The following is a summary of the actual AHCPR Clinical Practice Guideline. It is strongly recommend that you obtain and read a copy of this document.

For a copy, I've been given these two options:

1. Call 1-800-358-9295 or write to: AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.
2. Write to Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Willco Building, Suite 310, 6000 Executive Boulevard, Rockville, MD 20852.

Also, find it online at http://www.ahrq.gov/clinic/cpgonline.htm  (scroll down the page a bit)

Pressure Ulcer Staging

Please refer to the Staging section of this internet guide for a complete review.

• Stage 1 ulcers may be superficial, or they may be a sign of deeper tissue damage.
• Stage 1 pressure ulcers are not always reliably assessed, especially in patients with darkly pigmented skin.
• When eschar is present, a pressure ulcer CANNOT be accurately staged until the eschar is removed. Do not remove a "stable" heel eschar. Stable is defined as not having edema, erythema, fluctuance or drainage.
• Physical barriers may make it difficult to assess a pressure ulcer. (ie. casts, stockings, orthopedic devices)

Assessment of the Patient

• Assessment is the starting point of ulcer treatment. The entire patient, not just the ulcer, must be assessed.
• Note the size, depth, necrotic and granular tissue present
• Reassess at least weekly or sooner if deterioration of the ulcer is noted. Clean pressure ulcer with adequate blood flow should show some improvement in 2 - 4 weeks.
• Monitor the overall medical condition of the patient and watch for other complications like amyloidosis, endocarditis, maggot infestation, meningitis, peptic arthritis, squamous cell carcinoma in the ulcer, systemic complications of topical treatment, etc.
• Nutritional Assessment and Management - perform a Nutritional assessment at least every 3 months for patients at risk for malnutrition. Vitamin and mineral supplements may be necessary. Positive nitrogen balance and protein intake are important as well.
• Pain Assessment - The goal is to eliminate the cause of the pain, to provide analgesia, or both. Cover the wound, adjust support surface, reposition, give analgesia as needed or appropriate in an effort to reduce pain.
• Psychosocial Assessment - The goal is to create an environment conducive to patient adherence to the pressure ulcer treatment plan.

Tissue Load Management

• The goal of load management is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer (s).
• The vigilant use of proper positioning and support surfaces are important.
• Avoid positioning patients on a pressure ulcer. Do not use donut-type-devices.
• Use devices like pillows or foam to keep the heels off the bed, keep knees and ankles from touching
• Maintain the head of the bed at the lowest degree medically necessary.
• No evidence to show that any one support surface consistently performs better than another.
• A patient should avoid sitting if he/she has an ulcer on a sitting surface.
• Move a sitting patient at least once an hour.

Ulcer Care

• Initial ulcer care involves debridement, wound cleansing, dressing application and possible adjunctive therapy.
• Debridement should be performed to remove moist, devitalized tissue. See types of debridement for details.
• Small wounds can be debrided at bedside, extensive wounds in the operating room or special procedure room.
• Stable heel ulcers with eschar DO NOT need to be debrided. Edema, erythema, fluctuance or drainage would necessitate eschar debridement.
• Wound Cleansing - Weigh benefits of cleaning against trauma to tissue bed caused by the cleaning. Do not use povidone iodine, iodophor, sodium hypochlorite solution, hydrogen peroxide and acetic acid as they have been shown to be cytotoxic. Use normal saline at a pressure between 4 and 15 pounds per square inch (psi).
• Dressings - See product index for more information. An ideal dressing should protect the wound, be biocompatible, and provide ideal hydration. The cardinal rule is to keep the ulcer tissue moist and the surrounding intact skin dry.
• Electrotherapy has been shown to be effective in pressure ulcer treatment. See Physical Therapy Modalities.

Managing Bacterial Colonization and Infection

• All stage 2,3,4 ulcers are invariably colonized by bacteria. Topical antibiotics are appropriate. Watch for response and sensitivity.
• Swab cultures should not be used. They will only show surface contaminants.
• Use needle aspiration to obtain fluid or soft tissue biopsy for determining infecting organism.
• Bone biopsy is the gold standard for assessing osteomyelitis. WBC, ESR and plain x-ray have a positive predictive value 69 percent when all three tests are positive.
• Use appropriate systemic antibiotic therapy for patients with bacteremia, sepsis, advancing cellulitis or osteomyelitis.
• Use sterile instruments and clean dressings during wound care. Treat the most contaminated ulcer LAST in patients with multiple wounds. Change gloves and wash hands between patients.

Operative Repair

• Including direct closure, skin grafting, skin flaps, musculocutaneous flaps and free flaps.

Education

• Stress prevention and treatment.
• Discuss etiology, pathology, risk factors, terminology, principles of wound healing, nutritional support, cleaning, infection control, positioning, prevention, product selection, documentation.
• Monitor outcomes and identify deficiencies.

To see the Internet version of the AHCPR Clinical Practice Guideline, click here

Copyright 1995 - 2008