence Level = B) Perform or obtain initial comprehensive systems assessment on individuals with a PU if feasible (Chacon et al., 2010; Konishi et al., 2008). (Evidence Level = C)
      1. Malignancy (Institute for Healthcare Improvement [IHI], 2007) (Evidence Level = C) or severe chronic or terminal disease (Fowler, Scott-Williams, & McGuire, 2008) (Evidence Level = B)
      2. Diabetes, with hemoglobin A1c (HbA1c) ≥6.5 to document blood glucose control (Fowler, Scott-Williams, & McGuire, 2008; American Diabetes Association [ADA], 2009) (Evidence Level = A)
      3. Cardiovascular disease or condition including cardiovascular accident (CVA) leading to altered sensation or ability to move (Fowler, Scott-Williams, & McGuire, 2008; de Laat et al., 2007; IHI, 2007) (Evidence Level = A)
      4. Gastrointestinal, genitourinary, renal, endocrine or pulmonary disease or condition (IHI, 2007) (Evidence Level = C)
      5. Peripheral vascular disease/condition: assess lower extremity arterial disease or edema as co-morbidity for lower extremity PU (Chernecky & Berger, 2004; Fowler, Scott-Williams, & McGuire, 2008; IHI, 2007). Tests may include: (Evidence Level = A)
        1. Pulses, capillary refill time, edema or mobility (Evidence Level = A)
        2. Ankle/brachial systolic blood pressure >0.86 to rule out arterial disease in a heel pressure ulcer (Evidence Level = A)
      1. Sensory deficits, bowel and bladder habits (Chacon et al., 2010; Konishi et al., 2008) (Evidence Level = C)
      2. Malnutrition, dehydration, failure to thrive, severe chronic or terminal disease (Fowler, Scott-Williams, & McGuire, 2008; IHI, 2007) (Evidence Level = B)
      3. Neuromuscular system: spasticity, peripheral neuropathy, spinal cord injury, multiple sclerosis, Parkinson's disease or similar neurologic conditions (Chacon et al., 2010; Fowler, Scott-Williams, & McGuire, 2008; IHI, 2007) (Evidence Level = A)
      4. Conditions such as severe arthritis that prohibit repositioning/pressure redistribution (Fowler, Scott-Williams, & McGuire, 2008; IHI, 2007) (Evidence Level = B)
    1. Smoking or conditions that affect skin interface pressure, temperature, moisture (Cackmak et al., 2009; Smith et al., 2008; Suriadi et al., 2007). (Evidence Level = A) Consider other substance abuse issues that may affect skin PU risk. (Evidence Level = C)
    2. Review medications, e.g., sedation, steroid, immunosuppressive, anti-cancer or anti-embolic agent use (Chacon et al., 2010; Fowler, Scott-Williams, & McGuire, 2008; IHI, 2007). (Evidence Level = A)
    3. Record recent surgical procedures, falls, or traumatic injury (Fowler, Scott-Williams, & McGuire, 2008; de Laat et al., 2007; IHI, 2007; Mannesse, van Riet, & van der Cammen, 1994). (Evidence Level = A)
    4. Document details of prior PU. Include treatments or surgical interventions (Fowler, Scott-Williams, & McGuire, 2008; IHI, 2007). (Evidence Level = A)
    5. Obtain history of restricted mobility related to care, treatment, procedure or falls (Mannesse, van Riet, & van der Cammen, 1994): time spent immobile, room temperature, pressure reducing surfaces used and repositioning considerations if appropriate to patient for all settings. (Evidence Level = A)
      1. Acute care, including Emergency Department (Schoonhoven et al., 2006; Langemo & Brown, 2006; Linares et al., 1987; Lyder et al., 2001) (Evidence Level = A)
      2. Long-term care (Bergstrom & Braden, 1992; Bergstrom et al., 1998) (Evidence Level = A)
      3. Operating room and post-anesthesia care unit (Schoonhoven et al., 2006; Aronovitch, 2007) (Evidence Level = A)
      4. Procedural lab, e.g., for oncology, radiological or catheter-related procedures such as dialysis (Reed et al., 2003) (Evidence Level = C)
      5. Long ambulance or air transfers (Baharestani, 1994) (Evidence Level = C)
  1. Psychosocial and Quality of Life Assessment (Evidence Level = A)
    1. Assess psychological conditions
      1. Goals and motivation of patient, family, and care provider(s) to participate in care (Evidence Level = C)
      2. Adherence to health management protocols (Evidence Level = C)
      3. Cognition and ability to comprehend or retain information (Evidence Level = C)
      4. Behavioral disorders that may affect capacity to engage in self-care (Evidence Level = C)
      5. Pay special attention to those with more richly pigmented skin or with little social support (Saladin & Krause, 2009; Redelings, Lee, & Sorvillo, 2005). (Evidence Level = A) Culture or ethnicity can be related to risk of developing a PU (Saladin & Krause, 2009) or increased likelihood of mortality in patients with a PU (Redelings, Lee, & Sorvillo, 2005). (Evidence Level = C)
    1. Assess social support systems, including family or partner (Baharestani, 1994). (Evidence Level = C)
    2. Assess financial resources, access to equipment and related reimbursement limitations, and caregiver availability, skills, knowledge, and capacity to provide consistent quality care (Baharestani, 1994). (Evidence Level = C)
  1. Environmental Assessment (Evidence Level = A)
    1. Assess posturing irregularities/abnormalities: habitual positioning, paralysis, contractures, amputation, rigid or spastic condition (Registered Nurses' Association of Ontario [RNAO], 2005). (Evidence Level = C)
    2. Assess for ineffective positioning techniques (RNAO, 2005). (Evidence Level = C)
      1. Assess for pressure, sheer or friction in all positions, all environments and during lift, turn, repositioning and transfer events (RNAO, 2005). (Evidence Level = C)
    1. Monitor and document adherence to prescribed off-loading regimen and proper use of equipment or adaptive aids (Royal College of Nursing & NICE, 2005; RNAO, 2005; WOCN, 2010). (Evidence Level = C)
    2. Assess for ill-fitting devices, braces, seating and ineffective equipment/assistive devices (JHF, 2003; RNAO, 2005). (Evidence Level = C)
      1. Evaluate off-loading equipment quality, efficiency, proper use, effectiveness (e.g., feel for "bottoming out" or observe for PU development) (Rithalia, 2001; Brienza & Geyer, 2005). (Evidence Level = C)
      2. Observe seating and brace or other device accommodation to body size and/or contours while assessing skin areas affected for potential breakdown (RNAO, 2005). (Evidence Level = C)
  1. Physical Exam (Evidence Level = A)
    1. Perform head-to-toe assessment with attention to bony prominences and any skin surfaces in contact with removable devices (RNAO, 2005). See Table 4 for areas at risk in common positions. (Evidence Level = C)

    Table 4. Pressure Points to Examine if Patient Has Spent Time in Indicated Position (RNAO, 2005)

    Patient Position Sites to Examine Including All Other Sites at PU Risk
    Supine Occipital areas, sacrum, scapula(e) and heels
    Prone Chest, anterior superior iliac crests, symphysis, pubis, patella, anterior tibial regions
    Sitting Ischium, coccyx, elbow, trochanter
    Side-lying Trochanter, lateral foot, ankle, knee, ear
    All positions: Skeletal deviation areas, e.g.,: Bunion, kyphosis, lordosis, pelvic obliquity
    1. Document alterations in skin sites at risk of developing a PU. (Evidence Level = A)
      1. Color (Bates-Jensen, 1997; Sprigle et al., 2001) (Evidence Level = A)
      2. Texture, e.g., unusual hardness (induration), softness, or rough surface for this site (Bates-Jensen, 1997) (Evidence Level = A)
      3. Sensation (Braden & Bergstrom, 1994; Copeland-Fields & Hoshiko, 1989) (Evidence Level = A)
      4. Skin temperature at and around site (Nakagami et al., 2009; Sae-Sia, Wipke-Tevis, & Williams, 2005, 2007; Sprigle et al., 2001) (Evidence Level = A)
    1. Assess wound. (Evidence Level = A)
      1. Anatomic location (Bates-Jensen, 1997; Gardner et al., 2005) (Evidence Level = A)
      2. Size (PU length, width, depth). Measure using consistent, reliable method within and across institutions. (Evidence Level = A)
        1. Lack of area reduction in 2-4 weeks of care is a valid predictor of non-healing for PU (van Rijswijk & Polansky, 1994) and other chronic wounds (Kantor & Margolis, 1998). (Evidence Level = A)
        2. Reliable estimates of wound area are (a) longest length x longest perpendicular width (Bates-Jensen, 1997; Buntinx et al., 1996; Royal College of Nursing & NICE, 2005; Sanada et al., 2004) or (b) head-toe length and side-side width (Gunes, 2009; Stotts et al., 2001). (Evidence Level = A)
      1. Exudate type (e.g., bloody, serous, purulent, foul) and amount (e.g., none, moist, small, moderate, or large amount of exudate) usually based on appearance of dressing (Bates-Jensen, 1997; Stotts et al., 2001) (Evidence Level = A)
      2. Infection signs (e.g., erythema, edema, odor, purulent, or foul-smelling exudate, increase in ulcer pain and exudate, fever, friable or irregular granulation tissue) (Bates-Jensen, 1997; Gardner, Frantz, & Doebbling, 2001) (Evidence Level = A)
      3. Undermining, sinus tracts and tunneling (Bates-Jensen, 1997; Stotts et al., 2001) (Evidence Level = A)
      4. Stage of PU: Deep Tissue Injury, I, II, III, IV, Unstageable (Konishi et al., 2008; RNAO, 2005; "NPUAP draft," 2009) (Evidence Level = C)
      5. Tissue types & amounts (e.g., epithelium, granulation, yellow/white fibrin/slough, or black, brown or gray necrotic tissue) (Bates-Jensen, 1997; Stotts et al., 2001) (Evidence Level = A)
        1. Ulcer margin abnormalities (e.g., epiboly, exuberant granulation) (Bates-Jensen, 1997; Stotts et al., 2001) (Evidence Level = A)
        2. Peri-wound skin (e.g., erythema or edema) (Bates-Jensen, 1997; Stotts et al., 2001) (Evidence Level = A)
      1. Evaluate for complications as indicated by ulcer severity or chronicity, and if treated, document treatment and its duration (Bryan, Dew, & Reynolds, 1983; Lewis et al., 1988; Milne et al., 2009), e.g., fistulae, abscesses (Evidence Level = C), osteomyelitis, bacteremia (Evidence Level = A), cellulitis, cancer, heterotopic bone formation. (Evidence Level = C)
    1. For individuals with a PU, it is important to perform differential diagnoses (e.g., skin tear, herpes lesions, incontinence-associated dermatitis, candidiasis, arterial insufficiency ulcer) to improve accuracy of pressure ulcer diagnosis (Konishi et al., 2008). (Evidence Level = C)
    2. Conduct a pain assessment using an age-appropriate validated pain scale (Chang et al., 1998; Flock, 2003; Gardner, Franz, & Doebbling, 2001; Heyneman et al., 2008). (Evidence Level = A)
    3. Repeat above assessments regularly at same intervals as pressure ulcer risk assessment based on patient risk and institutional guidelines or on any change in patient condition (Konishi et al., 2008). (Evidence Level = C)
  1. Diagnostic Tests (Evidence Level = A)
    1. Use appropriate vascular laboratory consult as needed to assess tissue perfusion if limited vascular perfusion is suspected. Consider appropriate vascular laboratory consult or a bedside Ankle-to-Brachial Index to assist in differential diagnosis (Chernecky & Berger, 2004; Rennert et al., 2009). (Evidence Level = C)

    Table 5. Systolic Ankle/Brachial Blood Pressure (ABI) Differential Diagnosis (Arterial calcification may be associated with falsely high ABI ratios)

    Arterial Disease Severity ABI Value
    No disease: normal arterial perfusion At least 0.86
    Mild arterial disease 0.75-0.85
    Intermittent claudication (walking capacity limited) 0.50-0.75
    Severe arterial disease 0.20-0.50
    Gangrene Less than 0.20
    1. Obtain quantitative tissue, swab or bone culture in suspected infection, obvious cellulitis or on non-healing wounds if consistent with treatment goal (Gardner, Frantz, & Doebbeling, 2001; Rennert et al., 2009). (Evidence Level = A)
    2. Biopsy chronic non-healing ulcers for suspected malignancy if no healing is observed in response to optimal care during 12 weeks (Whitney et al., 2006). (Evidence Level = C)
    3. Obtain bone imaging using a patient-compatible method, (e.g., magnetic resonance imaging [MRI]/computed tomography [CT] scan/nuclear scan/positron emission tomography [PET]) in suspected osteomyelitis (Strobel & Stumpe, 2007; Rennert et al., 2009; Boutin et al., 1998). (Evidence Level = C)
    4. Obtain corresponding blood analysis as indicated to establish baseline values, assist in the diagnosis of infection and/or reflect the status of co-morbid conditions affecting wound healing: complete blood count with differential, metabolic profile, coagulation studies (prothrombin time [PT] and partial thromboplastin time [PTT]), lipid profile, HbA1c, hepatic function profile, pre-albumin, thyroid function (TSH), C-reactive protein, (CRP), erythrocyte sedimentation rate (ESR), blood cultures (if bacteremia or osteomyelitis is suspected) (Rennert et al., 2009). (Evidence Level = C)
  1. Documentation and Communication (Evidence Level = A)
    1. Document all assessments and findings on approved forms or tools (Milne et al., 2009). (Evidence Level = C)
    2. Ensure all members of interdisciplinary team have access to all formal assessments (Milne et al., 2009; Powers, 1997).(Evidence Level = C)

II. Prevent Pressure Ulcer Occurrence or Recurrence

  1. Skin Inspection and Maintenance (Evidence Level = A)
    1. Perform comprehensive visual and tactile skin inspections during patient care and regularly according to institutional guidelines (Schoonhoven et al., 2006; Bergstrom & Braden, 1992). (Evidence Level = B)
      1. Remove all special garments, protectors and devices, as medically feasible, to assess skin (Agency for Health Care Policy and Research [AHCPR], 1992; RNAO, 2005; Bergstrom & Braden, 1992). (Evidence Level = C)
      2. Assess splints, casts, tubes, and other devices as potential sites for pressure as feasible (RNAO, 2005). (Evidence Level = C)
    1. Manage excess moisture at affected sites, including areas affected by incontinence or perspiration, and skin folds in bariatric patients. (RNAO, 2005; Lyder et al., 2002). (Evidence Level = C)
      1. Manage skin temperature elevation at the support surface interface with the patient's skin (RNAO, 2005; AHCPR, 1992; Consortium for Spinal Cord Medicine, 2000) using pressure ulcer prevention interventions relevant to patient. (Evidence Level = C)
      2. Select effective under-pads and/or briefs to wick incontinence and moisture away from skin; avoid trapping moisture against skin, use appropriate skin protectants (RNAO, 2005). (Evidence Level = C)
    1. Clean and dry skin using non-friction bathing standards with a slightly warm, non-irritating, non-sensitizing, pH-balanced no-rinse skin cleanser avoiding saline or soap regularly and after each incontinence episode (Bergstrom et al., 2005; Hodgkinson, Nay, & Wilson, 2007; Lyder et al., 2002). (Evidence Level = B)
      1. Maintain skin hydration (RNAO, 2005) with non-sensitizing, pH balanced lubricating agents (Lyder et al., 2002). (Evidence Level = C)
    1. Establish an individualized bowel and bladder program for patients with incontinence (RNAO, 2005; WOCN, 2010). (Evidence Level = C)
      1. Determine the type of fecal or urinary incontinence based on symptoms and history; consider onset, duration, aggravating and relieving factors (WOCN, 2010). Consider referral to a continence specialist if appropriate (RNAO, 2005). (Evidence Level = C)
      2. Use incontinence skin barriers as needed to protect and maintain skin integrity (Lyder et al., 2002; RNAO, 2005; WOCN, 2010). (Evidence Level = C)
      3. Consider pouching system or collection device to contain urine or stool and protect skin from effluent (RNAO, 2005; WOCN, 2010) or indwelling catheter for brief periods if urine contributes to skin breakdown (WOCN, 2010). (Evidence Level = C)
    1. Reduce friction and shear (Lyder et al., 2002; AHCPR, 1992; RNAO, 2005; WOCN, 2010). (Evidence Level = B)
      1. Apply lubricants, transparent film or hydrocolloid dressings, or other topical friction or shear reduction agents to bony prominences to reduce mechanical injury from friction or shear (Flam & Raab, 1991; Milne et al., 1999; Ohura et al., 2005; Weng, 2008). (Evidence Level = B)
      2. Avoid vigorous massage over bony prominences (Ek, Gustavsson, & Lewis, 1985; Dyson, 1978). (Evidence Level = B)
    1. Document any skin changes. Record and notify patient care team of changes to care plan resulting from the change(s) in the skin condition (Schoonhoven et al., 2006; Milne et al., 2009). (Evidence Level = C)
  1. Hydration and Nutrition Plan of Care (Evidence Level = A)
    1. Maintain or restore adequate nutrition to maintain skin integrity as feasible and as compatible with patient and family wishes or condition (Reed et al., 2003; Stratton et al., 2005; Theilla et al., 2007). (Evidence Level = A)
      1. Restorative dining program if appropriate, providing foods with high nutritive value or nutrition supplements with or between meals if needed (Stratton et al., 2005; Desneves et al., 2005). (Evidence Level = A)
      2. Enteral nutrition only if medically needed to maintain adequate nutrition. This should be consistent with patient and family wishes (Bergstrom et al., 1996; Stratton et al., 2005; Theilla et al., 2007). (Evidence Level = A)
      3. Parenteral nutrition only if medically needed to maintain adequate nutrition and enteral nutrition is not an option, and if consistent with patient and family wishes (Compton et al., 2008). (Evidence Level = C)
      4. Offer hydrating fluids with repositioning schedule. Offer additional fluids if medically appropriate and patient has dehydration, fever, diaphoresis, diarrhea, or heavily draining wounds. Document fluid intake in patients unable to hydrate themselves (RNAO, 2005). (Evidence Level = C)
  1. Rehabilitative and Restorative Programs (Evidence Level = A)
    1. Address immobility and/or inactivity in bed- or chair-bound patients (Berlowitz & Wilking 1989; Allman et al., 1995). (Evidence Level = C)
      1. Begin progressive mobility program as soon as condition allows (RNAO, 2005). (Evidence Level = C)
      2. Implement ongoing exercise programs to maintain or restore mobility and activity, increase strength, and improve cardiovascular endurance (Rennert et al., 2009). (Evidence Level = C)
    1. Manage muscle spasms appropriately (Whitney et al., 2006). (Evidence Level = C)
  1. Positioning Standards of Care to Manage Pressure/Shear/Friction (Evidence Level = A)
    1. Vulnerable individuals should be repositioned to reduce pressure, friction, and shear. Individual status should determine frequency, not a ritualistic schedule (Royal College of Nursing & NICE, 2005; McInnes, 2004). (Evidence Level = C)
    2. Turn or reposition at least every 2–3 hours when on pressure redistributing surface if patient can tolerate this (Defloor & Grypdonck, 2005). (Evidence Level = C)
    3. Avoid folding and stretching of soft tissues when repositioned (RNAO, 2005). (Evidence Level = C)
    4. Use lift sheets or devices to turn and transfer dependent patients, avoid dragging ("NPUAP draft," 2009). (Evidence Level = C)
      1. When using mechanical handling devices remove slings/sleeves from under patient after maneuvering is complete, according to device instructions (Royal College of Nursing & NICE, 2005; McInnes, 2004). (Evidence Level = C)
    1. Use trapeze or side rails to facilitate patient independence with bed mobility (RNAO, 2005). (Evidence Level = C)
    2. Apply pillows and cushions or other appropriate devices such as foot orthoses to prevent bony prominences from contacting each other (i.e., between knees, ankles, feet, etc.) (RNAO, 2005). (Evidence Level = C)
    3. Maintain head of bed at or below 30 degrees or at the lowest degree of elevation consistent with medical condition (Bergstrom & Braden, 1992; RNAO, 2005). (Evidence Level = C)
    4. Relieve pressure under heels by suspension, support surfaces (Reddy, Gill, & Rochon, 2006) pressure-distributing dressings (Bots & Apotheker, 2004) or other devices (Cheney, 1993; Cheneworth et al., 1994; Zernike, 1994). (Evidence Level = A)
    5. Avoid positioning directly on trochanter; when side-lying, use a 30 degree laterally inclined position (RNAO, 2005). (Evidence Level = C)
    6. Instruct in self-performing pressure relief exercises every 15 minutes in chair-bound persons; if unable, reposition every hour when in chair (RNAO, 2005). (Evidence Level = C)
      1. Avoid prolonged sitting intervals (e.g., intervals of more than 4 h) for at-risk individuals (Defloor, De Bacquer, & Grypdonck, 2005; Whitney et al., 2006). (Evidence Level = C)
    1. Utilize small frequent position changes to redistribute pressure on bony areas (RNAO, 2005). (Evidence Level = C)
    2. When utilizing heating/cooling blankets, place on top of an individual. Avoid positioning these devices underneath weight bearing zones (Aronovitch, 2007; Reger, Ranganathan, & Sahgal, 2007). (Evidence Level = C)
  1. Off-Loading Equipment Including Chairs, Intensive Care and Operating Rooms (Evidence Level = A)
    1. Avoid doughnut-shaped pressure redistribution devices (except on plantar surface of the foot) (AHCPR, 1992; "NPUAP draft," 2009; Whitney et al., 2006). (Evidence Level = C)
    2. Avoid use of sheepskin for pressure reduction without added heel and elbow protection (Reddy, Gill, & Rochon, 2006). (Evidence Level = B)
    3. Avoid standard (spring-style) mattresses (Reddy, Gill, & Rochon, 2006). (Evidence Level = A)
    4. All individuals vulnerable to pressure ulcers require a patient-acceptable support surface, e.g., "high specification foam mattress," static air mattress, overlay, low air loss or alternating pressure mattress, alternating pressure overlay and regular repositioning at a minimum. Support surface should prevent "bottoming out" (Defloor, De Bacquer, & Grypdonck, 2005; McInnes et al., 2008; Nicosia et al., 2007; Nixon et al., 2006; Reddy, Gill, & Rochon, 2006). (Evidence Level = A)
      1. Use holistic assessment to determine supportive devices; risk level, general health status, comfort, skin assess, lifestyle and abilities, critical care needs and acceptability by patient/caregiver (Konishi et al., 2008; "NPUAP draft," 2009; "EPUAP draft," 2009) (Evidence Level = C)
    1. Use devices such as a low-air-loss mattress, high-density air flotation, high specification foam or similar pressure redistribution replacement mattress if patient has pressure ulcer history, elevated risk score, if indicated by clinical condition or when a less effective device has failed to prevent a pressure ulcer (Pemberton, Turner, & VanGilder, 2009; Russell et al., 2003; Sterzi et al., 2003; Vanderwee, Grypdonck, & Defloor, 2008). (Evidence Level = A)
      1. Assess and review support surfaces regularly; consider clinical outcomes, comfort, abilities, changes in general status (Konishi et al., 2008; Royal College of Nursing & NICE, 2005). (Evidence Level = C)
    1. Use pressure redistribution devices intra-operatively for individuals assessed to be at risk for pressure ulcer development (Bots & Apotheker, 2004; Reddy, Gill, & Rochon, 2006). (Evidence Level = A)
    2. Use heel/foot/elbow area off-loading devices to augment support surfaces, e.g., pressure-distributing heel dressings (Reddy, Gill, & Rochon, 2006; Weng, 2008). (Evidence Level = A)
    3. Ensure regular repositioning according to institutional guidelines and provision of support surfaces or devices, incontinence pads & positioning devices are available in all at-risk environments for all surfaces used by patients (Konishi et al., 2008; Royal College of Nursing & NICE, 2005). (Evidence Level = C)
    4. Position all chair-bound patients with attention to anatomy, postural alignment, and distribution of weight, foot support, balance and stability. Educate personnel on assessing proper support surface function (Bergstrom et al., 1994; Milne et al., 2009; "NPUAP draft," 2009; "EPUAP draft," 2009). (Evidence Level = C)
      1. Seating assessments for cushions, supportive aids and equipment should be carried out by trained assessors with specific knowledge and expertise on effective weight redistribution principles and support surface function (Magnan & Maklebust, 2008; Maklebust & Magnan, 2009; Milne et al., 2009). (Evidence Level = B)
    1. Provide an individually prescribed wheelchair and pressure redistribution surface for wheelchair-bound individuals with severe mobility or/positioning deficits (RNAO, 2005). (Evidence Level = C)
      1. Prescribe wheelchairs and seating systems according to individualized anthropometric, ergonomic and functional principles (RNAO, 2005). (Evidence Level = C)
      2. Measure the effects of posture and deformity on interface pressure distribution if feasible. Use clinical judgment and objective data in determining the compatibility of individuals shape or posture with seating system (RNAO, 2005). (Evidence Level = C)
      3. Use power weight shifting wheelchair system for individuals who are unable to independently perform effective weight shift (RNAO, 2005). (Evidence Level = C)
      4. Inspect & maintain functionality of a wheelchair support surface at regularly scheduled intervals, including 3-4" high density foam, static air cushions or other therapeutic cushion designed for pressure redistribution (Defloor & Grypdonck, 2000; Brienza & Geyer, 2005). (Evidence Level = C)
  1. Interdisciplinary Approach (Evidence Level = A)
    1. Utilize a multidisciplinary team for development of an individualized plan of care based on intrinsic and extrinsic PU risk factors and risk score data (Bogie & Ho, 2007; Konishi et al., 2008; Powers, 1997; Milne et al., 2009). (Evidence Level = C)
      1. Have available a position statement on the benefits of team care with references, such as the Association for the Advancement of Wound Care (AAWC) Statement on Benefits of Team Care (Milne et al., 2009). (Evidence Level = C)
    1. Assign specific healthcare professionals trained in the principles of off-loading to select and implement appropriate pressure redistribution devices for beds, chairs, and wheelchairs for all "at-risk" individuals (Allman et al., 1987; Cullum et al., 2004; Maklebust & Magnan, 2009; Milne et al., 2009). (Evidence Level = A)
    2. Consult a dietitian in cases of malnutrition or suspected malnutrition or for patients assessed at risk for pressure ulcers (Langer et al., 2003; Reed et al., 2003; Van Rijswijk & Polansky, 1994). (Evidence Level = A)
    3. Determine need for referral to continence care specialist (Horn et al., 2010; RNAO, 2005). (Evidence Level = C)
    4. Consult occupational or physical therapy seating specialist for wheelchair-bound individuals (RNAO, 2005). (Evidence Level = C)
  1. Education (Evidence Level = B)
    1. Develop and implement organized, structured, and comprehensive training programs for healthcare personnel, patients, families, and all care givers for prevention and treatment of pressure ulcers (Horn et al., 2010; Magnan & Maklebust, 2008; Maklebust & Magnan, 2009; Milne et al., 2009; Tippet, 2009). (Evidence Level = B) Include:
      1. Written and verbal instruction about negative impact of smoking, alcohol & drug abuse on pressure ulcer outcomes (both prevention & treatment) (Rosen et al., 2006; Milne et al, 2009; Rennert et al., 2009) (Evidence Level = C)
      2. Principles of pressure ulcer prevention (Horn et al., 2010; Milne et al., 2009) (Evidence Level = C)
      3. Individualized interventions to reduce pressure shear friction (Horn et al., 2010; Milne et al., 2009) (Evidence Level = C)
      4. Skin inspection methods and maintenance care (Horn et al., 2010; Milne et al., 2009) (Evidence Level = C)
      5. Use and maintenance of pressure redistribution devices (Cheney, 1993; Horn et al., 2010; Milne et al., 2009) (Evidence Level = C)
      6. Available resources for assistance and advice (Horn et al., 2010; Milne et al., 2009) (Evidence Level = C)
      7. Signs and symptoms of infection, or other complications (Milne et al., 2009) (Evidence Level = C)
      8. Nutrition and hydration interventions (Horn et al., 2010; Milne et al., 2009) (Evidence Level = C)
    1. Develop organized, structured, and comprehensive healthcare personnel training programs (Horn et al., 2010; Magnan & Maklebust, 2008; Maklebust & Magnan, 2009; Milne et al., 2009). (Evidence Level = B) Include:
      1. Risk assessment factors and patient assessment tool (Evidence Level = B)
      2. Pressure ulcer pathophysiology and prevention strategies (Evidence Level = B)
      3. Skin and wound assessment parameters (Evidence Level = B)
      4. Roles and responsibilities related to assessment and prevention (Evidence Level = B)
      5. Development and implementation of individualized plan of care (Evidence Level = B)
      6. Selection, use and maintenance of pressure redistribution devices (Evidence Level = B)
      7. Patient education and information giving techniques (Evidence Level = B)
      8. Accurate documentation of pertinent data (Evidence Level = B)
      9. Demonstration of positioning and transferring techniques (Evidence Level = B)

III. Pressure Ulcer Treatment Strategies

  1. Implement or Continue all Measures to Prevent new PU and Optimize Wound Healing (Evidence Level = B)
    1. Evaluate effectiveness of previous and current preventive or treatment programs (Horn et al., 2010; Magnan & Maklebust, 2008; Maklebust & Magnan, 2009; Milne et al., 2009). (Evidence Level = B)
    2. Set treatment goals consistent with patient's goals, values, and lifestyle (RNAO, 2007). (Evidence Level = C)
  1. Remove or Alleviate all Causes of Pressure Ulcer Damage (Milne et al., 2009) (Evidence Level = A)
    1. Use a pressure redistribution product with verified functionality for individuals with unstageable, deep tissue injury, Stage III, Stage IV, or multiple ulcers over several turning surfaces ("NPUAP draft," 2009; Royal College of Nursing & NICE, 2005). (Evidence Level = C)
      1. 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 (Cheney, 1993; Cheneworth et al., 1994; Cullum et al., 2004). There is insufficient evidence for differences in PU outcomes using different types of static devices (Cullum et al., 2004). (Evidence Level = B)
      2. Select a dynamic air support surface if individual cannot be positioned without pressure on an ulcer, when a static support surface bottoms out, if no evidence of healing or if new ulcers develop (Cullum et al., 2004; Ferrell, Osterweil, & Christenson, 1993; Rosenthal et al., 2003). (Evidence Level = A)
      3. Use support surfaces with verified functionality such as dynamic air flotation, algorithm sensing technology support system, low air loss or air fluidized bed in the treatment of PU or unstageable deep tissue injury on multiple surfaces, compromised skin, or for temperature and moisture control in the presence of large stage III or IV PU, or for surgical graft sites (Allman et al., 1987; Cullum et al., 2004; Ferrell, Osterweil, & Christenson, 1993; Economides, Skoutakis, & Carter, 1995; Rosenthal et al., 2003). (Evidence Level = A)
    1. Avoid positioning directly on pressure ulcer when on bed surface (AHCPR, 1992; "NPUAP draft," 2009). (Evidence Level = C)
      1. Use cushions and positioning aids to relieve pressure ulcers or vulnerable skin by elevating the skin or ulcer away from the support surface (AHCPR, 1992; "NPUAP draft," 2009). (Evidence Level = C)
    1. Avoid positioning a wheelchair-seated individual directly on a pressure ulcer (AHCPR, 1992; "NPUAP draft," 2009). (Evidence Level = C)
      1. Allow limited sitting if individual is capable of performing weight shifts every 15 minutes; use power weight-shifting wheelchair system for individuals who are unable to independently perform effective weight shifts (AHCPR, 1992; "NPUAP draft," 2009). (Evidence Level = C)
      2. Reposition at least every hour; if not possible, return individual to bed (AHCPR, 1992; "NPUAP draft," 2009). (Evidence Level = C)
  1. Manage Local and Systemic Factors: Debride, Cleanse and Dress Wound (Evidence Level = A)
    1. Debride PU areas with eschar and/or devitalized tissue to manage bacterial load (Alvarez et al., 2002; Burgos et al., 2000; Jones & Fennie, 2007; Rennert et al., 2009). (Evidence Level = C) Choose a debridement method appropriate to PU status, individual condition, and goals of care (Evidence Level = A):
      1. Autolytic debridement (Barr et al., 1995; Jones & Fennie, 2007; Sayag, 1988) is as effective (Burgos et al., 2000) or more so (Konig et al., 2005) than enzymatic debridement with collagenase. (Evidence Level = A)
      2. Enzymatic debridement efficacy and safety varies with different enzymes. Collagenase efficacy has been shown better than placebo (Ramundo & Gray, "Enzymatic," 2008) (Evidence Level = A), similar to some enzymes (Püllen et al., 2002) or autolytic debridement (Burgos et al., 2000) and less effective than papain-urea, with similar healing results (Alvarez et al., 2002). (Evidence Level = C)
      3. Mechanical debridement (AHCPR, 1992; RNAO, 2007) using wet-to-dry gauze is considered substandard practice (Jones & Fennie, 2007; Royal College of Nursing & NICE, 2005). (Evidence Level = C)
      4. Surgical debridement, including conservative sharp debridement, is indicated to achieve rapid removal of necrotic tissue. If debriding large amounts of necrotic tissue use the operating room (Barr et al., 1995; Bluestein & Javaheri, 2008; Chow, Galpin, & Guze, 1977; Golinko et al., 2009; Gordon, 1996; Ramundo & Gray, "Enzymatic," 2008; Rennert et al., 2009; Whitney et al., 2006). (Evidence Level = C)
      5. High flow irrigation (Fujioka et al., 2008; Whitney et al., 2006) (Evidence Level = C)
      6. Biological debridement with maggots (Gray, 2008) (Evidence Level = C)
      7. Contraindications for debridement include compromised vascular circulation at ulcer site, stable heel eschar, or gravely palliative or critically unstable patients (Bluestein & Javaheri, 2008; Langemo, Black, & NPUAP, 2010; "NPUAP draft," 2009). (Evidence Level = C)
    1. Cleanse all wounds at each dressing change using a cleansing method to optimize removal of debris and prevent trauma (Bergstrom et al., 2005; Rodeheaver & Ratliff, 2007). (Evidence Level = C)
      1. Optimal irrigation pressure of 4-15 pound per square inch (psi) may be obtained using a 35 cc syringe with 19 gauge angiocath (Evidence Level = B) or a single-use 100 ml saline squeeze bottle (Bergstrom et al., 1994; Rodeheaver & Ratliff, 2007). (Evidence Level = C)
      2. Cleansing may also be performed during hydrotherapy (Burke et al., 1998; Rodeheaver & Ratliff, 2007). (Evidence Level = C)
      3. Avoid manual trauma or scrubbing the wound vigorously (Rodeheaver & Ratliff, 2007). (Evidence Level = C)
      4. Wound cleansing solutions may be normal saline, sterile water, Ringer's lactate, or tap water. (Bergstrom et al., 1994; Moore & Cowman, 2008; Rodeheaver & Ratliff, 2007) (Evidence Level = B)
      5. Use safe wound cleansers with surfactants for heavy exudate or adherent material (Bergstrom et al., 1994; Bolton et al., 2004; Rodeheaver & Ratliff, 2007). (Evidence Level = B)
      6. Avoid topical antiseptic or cytotoxic agents (Bergstrom et al., 1994; Bluestein & Javaheri, 2008; Rodeheaver & Ratliff, 2007). (Evidence Level = B)
      7. Cleanse the ulcer and perimeter with enough irrigant for the wound size, depth, and condition (usually 100–150 ml) warmed to room temperature (Rodeheaver & Ratliff, 2007). (Evidence Level = C)
    1. Manage bacterial colonization and infection (RNAO, 2007; Whitney et al., 2006). (Evidence Level = C)
      1. Implement appropriate clean or sterile technique with standards and universal precautions for wound management: hand washing, protective equipment, dressing disposal appropriate for the patient, and isolation as indicated (RNAO, 2007). (Evidence Level = C)
      2. Evaluate ulcer for signs and symptoms of clinical infection at each dressing change (Gardner, Frantz, & Doebbeling, 2001; RNAO, 2007). (Evidence Level = C)
      3. If ulcer infection is suspected based on clinical signs of infection and/or if wound regresses or plateaus despite appropriate preventive and treatment measures, determine type and level of microorganisms by validated quantitative swab cultures (Gardner, Frantz, & Doebbeling, 2001; RNAO, 2007). (Evidence Level = C)
        1. Irrigate wound with normal saline before obtaining swab culture, swab 1 cm2 viable wound area, avoid eschar/slough/surface exudate/edges (Gardner, Frantz, & Doebbeling, 2001; RNAO, 2007). (Evidence Level = C)
      1. If osteomyelitis is suspected, obtain a tissue and/or a bone biopsy (Lewis et al., 1988; Rennert et al., 2009; Whitney et al., 2006). (Evidence Level = A)
        1. Conservatively debride bone; excise ulcer necrotic tissue (Chow, Galpin, & Guze, 1977; Rennert et al., 2009). (Evidence Level = C)
        2. Remove underlying bony prominence and fibrotic bursa cavities if indicated (Rennert et al., 2009). (Evidence Level = C)
      1. Use systemic antibiotics specific to sensitivity report for bacteremia, sepsis, advancing cellulitis, osteomyelitis (Bergstrom et al., 1994; Chow, Galpin, & Guze, 1977; Rennert et al., 2009; RNAO, 2007). (Evidence Level = A)
      2. Treat distant infections such as urinary tract, pneumonia, cranial sinus, or cardiac valves in patients with or at risk of developing a pressure ulcer (Whitney et al., 2006). (Evidence Level = B)
      3. Use topical antimicrobial cleansing solutions, dressings, gels, ointments, creams and aqueous preparations effective against gram-negative, gram-positive and anaerobic organisms, e.g., with safe, sustained release of ionic silver (Munter et al., 2006), iodine, or other agents with evidence of safety on PU (Bluestein & Javaheri, 2008; RNAO, 2007). (Evidence Level = C)
        1. Initiate on clean ulcers with delayed healing despite 2-4 weeks of optimal care (RNAO, 2007). (Evidence Level = C)
        2. Re-evaluate use after 2 weeks and discontinue use as infection abates (RNAO, 2007). (Evidence Level = C)
    1. Select and apply appropriate ulcer dressing(s) to protect PU and surrounding skin from friction, shear, pressure, and physical or chemical trauma and to manage exudate and prevent ulcer drying, injury, or maceration (Bots & Apotheker, 2004; Bouza et al., 2005; Cullum & Petherick, 2008; de Laat, Scholte op Reimer, & van Achterberg, 2005; Heyneman et al., 2008). (Evidence Level = A)
      1. Manage excess ulcer drainage with absorptive dressings (Barr et al., 1995; Bolton et al., 2004; Payne et al., 2009; Smitten & Bolton, 2005). (Evidence Level = B)
      2. Maintain moist ulcer environment, e.g., with hydrocolloid (Kerstein et al., 2001), foam (Munter et al., 2006), hydrogel or similar moisture retentive dressing (Bouza et al., 2005; Cullum & Petherick, 2008; de Laat, Scholte op Reimer, & van Achterberg, 2005; Heyneman et al., 2008). (Evidence Level = A)
      3. Hydrate dry ulcers, e.g., with hydrogel dressings (Heyneman et al., 2008) (Evidence Level = A), except in case of a stable ischemic heel eschar. (Evidence Level = C)
      4. Fill ulcer cavities to reduce dead space (Bolton et al., 2004). (Evidence Level = C)
      5. Provide thermal insulation and ulcer temperature stability (RNAO, 2007) (Evidence Level = C)
      6. Choose the most appropriate dressing consistent with principles of ulcer care, patient needs, individual ulcer status, cost/availability and caregiver ability (Heyneman et al., 2008; Kerstein et al., 2001; Payne et al., 2009). (Evidence Level = A) (See Table 6 in the original guideline document for levels of support for dressing study evidence mainly compared to saline or ointment in gauze.) Please see product package inserts for individual claims for specific dressings.
        1. Avoid gauze use as a primary PU dressing. It delays healing, increases pain, infection rates (Hutchinson & McGuckin, 1990), and dressing change frequency, and it is not cost effective (Heyneman et al., 2008; Kerstein et al., 2001). (Evidence Level = A)
      1. Monitor dressing site daily; schedule change frequency based on assessment of patient, ulcer status, dressing condition, and package insert instructions. Manage hypergranulation; record wound status at each dressing change and revise dressings according to ulcer outcomes and patient goals (Paralyzed Veterans of America [PVA], 2000; RNAO, 2007). (Evidence Level = C)
    1. Manage pressure ulcer-related pain (de Laat, Scholte op Reimer, & van Achterberg, 2005). (Evidence Level = A)
      1. Maintain a moist ulcer environment (Kerstein et al., 2001; Maume et al., 2003). (Evidence Level = A)
      2. Use topical analgesics, such as EMLA (lidocaine and prilocaine) cream (Evans & Gray, 2005) or anesthetics when appropriate (de Laat, Scholte op Reimer, & van Achterberg, 2005). (Evidence Level = A)
      3. Refer patient to pain specialist and use systemic pain medications when appropriate (Reddy et al., 2003). (Evidence Level = C)
      4. Correct patient posture and use support surfaces to minimize pain (Reddy et al., 2003). (Evidence Level = C)
      5. Use meditation or diversion techniques or refer patient for psycho-social interventions if appropriate (Reddy et al., 2003). (Evidence Level = C)
      6. Refer patient for massage if needed to manage muscle cramping or lymphatic conditions (RNAO, 2007). (Evidence Level = C)
        1. Avoid massage over reddened bony prominences (RNAO, 2007). (Evidence Level = C)
    1. Implement nutritional interventions (Langer et al., 2003; Lee et al., 2006; Theilla et al., 2007). (Evidence Level = A)
      1. Ensure adequate nutrient and fluid intake to maximize potential for wound healing (Langer et al., 2003; van Rijswijk & Polansky, 1994). (Evidence Level = A)
        1. Calories (35-40 kcal/kg/day) (Cereda et al., 2009; Langer et al., 2003; Pinchcofsky-Devin & Kaminski, 1986) (Evidence Level = A)
        2. Protein (1.0-1.5 g protein/kg/day) (Cereda et al., 2009; Langer et al., 2003; Lee et al., 2006) (Evidence Level = A)
        3. Micronutrients; if vitamin or mineral deficiencies are confirmed or suspected, provide appropriate supplements (Cereda et al., 2009; Desneves et al., 2005; Theilla et al., 2007) e.g., zinc, amino acids, Vitamin C (Evidence Level = A), A, or E (Evidence Level = C)
        4. Hydration program 30-35 cc/kg of body weight or as medically indicated (RNAO, 2007) (Evidence Level = C)
      1. If underweight or losing weight, enhance intake to place the individual into positive nitrogen balance (Cereda et al., 2009; Langer et al., 2003; Pinchofsky-Devin & Kaminski, 1986). (Evidence Level = A)
        1. Anabolic agents or appetite stimulants may be used (Spungen et al., 2001). (Evidence Level = C)
      1. Evaluate effectiveness of nutritional interventions regularly (Pinchcofsky-Devin & Kaminski, 1986; van Rijswijk & Polansky, 1994). (Evidence Level = C)
  1. Advanced or Adjunctive Interventions if PU Is Unresponsive to A-Level Management (Evidence Level = A)

    Note: Modalities below were not compared in a randomized controlled trial (RCT) on PU to any dressing with A-Level evidence in Table 6 in the original guideline document.

    1. Electrical stimulation (Gardner, Frantz, & Schmidt, 1999; Feedar, Kloth, & Gentzkow, 1991; Wood et al., 1993; Mulder, 1991) (Evidence Level = A)
    2. Hyperbaric oxygen therapy (Kranke et al., 2004) (Evidence Level = C)—no studies supported PU effect (Evidence Level = A), but it may be useful if ischemic condition or osteomyelitis is present. (Evidence Level = C)
    3. Negative Pressure Wound Therapy (Evidence Level = B)—no consistent effect on PU healing (Gregor et al., 2008; Ubbink et al., 2008). Increased granulation, less fibrin compared to Redon drain (Wild et al., 2008), earlier use may shorten home care stays (Baharestani, Houliston-Otto, & Barnes, 2008). Lower cost than gauze (Mody et al., 2008). The U.S. Food and Drug Administration (FDA) has advised caution in selecting patients for this therapy due to serious, occasionally fatal, complications. Please read the FDA notice at: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm190658.htm External Web Site Policy. (Evidence Level = C)
    4. Therapeutic ultrasound; contact or non-contact—no PU RCTs supported healing or debridement (Baba-Akbari et al., 2006; Ramundo & Gray, "Is ultrasonic mist," 2008). (Evidence Level = C)
    5. Ultraviolet (UV) light/or multi-wavelength phototherapy (Taly et al., 2004) (Evidence Level = C)
    6. Growth factors are not indicated for PU use at this time. They have been compared to gauze primary dressings (Rees et al., 1999; Robson et al., 1992), which are recognized as substandard practice (de Laat, Scholte op Reimer, & van Achterberg, 2005; Kerstein et al., 2001; Maume et al., 2003). No PU RCT compared a growth factor to dressings with A-Level evidence in Table 6 in the original guideline document. (Evidence Level = C)
    7. Infrared or monochromatic light stimulation (Dehlin, Elmstahl, & Gottrup, 2007; Durovic et al., 2008; Schubert, 2001) (Evidence Level = A)
    8. Allograft (RNAO, 2007) (Evidence Level = C)
  1. Surgical Interventions (Brown, Kasten, & Smith, 2007; Isik et al., 1997; Wong & Ip, 2006; Yamamoto et al., 1997) (Evidence Level = B)
    1. Direct closure (Whitney et al., 2006) seldom helps unless pressure source is eliminated and PU is small (Brown, Kasten, & Smith, 2007). (Evidence Level = C)
    2. Flaps: myocutaneous free, fasciocutaneous, cutaneous (Ichioka et al., 2007; Lemaire, Boulanger, & Heymans, 2008; Wong & Ip, 2006; Rennert et al., 2009; Yamamoto et al., 1997) (Evidence Level = B)
    3. Skin grafts (Whitney et al., 2006), though they exhibit "poor take" over exposed bone (Brown, Kasten, & Smith, 2007) (Evidence Level = C)
    4. Perioperative considerations (Brown, Kasten, & Smith, 2007; Whitney et al., 2006) (Evidence Level = C)
      1. Pre-operative; smoking cessation, bowel regulation, spasms/contractures managed, medically stable, nutrition/hydration adequate, infection managed (Evidence Level = C)
      2. Reduce ulcer bacterial burden to <105 colony forming units per g of sample before surgical closure (Brown, Kasten, & Smith, 2007; Murphy et al., 1986; Whitney et al., 2006). (Evidence Level = B)
    1. Post-operative: use highly effective support surface (e.g., air fluidized bed), increase mobility to sitting over 4-8 weeks. Educate patient and caregiver re: re-injury and recurrence, conduct daily skin examination, and provide intermittent pressure relief techniques and patient-oriented nutrition and hydration (Isik et al., 1997; Milne et al., 2009). (Evidence Level = C)
      1. Evaluate for and address surgical complications: such as wound dehiscence, infection, abscess, hematoma/seroma, procedure-related pain (Isik et al., 1997). (Evidence Level = C)
  1. Documentation of Patient Response to Treatment Program (Evidence Level = A)
    1. Measure ulcer and document overall progress weekly, or sooner if there is a significant change in ulcer status, on an approved data collection form; with wound photograph if feasible. Consider validated tools such as the BWAT® (Bates-Jensen Wound Assessment Tool©) DESIGN Tool or PUSH© (Pressure Ulcer Scale for Healing) (Bolton et al., 2004; Milne et al., 2009; Sanada et al., 2004). (Evidence Level = C)
    2. If no significant reduction in wound area after 2-4 weeks of a treatment regimen, re-evaluate diagnosis and/or care plan (van Rijswijk, 1993; van Rijswijk & Polansky, 1994). Note: Kurd et al., 2009 reported improved healing outcomes in RCTs for venous leg ulcers and diabetic foot ulcers if wound care providers received feedback of 4-week healing rates. (Evidence Level = A) There is not yet a corresponding RCT for PU. (Level A for chronic wounds pending PU study.) (Evidence Level = C)
    3. If complications, non-adherence to protocol or nutritional concerns arise, revise plan of care or goals of treatment to address patient issues (Pinchcofsky-Devin & Kaminski, 1986; Reed et al., 2003). (Evidence Level = C)
  1. Palliative Care for the Qualifying Individual (Evidence Level = A)
    1. Assess skin for signs of "terminal ulcers" in gravely ill individuals (Langemo & Brown, 2006; Kennedy-Evans, 2009). (Evidence Level = C)
    2. Establish individualized goals of care as determined by patient wishes and medical condition (Alvarez et al., 2007) including the following (McDonald & Lesage, 2006) (Evidence Level = C):
      1. Stabilize and manage all PU and surrounding skin as much as possible while optimizing patient comfort (Langemo, Black, & NPUAP, 2010; Letizia, Uebelhor, & Paddack, 2010; McDonald & Lesage, 2006). (Evidence Level = C)
      2. Assess individual co-morbid conditions and address PU causes to prevent new PU and surrounding skin breakdown by using methods and materials consistent with patient and family wishes to protect skin, e.g., heel protection and maintain patient hydration, nutrition, etc. as in section II of this Guideline (Langemo, Black, & NPUAP, 2010; Letizia, Uebelhor, & Paddack, 2010; McDonald & Lesage, 2006). (Evidence Level = B)
      3. Minimize or eliminate odor including wound odor (Paul & Pieper, 2008) (Evidence Level = A) due to infection or incontinence (Langemo, Black, & NPUAP, 2010; Letizia, Uebelhor, & Paddack, 2010; McDonald & Lesage, 2006). (Evidence Level = C)
      4. Assess each PU regularly using reliable, valid scale including PU pain every shift or at dressing change. Manage pain with an effective analgesic (e.g., as in the section titled, "Manage Local and Systemic Factors: Debride, Cleanse and Wound Dress" of this Guideline or with topical diamorphine hydrogel) and by keeping wound bed moist while adhering to PU prevention principles in the section titled, "Prevent Pressure Ulcer Occurrence or Recurrence" above that are acceptable to the patient (Langemo, Black, & NPUAP, 2010; Letizia, Uebelhor, & Paddack, 2010; McDonald & Lesage, 2006). (Evidence Level = B)
      5. Prevent and manage PU infection to extent acceptable to patient and family (Langemo, Black, & NPUAP, 2010; Letizia, Uebelhor, & Paddack, 2010; McDonald & Lesage, 2006). (Evidence Level = C)
      6. Absorb exudate, e.g., with a foam or hydrocolloid dressing that lengthens dressing wear time. This minimizes dressing change frequency while keeping wound bed moist to reduce pain of dressing removal. (Langemo, Black, & NPUAP, 2010; Letizia, Uebelhor, & Paddack, 2010; McDonald & Lesage, 2006). (Evidence Level = B)
      7. Maintain individual dignity and provide psychosocial support to reduce isolation (Letizia, Uebelhor, & Paddack, 2010; McDonald & Lesage, 2006). (Evidence Level = C)

Definitions:

Strength of Evidence Level

  1. Results of a meta-analysis or two or more pressure (PU)-related randomized controlled trials (RCTs) on humans provide support (or for diagnostics or risk assessment: prospective cohort [CO] studies and/or controlled studies reporting recognized diagnostic or predictive validity measures).
  2. Results of one PU-related RCT in humans plus two or more similar historically controlled trials (HCTs) or convenience controlled trials (CCTs) or one HCT and one CCT provide support or when appropriate, results of two or more RCTs in animal model validated as clinically relevant to PU provide indirect support. For diagnostics or risk assessment one PU-related prospective CO study and/or a controlled study reporting recognized diagnostic or predictive validity measures.
  3. This rating requires one or more of the following:

    C1: Results of one controlled trial, e.g., RCT, CCT or HCT (or for diagnostics or risk prediction one prospective CO study may be substituted for a controlled trial)

    C2: Results of at least two case series (CS) or descriptive studies or a cohort study in humans

    C3: Expert opinion (EO)

Clinical Algorithm(s)

A clinical algorithm is provided in the original guideline document for managing a patient with pressure ulcer risk or a pressure ulcer.

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate pressure ulcer risk assessment, diagnosis, screening, prevention, and treatment leads to decreased pressure ulcer incidence, healing times, and recurrence and can improve patient pain and quality of life while reducing resource use and costs of patient care.

Potential Harms
  • Avoid positioning heating/cooling blankets devices underneath weight-bearing zones.
  • Avoid massage over reddened bony prominences.
  • Surgical complications include wound dehiscence, infection, abscess, hematoma/seroma, and procedure-related pain.
  • Interventions described may have side effects described on each intervention's package insert.

Contraindications

Contraindications

Contraindications for debridement include compromised vascular circulation at ulcer site, stable heel eschar, and gravely palliative or critically unstable patients.

Qualifying Statements

Qualifying Statements
  • Though the evidence supporting these recommendations may serve as a legitimate basis for informing clinical decisions, the recommendations are not to be construed as legal requirements or precedents. The Association for the Advancement of Wound Care (AAWC) Pressure Ulcer Guideline is intended to supplement clinical decision making by providing ready access to best available evidence for clinically relevant recommendations for pressure ulcer management.
  • This document can be used to highlight opportunities for pressure ulcer research for which A-level evidence is lacking or identify opportunities for pressure ulcer education where a recommendation with A-level evidence has little clinical credibility as indicated by a low content validity index. Future research may change the evidence level of any recommendation.

Implementation of the Guideline

Description of Implementation Strategy

Providers of care for patients with or at risk of developing a pressure ulcer may download and use the summary algorithm, professional tools and one or more recommendations with evidence and content validity indexes as well as corresponding evidence at the Association for the Advancement of Wound Care (AAWC) Web site External Web Site Policy and include appropriate recommendations in their institutional protocols free of charge.

Implementation Tools
Clinical Algorithm
Quick Reference Guides/Physician Guides
Slide Presentation
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Association for the Advancement of Wound Care (AAWC). Association for the Advancement of Wound Care guideline of pressure ulcer guidelines. Malvern (PA): Association for the Advancement of Wound Care (AAWC); 2010. 14 p.
Adaptation

This guideline synthesized recommendations from the following 11 pressure ulcer guidelines:

  1. Registered Nurses Association of Ontario (RNAO). Risk assessment and prevention of pressure ulcers. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 80 p. [70 references]
  2. Registered Nurses Association of Ontario (RNAO). Assessment and management of stage I to IV pressure ulcers. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2007 Mar. 112 p. [118 references]
  3. Hartford Institute for Geriatric Nursing. Ayello EA, Sibbald RG. Preventing pressure ulcers and skin tears. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan. p. 403-29. [91 references]
  4. National Collaborating Centre for Nursing and Supportive Care and National Institute for Clinical Excellence. The management of pressure ulcers in primary and secondary care: a clinical practice guideline developed by the Royal College of Nursing. 2003 Oct.
  5. Paralyzed Veterans of America. Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health care professionals. Washington (DC): Paralyzed Veterans of America; 2000 Aug. 94 p. [448 references]
  6. American Medical Directors Association (AMDA). Pressure ulcers in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2008. 44 p. [57 references]
  7. Agency for Health Care Policy and Research (AHCPR). Treatment of pressure ulcers. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, AHCPR; 1994 Dec. 154 p. (Clinical practice guideline; no. 15). [333 references]
  8. Agency for Health Care Policy and Research (AHCPR). Pressure ulcers in adults: prediction and prevention. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, AHCPR; 1992 May. 63 p. (Clinical practice guideline; no. 3). [127 references]
  9. Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Mount Laurel (NJ): Wound, Ostomy, and Continence Nurses Society (WOCN); 2010 Jun 1. 96 p. (WOCN clinical practice guideline; no. 2). [341 references]
  10. Whitney J, Phillips L, Aslam R, Barbul A, Gottrup F, Gould L, Robson MC, Rodeheaver G, Thomas D, Stotts N. Guidelines for the treatment of pressure ulcers. Wound Repair Regen. 2006 Nov-Dec;14(6):663-79.
  11. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington (DC): National Pressure Ulcer Advisory Panel; 2009. p. 21-50. [214 references]
Date Released
2010 Oct 1
Guideline Developer(s)
Association for the Advancement of Wound Care - Nonprofit Organization
Source(s) of Funding

Association for the Advancement of Wound Care

Guideline Committee

Association for the Advancement of Wound Care Guideline Department

Composition of Group That Authored the Guideline

Guideline Department Members: Mona M. Baharestani, PhD, ANP, CWON, CWS (NPUAP Liaison), Associate Professor, East Tennessee State Univ, Center for Nursing Research, Johnson City, TN; Teri M Berger, RN, CWCN, Providence Hospice and Home Care of Snohomish County, Everett, WA; Laura L Bolton, PhD, (Co-Chair), Adj. Assoc Prof Surgery, RWJMS, President, BoltonSCI, Metuchen, NJ; Linda Foster RN, CWCN, Providence Hospice and Home Care of Snohomish County, WA; DeSales (Dee) Foster, MSN, CWOCN, CRNP, Riddle Memorial Hospital, Main Line Health System, Media, PA; Susan Girolami, RN, BSN, CWOCN, (Co-Chair), Clinical Manager, THERAPY SUPPORT, Inc., Cincinnati, OH; Roslyn Jordon, RN, BSN, CWOCN, Northport, AL; Soofia Khan, MD, MBBS, MS GenSurgery, (Ad Hoc Member), Physiatrist, VA Albuquerque Medical Center, Albuquerque, NM; Patrick McNees, PhD, FAAN, (Ad Hoc) Professor and Associate Dean for Research, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL; Diane Merkle, APRN, CWOCN, Bridgeport Hospital, Bridgeport, CT; Laurie Rappl, PT, Clinical Manager, CytoMedix, Simpsonville, SC; Stephanie A Slayton, PT, DPT, CWS, Pitt County Memorial Hospital, Greenville, NC; Jeremy Tamir, MD, FAPWCA, Halstead Hospital & Rehabilitation Center, Halstead, KS; Katherine Whittington, RN, MS, CWCN, Clinical Director, Wound Care Marketing, Molnlycke Healthcare, Boerne, TX

Financial Disclosures/Conflicts of Interest

Most members of the Association for the Advancement of Wound Care (AAWC) Guideline Department have conducted industry-supported research or educational activities on pressure ulcers or used various product categories listed in the guideline. None are major stakeholders or officers in any company with a prior or current major interest in products described in this guideline.

Guideline Endorser(s)
Canadian Association for Enterostomal Therapy - Professional Association
Wound Healing Society - Nonprofit Organization
Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Association for the Advancement of Wound Care Web site External Web Site Policy.

Print copies: Available from the Association for the Advancement of Wound Care, 83 General Warren Blvd., Suite 100, Malvern, PA 19355

Availability of Companion Documents

The following is available:

  • AAWC pressure ulcer guideline. A quick reference guide for pressure ulcer prevention and treatment. Malvern (PA): Association for the Advancement of Wound Care; 2009. 1 p. Electronic copies: Available in Portable Document Format (PDF) from the Association for the Advancement of Wound Care (AAWC) Web site External Web Site Policy.

Print copies: Available from the Association for the Advancement of Wound Care, 83 General Warren Blvd., Suite 100, Malvern, PA 19355

The following are also available:

  • AAWC guideline department pressure ulcer care initiative (PUCI). Evidence table. Malvern (PA): Association for the Advancement of Wound Care; 2010 Nov. 52 p. Electronic copies: Available in PDF from the AAWC Web site External Web Site Policy.
  • Developing a comprehensive content validated pressure ulcer guideline. Slide set. Malvern (PA): Association for the Advancement of Wound Care; 2009 Feb. 20 p. Electronic copies: Available from the AAWC Web site External Web Site Policy.
  • Bolton L, Girolami S, Slayton S, Berger TM, Foster L, Whittington KT, Merkle D; Association for the Advancement of Wound Care Guideline Subcommittee. Assessing the need for developing a comprehensive content-validated pressure ulcer guideline. Ostomy Wound Manage. 2008 Nov;54(11):22-30. Electronic copies: Available from the AAWC Web site External Web Site Policy.

In addition, an online E-learning resource for healthcare professionals on predicting pressure ulcer risk is available from the AAWC Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on April 28, 2011. The information was verified by the guideline developer on June 9, 2011. This summary was updated by ECRI Institute on March 6, 2014 following the U.S. Food and Drug Administration advisory on Over-the-Counter Topical Antiseptic Products.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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