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Evidence Based Practice Information Sheets for Health Professionals
Grade I Discolouration of intact skin, including non-blancheable erythema, blue/purple and black
discolouration
Grade I I Partial-thickness skin loss or damage involving epidermis and/or dermis
Grade I I I Full thickness skin loss involving damage or necrosis of subcutaneous tissues; but not through
the underlying fascia and not extending to the underlying structures
Grade IV Full thickness skin loss with extensive destruction, and tissue necrosis extending to the
underlying bone, tendon or joint capsule
2. Risk Assessment They can be divided into the plan to the needs and wishes of
To allow for appropriate local complications such as si- the patient and so maximise the ef-
planning of care and to determine nus tract or abscess, fistula, fect of the program. (AHCPR 1994)
progress, the patient with the pres- maggot infestation, squamous
cell carcinoma in the ulcer, gen- Recommendations Relating
sure sore should receive assess-
ment and reassessment in a com- eral complications including To Assessment:
prehensive and holistic manner. septi-caemia , septic arthritis, •Any patient presenting with a pressure
(AHCPR 1994) men-ingitis, and complications sore should have a complete history
Pressure Sore Assessment & of topical treatment (eg., iodine and physical and psychosocial
Grading toxicity and hearing loss after examination. (AHCPR 1994) ER = Op
As with any wounds it is topical neomycin and systemic •The damaged area should be graded
important to determine the dimen- gentamicin) (AHCPR 1994 with a uniform grading system (as in
sions of the wound, the type of P.5). Table 1). A baseline of the location, size
tissue present and the level and Nutritional Assessment &
and shape, tissue type, and exudate
type of exudate. Many pressure Management
(amount and type) should be assessed
sore grading or staging systems The link between pressure
sores and malnutrition is well and documented (AHCPR 1994)
have been devised. Ideally pres-
documented. Baseline and on- ER = Op
sure sore grading systems should
provide cross discipline uniform going assessment of nutritional •Reassessment should occur following,
understanding of diagnosis and status and needs are required to a significant clinical event or change in
progress of pressure sores. They ensure adequate nutrients to pre- condition, and/or at least weekly.
should also allow for auditing of vent further deterioration and (AHCPR 1994) ER = Op
performance relating to preven- provide support for healing • Clinicians should be wary of
tion and treatment of pressure (AHCPR 1994). complications related to pressure sores
sores and finally to compare clini- Pain Assessment & as listed above. (AHCPR 1994)
cal trials relating to interventions Management
ER = Op
and devices. (Reid and Morrison, Pain relief should always
have an high priority. In the case •Nutritional assessment should occur
1994)
of patients with pressure sores on admission and at least three monthly
An example of a pressure
sore grading scale is given in Ta- dressing types and frequency, for patients at risk of malnutrition
ble 1. These simple grading sys- support surfaces and reposition- (AHCPR 1994) ER = Op
tems are often modified to provide ing can both contribute to and •Monitoring of dietary intake in the at
more detail within each stage/ provide relief from pain. risk patient should be undertaken to
grade. This makes them more (AHCPR 1994) ‘ensure adequate dietary intake to
clinically useful but less practical Psychosocial Assessment & prevent malnutrition’ (AHCPR 1994).
for audit and comparison of trial Management ER =F.
results. The success of any treat- •Nutritional support (eg. tube feeding)
Assessing Complications ment program relies on the abil-
should be considered if intake
Pressure sores are often as- ity and motivation of the patient
continues to be inadequate (AHCPR
sociated with significant compli- and carers to adhere to the plan
of care. The psychosocial as- 1994). ER = Op
cations that the clinician should
be wary of. sessment is important to tailor •Pain management should include
volume 1, issue 2, page 2, 1997
adequate analgesia but must also to avoid direct pressure on already patients that are unable to tolerate
attempt to eliminate or control the damaged tissue. (AHCPR 1994) other methods but should not be used
source of pain eg; wound care, ER = Op if there is a high risk of infection.
inappropriate or prolonged •In patients with existing pressure (AHCPR 1994)
positioning. (AHCPR 1994) sores a static support surface
ER = Op should be used if the patient can Recommendations Relating To
•Psychosocial assessment should be positioned without weight The Debridement Of Pressure
determine the patients ability and bearing on the pressure sore and Sores:
motivation to adhere to the without ‘bottoming out’(A hand •Devitalised/necrotic tissue should be
treatment program. Assessment placed beneath the support removed using one of the following
should include mental status, surface checks to determine that methods: Sharp, mechanical, and/or
cognitive ability, social support, the compression of the surface is autolytic debridement techniques.
alcohol and/or drug abuse, lifestyle, no less than 2cm). (AHCPR 1994) (AHCPR 1994) ER = Op
sexuality; culture and ethnicity; and ER =F •Choice of method is based on patient’s
stressors. (AHCPR 1994)ER = Op •Patients should be placed on a condition and goals, and on available
• Assessment of resources and dynamic support surface such as clinical expertise. Sharp debridement
support is crucial in planning for a large cell alternating pressure should be considered particularly in
continuing care. (AHCPR 1994) mattress, low-air loss or air urgent cases such as the presence of
ER = Op fluidised bed if positioning options infection. (AHCPR 1994) ER = Op
•Above all, the values, needs and are limited or if the patient bottoms •Autolytic debridement should not be
lifestyle of the patient and care out on a static surface. (AHCPR used if the wound is infected. (AHCPR
givers must be considered when 1994) (NHS 1995) ER =F 1994) ER = Op
establishing treatment goals. •In the least, patients with large Pressure Sore Cleansing
(AHCPR 1994) ER = Op grade III or IV pressure sores The object of wound cleansing
should be considered for a is to remove non viable tissue, excess
3. Managing Tissue Loads dynamic support surface . (AHCPR exudate, metabolic wastes and resi-
Managing tissue loads is 1994) ER = Op due from topical therapy without fur-
directed at relieving pressure to ther traumatising the area. (AHCPR
4. Pressure Sore Wound 1994)
already damaged tissue and pre-
Care Skin cleansers and antiseptic
venting further tissue damage to
Management of the pres- agents (eg., povidone iodine, iodo-
other areas. Any patient with ex- phor, sodium hypochlorite solution
isting pressure damage should be sure sore is directed to: promot-
ing an optimum environment [Dakin’s solution], hydrogen perox-
considered ‘at risk’ of further ide, acetic acid), are non selective and
for healing by second intention,
damage and recommendations in are cytotoxic to healthy tissue.
preparation for surgical man-
Practice Information Sheet I Part (AHCPR 1994)
agement as indicated or main-
I should be followed with regard tenance and comfort when heal- Recommendations Relating To
to; Skin care, hygiene, moisture ing is not a priority. Wound Cleansing Of Pressure
management, pressure relieving Debridement Sores:
interventions, devices and sup- Devitalised tissue provides • Initiallypressure sores should be
port surfaces. In addition it an ideal environment for infec- cleansed at each dressing change.
should be considered that the tion, prolongs inflammation and (AHCPR 1994) ER = Op
greater the existing damage the retards healing (AHCPR 1994). • Minimal mechanical force and less
less tolerant will that tissue be to Sharp debridement is the most coarse materials should be used when
further pressure (AHCPR 1994). rapid method of removing cleansing the pressure sores with gauze
necrotic tissue but is restricted or sponges etc. (AHCPR 1994) ER = Op
Recommendations Relating to those with the necessary clini- •When cleaning pressure sores, skin
To Managing Tissue Loads cal skills (AHCPR 1994). Mod- cleansers or antiseptic agents should be
For Patients With Existing ern moist wound healing prod- avoided. (AHCPR 1994) ER =F
Pressure Sores: ucts if used appropriately sup- •Normal saline at room temperature is
• Positioning and devices such as port autolytic debridement. This the preferred cleanser. (AHCPR 1994)
pillows and foams should be used takes longer and is useful for ER = Op
Recommendations For lence and foul odour are positive management has failed to provide
Dressing Of Pressure signs of infection but infection any improvement. (AHCPR 1994)
Sores: ER = G
must also be suspected in wounds
•A dressing should be chosen that that appear clean but do not re- •When pressure sores do not respond
manages exudate to keep the spond after 2-4 weeks of appro- to topical antibiotic therapy quantitative
wound bed moist (AHCPR 1994) bacterial cultures of soft tissue and
priate care (AHCPR 1994). evaluation for osteomyelitis should be
ER =F Although widely used to di-
•The dressing should also prevent agnose infection, swab cultures performed. (AHCPR 1994) ER = Op
maceration of surrounding skin, •Topical antiseptic agents should be
may not truly reflect the avoided. (AHCPR 1994) ER =F
and avoids desiccation of the wound
bed (AHCPR 1994) ER = Op
organism(s) causing the infection. •Patients with systemic infections must
•Dressings that are able to maintain (AHCPR 1994) When the wound be treated with appropriate systemic
an optimum environment and fails to respond to topical antibi- antibiotics. (AHCPR 1994) ER = G
require less care giver time can be otics, quantitative bacterial cul-
very cost effective (AHCPR 1994) tures provide more precise infor- 6. Operative Repair
ER =F mation about soft tissue infection Wounds can be closed by di-
• Dead space is eliminated by and osteomyelitis. rect closure, or with the use of vari-
loosely filling all cavities with moist ous reconstructive techniques such
wound healing materials. (AHCPR Recommendations Relating as skin grafting, local and free flaps.
1994) ER = Op To Infection And Pressure Choice of technique is based on in-
Sores: dividual patient’s needs, overall
5. Infection •Wound cleansing and debridement goals, the specific site and extent of
All open pressure sores are is performed to minimise bacterial the tissue damage. Extrinsic factors
likely to be colonised with bac- colonisation (AHCPR 1994) ER = G that might impair healing include;
teria. However, adequate cleans- •In clean pressure sores that are not smoking, spasticity, and the ability
ing and debridement will usually healing and those that continue to to maintain pressure relief post-op-
prevent the wound from pro- produce exudate after 2 to 4 weeks eratively. Intrinsic factors include
gressing to the point of clinical a 2-week trial of topical antibiotics levels of bacterial colonisation, in-
infection where healing is im- may be considered but with caution continence and urinary tract infec-
paired. (AHCPR 1994). Puru- and only after appropriate tion. (AHCPR 1994)
pressure relief to the operative site •Individualised program of skin care. by Rick Wiechula and is based principally on the
following publications which the Joanna Briggs
for a minimum of 2 weeks. (AHCPR •Principles of cleansing and infection Institute for Evidence Based Nursing gratefully
control. acknowledges.
1994) ER=OP
•Tolerance of the operative site to •Principles of post-operative care 1. Panel for the Prediction and Prevention of
•Principles of prevention Pressure Ulcers in Adults. Pressure Ulcers in
pressure must be gradually •Product selection (ie., categories Adults: Prediction and Prevention. Clinical
developed and monitored closely. Practice Guideline, Number 3. AHCPR
and uses of support surfaces, Publication No. 92-Rockville, MD: Agency
(AHCPR 1994) ER=OP dressings, topical medications, or for Health Care Policy and Research, Public
•Preventing recurrence of pressure other agents). Health Service, U.S. Department of Health
sores relies on education and •Effects or influence of the physical and Human Services, May 1992.
encouragement to adhere to daily and mechanical environment on the 2. Bergstrom N, Bennett MA, Carlson CE, et al.
Treatment of Pressure Ulcers. Clinical
skin examination, pressure pressure sore, and strategies for Practice Guideline, Number 15. Rockville,
reduction and intermittent relief management. MD: U.S. Department of Health and Human
techniques. (AHCPR 1994) ER=G •Mechanisms for accurate Services. Public Health Service, Agency for
documentation and monitoring of Health Care Policy and Research, AHCPR
7. Continuous Quality pertinent data, including treatment Publication No. 95-0652 December 1994.
3. NHS Center for Reviews and Dissemination. The
Improvement interventions and healing progress. prevention and treatment of pressure sores
Continuous quality impro- (AHCPR 1994) ER = Op (effective health care bulletin) York: University
vement should be focused on Of York; 1995.
reducing the incidence of pres- Program revision. Update Other references include:
sure sores and reducing variabil- educational programs on an Reid, J., Morison, M. (1994). Towards a concensus:
ity in treatment of existing pres- ongoing and regular basis to Classification of Pressure Sores. Journal of Wound
sure sores. This should be integrate new knowledge, Care. 3 (3), 157-160.
Achieving Continuous
Quality Improvement:
See Practice Information Sheet I,
Part I with regard to prevention. T HE JOANNA BRIGGS INSTITUTE
Education programs for the FOR E VIDENCE BASED NURSING
treatment of pressure sores should