Guideline sources The following summarized guidelines for the evaluation and management of pressure ulcer (PU) are prepared by our editorial team based on guidelines from the European Pressure Ulcer Advisory Panel (EPUAP/PPPIA/NPIAP 2019), the Wound Healing Society (WHS 2016), and the American College of Physicians (ACP 2015). 1 2 3 4 Guidelines 1. Classification and risk stratification Risk assessment: As per EPUAP 2019 guidelines, obtain a pressure injury risk screening as soon as possible after admission to the care service, and periodically thereafter, to identify patients at risk of developing pressure injuries. B Show 4 more https://web.pathway.md/diseases/recwx0koFPAIBxKKA 1/10 6/29/23, 11:26 PM Pressure ulcer Pathway Show 4 more As per WHS 2016 guidelines, assess all patients for their risk of developing PUs. A As per ACP 2015 guidelines, obtain risk assessment to identify patients at risk of developing PUs. B 2. Diagnostic investigations History and physical examination: As per EPUAP 2019 guidelines, perform a comprehensive skin and tissue examination in all persons at risk of pressure injuries: as soon as possible after admission/transfer to healthcare service as a part of every risk assessment periodically as indicated by the patient's degree of pressure injury risk before discharging from the care service. B Show 6 more As per WHS 2016 guidelines, review medications, A , assess nutritional status, B perfusion and oxygenation, A and evaluate for systemic diseases in patients with PUs. A Evaluation for wound infection: As per EPUAP 2019 guidelines, suspect local infection in a pressure injury in the presence of: delayed healing lack of signs of healing in the preceding 2 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. B Show 5 more As per WHS 2016 guidelines, recognize that classic signs of infection (purulent exudate, heat, edema, and erythema) may not always be present. A Show 3 more 3. Diagnostic procedures Bone biopsy: perform bone biopsy for culture and histology in patients with suspected osteomyelitis associated with a PU. B https://web.pathway.md/diseases/recwx0koFPAIBxKKA 2/10 6/29/23, 11:26 PM Pressure ulcer Pathway 4. Medical management Topical antimicrobials: As per EPUAP 2019 guidelines: Apply topical antiseptics in tissue-appropriate strengths to control microbial burden and to promote healing in pressure injuries showing delayed healing. B Apply topical antiseptics active against biofilm in tissue-appropriate strengths in conjunction with regular debridement to control and eradicate suspected (or confirmed) biofilm in pressure injuries showing delayed healing. B As per WHS 2016 guidelines, recognize that topical antimicrobials (silver-containing cream, antimicrobial-containing foam dressing, cadexomer iodine) have been shown to decrease the bacterial load in ulcers. A Systemic antibiotics: As per EPUAP 2019 guidelines, administer systemic antibiotics to control and eradicate the infection in patients with pressure injuries and clinical evidence of systemic infection. B As per WHS 2016 guidelines, insufficient evidence to support the use of systemic antibiotics to lower bacterial bioburden in wounds. I Management of osteomyelitis: Perform adequate debridement and initiate culture-guided antibiotics in patients with osteomyelitis underlying a PU. A Consider performing reconstruction with well-vascularized tissue to facilitate healing of osteomyelitis in appropriately selected patients. B Management of distant infections: treat distant infections (such as urinary tract, cardiac valves, cranial sinuses) with appropriate antibiotics in PU-prone patients or patients with established ulcers. B Growth factor therapy: As per EPUAP 2019 guidelines: Consider offering platelet-rich plasma for promoting healing in pressure injuries. C Consider offering platelet-derived growth factor for promoting healing in stage 3-4 pressure injuries. C As per WHS 2016 guidelines, consider offering growth factor therapy in patients with PUs not responding to initial comprehensive therapy and/or before surgical repair. C Management of pain: obtain a comprehensive pain assessment in patients with a pressure injury. B Show 5 more 5. Nonpharmacologic interventions Offloading: elevate the heels using a specifically designed heel suspension device in patients with stages 1-2 B and stage 3 PUs, B or a pillow/foam cushion in patients with stages 1-2 PUs, offloading the heel completely to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. B https://web.pathway.md/diseases/recwx0koFPAIBxKKA 3/10 6/29/23, 11:26 PM Pressure ulcer Pathway Nutritional support: As per EPUAP 2019 guidelines, obtain nutritional screening in patients at risk of a pressure injury. B Show 5 more As per WHS 2016 guidelines, obtain nutritional assessment at admission to a new healthcare setting and whenever there is a change in the patient's condition increasing the risk of undernutrition. B Show 4 more As per ACP 2015 guidelines, offer protein or amino acid supplementations to reduce wound size in patients with PUs. B 6. Therapeutic procedures Electrical stimulation: As per EPUAP 2019 guidelines, offer pulsed current electrical stimulation to facilitate wound healing in patients with recalcitrant stage 2 pressure injuries and stage 3-4 pressure injuries. B As per WHS 2016 guidelines, consider offering electrical stimulation in patients with PUs not responding to conventional therapy. B As per ACP 2015 guidelines, offer electrical stimulation as adjunctive therapy to accelerate wound healing in patients with PUs. B Negative pressure wound therapy: As per EPUAP 2019 guidelines, consider offering negative pressure wound therapy as an early adjunct therapy for reducing the size and depth of stage 3-4 pressure injuries. C As per WHS 2016 guidelines, consider offering negative pressure wound therapy for stage III or IV PUs not responding to with conventional therapy. B Hyperbaric oxygen therapy: do not offer hyperbaric oxygen therapy for PU healing. D Ultrasound therapy: Consider offering non-contact low-frequency ultrasound therapy as an adjunct therapy to facilitate healing in patients with stage 3-4 pressure injuries and suspected deep tissue injuries. C Consider offering high-frequency ultrasound therapy at 1 MHz as an adjunct therapy to facilitate healing in patients with stage 3-4 pressure injuries. C 7. Perioperative care Perioperative management: As per EPUAP 2019 guidelines, monitor the wound regularly and immediately report signs of flap failure. B Show 3 more As per WHS 2016 guidelines: https://web.pathway.md/diseases/recwx0koFPAIBxKKA 4/10 6/29/23, 11:26 PM Pressure ulcer Pathway Manage muscle spasms and fixed contractures preoperatively and continue management at least until the wound is completely healed. B Optimize glucose control in the perioperative period. A 8. Surgical interventions Debridement: As per EPUAP 2019 guidelines: 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. B Avoid disturbing stable, hard, dry eschar in ischemic limbs and heels unless an infection is suspected. D As per WHS 2016 guidelines, perform initial debridement (sharp, mechanical, enzymatic, or autolytic; more than one method may be appropriate) to remove the obvious necrotic or devitalized tissue, excessive bacterial burden, and cellular burden of dead and senescent cells. Perform maintenance debridement to maintain the appearance and readiness of the wound bed for healing. A Show 4 more Wound cleansing: As per EPUAP 2019 guidelines, cleanse the pressure injury. B Show 2 more As per WHS 2016 guidelines: Cleanse wounds initially and at each dressing change using a pH-balanced, non-irritating, non-toxic solution. Perform routine wound cleansing with a minimum of chemical and/or mechanical trauma. B Insufficient evidence to recommend a specific type of wound cleansing solution or technique for PUs. Avoid using antiseptic agents as granulation tissue will be destroyed. Recognize that tap water is appropriate to use for wound cleansing. I Wound dressings: As per EPUAP 2019 guidelines, choose the most appropriate wound dressing based on the goals and self-care abilities of the patient with pressure injuries 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. B Show 10 more https://web.pathway.md/diseases/recwx0koFPAIBxKKA 5/10 6/29/23, 11:26 PM Pressure ulcer Pathway As per WHS 2016 guidelines, choose dressings based on clinical judgment at least meeting the following requirements: maintain a moist wound environment A manage the wound exudate A protect the skin surrounding A minimize issues with friction, shearing, skin irritation, and additional pressure B cost-effective. A As per ACP 2015 guidelines, use hydrocolloid or foam dressings to reduce wound size in patients with PUs. B Surgical closure: As per EPUAP 2019 guidelines, obtain surgical consultation for patients with a pressure injury: having advancing cellulitis or suspected source of sepsis having undermining, tunneling, sinus tracts, and/or extensive necrotic tissue not easily removed by conservative debridement stage 3-4 not closing with conservative treatment. B Show 4 more As per WHS 2016 guidelines, perform surgical closure of a PU if it does not respond to wound care and there is no other contraindication to the surgical procedures, with exceptions to this procedure being elderly or having a fatal illness for which palliative, local wound care is more appropriate. Recognize that composite tissue closure leads to the best chance of sustained wound closure although recurrence can occur. B Show 2 more Fecal and urinary diversion: recognize that fecal and urinary surgical diversions are rarely needed to achieve wound healing. B Amputation: consider performing amputation or hemicorporectomy only in rare and extreme cases. C 9. Specific circumstances Pediatric patients: obtain an age-appropriate nutritional screening and assessment in neonates and pediatric patients at risk of pressure injuries. B Show 2 more Seated patients: As per EPUAP 2019 guidelines, use a seat and seating support surface meeting the patient's needs for pressure redistribution with consideration to: body size and configuration effects of posture and deformity on pressure distribution mobility and lifestyle needs. B Show 3 more https://web.pathway.md/diseases/recwx0koFPAIBxKKA 6/10 6/29/23, 11:26 PM Pressure ulcer Pathway As per WHS 2016 guidelines, advise avoiding prolonged sitting in patients at risk of developing PUs. Consider ensuring postural alignment, distribution of weight, balance, stability, and pressure redistribution in seated patients. B Show 2 more Patients with medical devices: Review and select medical devices taking the following factors into account in order to reduce the risk of medical device-related pressure injuries: the device's ability to minimize tissue damage correct sizing/shape of the device for the patient ability to correctly apply the device according to manufacturers instructions ability to correctly secure the device. B Show 6 more 10. Preventative measures Skin care: Implement a skin care regimen including: keeping the skin clean and appropriately hydrated cleansing the skin promptly after episodes of incontinence avoiding the use of alkaline soaps and cleansers protecting the skin from moisture with a barrier product. B Show 4 more Pressure-relieving surfaces: As per EPUAP 2019 guidelines, use a support surface meeting patient's needs 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 patient number, severity, and location of existing pressure injuries risk for developing new pressure injuries. B Show 11 more As per WHS 2016 guidelines, use pressure-reducing surfaces in patients at risk of developing PUs. Use support surfaces properly matching the patient's needs for pressure redistribution, shear reduction, and microclimate control. A Show 2 more As per ACP 2015 guidelines: Use advanced static mattresses or advanced static overlays in patients at an increased risk of developing PUs. B Do not use alternating-air mattresses or alternating-air overlays in patients at an increased risk of developing PUs. D Repositioning: As per EPUAP 2019 guidelines, perform repositioning in all patients with or at risk of pressure injuries on an individualized schedule, unless contraindicated. B https://web.pathway.md/diseases/recwx0koFPAIBxKKA 7/10 6/29/23, 11:26 PM Pressure ulcer Pathway Show 17 more As per WHS 2016 guidelines: Establish a repositioning schedule and avoid positioning patients on PUs and bony prominences. B Maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. Limit the amount of time the head of the bed is elevated and elevate only when there is a compelling medical indication (such as 1-2 hours after tube feeding or with severe respiratory or cardiac compromise). Raise the patient's knees before the head of the bed is raised to reduce shearing forces when possible. B Offloading: Elevate the heels using a specifically designed heel suspension device or a pillow/foam cushion offloading the heel completely to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein in patients at risk of heel pressure injuries. B Use a prophylactic dressing as an adjunct to heel offloading and other strategies to prevent heel pressure injuries. B 11. Follow-up and surveillance Serial clinical assessment: reassess the pressure injury at least weekly to monitor progress toward healing. B Show 4 more Management of chronic ulcers: As per EPUAP 2019 guidelines, suspect local infection in pressure injuries with delayed healing or lack of signs of healing in the preceding 2 weeks despite appropriate treatment. B Show 5 more As per WHS 2016 guidelines, recognize that bacterial biofilms contribute to the development of chronic non-healing wounds. Suspect a biofilm formation in patients with poorly healing chronic wounds and wounds with a high multispecies bacterial burden, and consider obtaining molecular microbial identification testing. B Show 3 more 12. Quality improvement Documentation: document wound history, recurrence, and characteristics (location, staging, size, base, exudates, infection condition of surrounding skin, and pain). B Clinical findings Patient demographics Symptoms Elderly age Fever https://web.pathway.md/diseases/recwx0koFPAIBxKKA 8/10 6/29/23, 11:26 PM Pressure ulcer Pathway Foul-smelling wound Past medical history Malaise CKD Pain Critical illnes Weight loss DVT Social history Diabetes mellitus HF Residing in nursing facilities Immobility Osteomyelitis Neurological exam PAD Coma Spinal cord injury Stroke Integument exam Traumatic injury Discolored granulation tissue Anthropomorphic exam Draining sinus tract Eschar Frailty Exposed bone Malnutrition Friable granulation tissue Lymphatic exam Kennedy terminal ulcer Purulent exudate Lymphadenopathy Skin discoloration Skin edema Lab findings Skin erythema Hypoalbuminemia Skin induration ESR Skin tenderness serum CRP Skin ulceration Skin warmth Skin wounds Tissue necrosis Wound exudate Hematological findings Anemia WBC count blood platelet count References 1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. EPUAP/NPIAP/PPPIA. 2019. Open 2. Lisa Gould, Mike Stuntz, Michelle Giovannelli et al. Wound Healing Society 2015 update on guidelines for pressure ulcers. Wound Repair Regen. 2016 Jan-Feb;24 1 145 62. Open 3. Qaseem A, Humphrey LL, Forciea MA et al. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162 5 370 9. Open https://web.pathway.md/diseases/recwx0koFPAIBxKKA 9/10 6/29/23, 11:26 PM Pressure ulcer Pathway 4. Qaseem A, Mir TP, Starkey M et al. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162 5 359 69. Open 5. N Bergstrom, B J Braden, A Laguzza et al. The Braden Scale for Predicting Pressure Sore Risk. Nurs Res. Jul-Aug 1987;36 4 205 10. Open 6. Doris Grinspun, RN, MSN et al. Assessment and Management of Pressure Injuries for the Interprofessional Team. RNAO. May 2016;. Open https://web.pathway.md/diseases/recwx0koFPAIBxKKA 10/10