Pressure Ulcer Prevention and Management

Definition and Risk Factors

Pressure ulcers are defined as localized injuries to the skin and/or underlying tissue, usually over a bony prominence, resulting from pressure alone or in combination with shear forces, and commonly occur in patients with limited mobility, such as those in hospitals or long-term care settings 1
Risk factors for developing pressure ulcers include limited mobility, older age, black race or Hispanic ethnicity, lower body weight, cognitive impairment, physical impairments, comorbid conditions affecting tissue integrity, and poor nutrition and hypoalbuminemia, as recommended by the American College of Physicians 1

Use advanced static mattresses or overlays to prevent pressure ulcers, with a strong recommendation and moderate-quality evidence from the American College of Physicians 1
Avoid alternating-air mattresses or overlays to prevent pressure ulcers, with a weak recommendation and moderate-quality evidence from the American College of Physicians 1
Ensure adequate protein intake (1.2-1.5 g/kg/day) to enhance tissue integrity and healing, as recommended by medical experts 2
High protein oral nutritional supplements (30% energy from protein) significantly reduce pressure ulcer development and improve healing in hospice patients, with a strong recommendation from medical societies 3
Use pressure-redistributing foam mattresses to prevent breakdown and reduce pain in hospice patients, with economic evidence supporting early prevention 4
Consider reclining chairs instead of gurney beds when appropriate, to reduce pressure and prevent ulcers, although the strength of evidence is not specified 4
Reposition patients every 2-4 hours to prevent progression of pressure ulcers, with a weak recommendation and low-quality evidence 1, 5, 6

Evaluate wounds for signs of infection, such as spreading cellulitis and systemic signs of infection, to guide treatment decisions, as recommended by the World Health Organization 7
Document wound characteristics, including size, depth, exudate level, and presence of necrotic tissue, to classify severity based on depth and tissue involvement, as recommended by the World Health Organization 7
Reassess the wound within 3 days of initial identification, as almost 50% of stage 1 pressure ulcers may resolve quickly with proper intervention, although the strength of evidence for this is not specified
If evidence of infection has not resolved after 4 weeks of appropriate therapy, re-evaluate and consider alternative treatments, based on moderate-quality evidence 8

Surgical debridement is necessary to remove all necrotic tissue and fully visualize the wound, with a strong recommendation from the World Health Organization 7
Broad-spectrum antibiotic therapy is recommended for infected pressure ulcers, targeting both aerobic and anaerobic organisms, including Gram-positive and Gram-negative bacteria, as suggested by the American College of Surgeons 7
Consider MRSA coverage in high-prevalence settings (>20% MRSA in local isolates) when selecting antibiotic therapy, according to the American College of Surgeons 7

Select dressings primarily based on exudate control, comfort, and cost rather than specific dressing types for infected wounds, as recommended by the International Working Group on the Diabetic Foot (IWGDF) 9
Avoid using dressings containing antimicrobial agents with the sole aim of accelerating wound healing, as explicitly recommended against by the IWGDF 9
Use the following dressings based on exudate level:

Exudate Level	Recommended Dressing	Evidence
Minimal	Hydrocolloid	Reduces ulcer size (weak recommendation, low-quality evidence) [2]
Moderate	Foam dressings	Reduces ulcer size (weak recommendation, low-quality evidence) [2]

Consider negative pressure wound therapy (NPWT) for post-operative wounds or wounds with significant depth, with a strength of evidence based on expert opinion 10
Consider hyperbaric oxygen treatment for poorly healing wounds, although the specific recommendations are not provided in the guidelines 10
Consider electrical stimulation as adjunctive therapy to accelerate wound healing, with a weak recommendation and moderate-quality evidence, according to the Wound, Ostomy, and Continence Nurses Society 2

Don't delay treatment of ischemic or infected ulcers as this increases the risk of amputation, with a strength of evidence based on high-quality studies 11
Don't rely solely on soft tissue cultures when osteomyelitis is suspected; bone cultures are more accurate, based on moderate-quality evidence 8
Don't use silver or antimicrobial dressings routinely as they are not well-supported for wound management, with a strength of evidence based on expert opinion 10
Don't use biologically active products (collagen, growth factors) routinely for neuropathic ulcers, based on expert opinion 10