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Pressure ulcer
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of pressure ulcer are prepared by our editorial team based on guidelines from the Wound Healing Society (WHS 2024), the American Academy of Family Physicians (AAFP 2023), the European Pressure Ulcer Advisory Panel (EPUAP/PPPIA/NPIAP 2019), and the American College of Physicians (ACP 2015).
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Classification and risk stratification
Diagnostic investigations
History and physical examination: as per WHS 2024 guidelines, review medications,
A
, assess nutritional status, B
perfusion and oxygenation, A
and evaluate for systemic diseases in patients with PUs. A
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Evaluation for wound infection
Diagnostic procedures
Medical management
Topical antimicrobials: as per WHS 2024 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
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Systemic antibiotics
Management of osteomyelitis
Management of distant infections
Growth factor therapy
Management of pain
Management of odor
Nonpharmacologic interventions
Offloading: as per EPUAP/NPIAP/PPPIA 2019 guidelines, 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
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Pressure-relieving surfaces
Nutritional support
Therapeutic procedures
Electrical stimulation: as per WHS 2024 guidelines, consider offering electrical stimulation in conjunction with conventional therapy in patients with chronic stage 2-4 PUs.
B
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Negative pressure wound therapy
Therapeutic ultrasound
Laser therapy
Perioperative care
Surgical interventions
Debridement: as per WHS 2024 guidelines, perform initial debridement (sharp, mechanical, enzymatic, ultrasonic, 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
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Wound cleansing
Wound dressings
Surgical closure
Fecal and urinary diversion
Amputation
Specific circumstances
Pediatric patients: as per EPUAP/NPIAP/PPPIA 2019 guidelines, obtain an age-appropriate nutritional screening and assessment in neonates and pediatric patients at risk of pressure injuries.
B
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Seated patients
Patients with medical devices
Preventative measures
Skin care: as per WHS 2024 guidelines, apply prophylactic dressings over bony prominences for PU prevention in patients in the ICU.
A
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Offloading
Pressure-relieving surfaces
Repositioning