What are the WOCN treatment guidelines for pressure injuries (pressure ulcers)?

Updated: Mar 26, 2020
  • Author: Christian N Kirman, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

Recommendations for management included the following:

  • Float/elevate the heel(s) completely off the surface with a pillow or heel suspension device for stage 1 and 2 pressure ulcers or a heel suspension device for stage 3 and 4 heel pressure ulcers. 
  • Turn and reposition the patient regularly and frequently.
  • Utilize support surfaces for patients with pressure ulcers (i.e., mattresses, mattress overlays, integrated bed systems, seat cushions or seat cushion overlays) that meet the individual's needs, and are compatible with the care setting. 
  • Consider using the WOCN Society's Evidence-and Consensus-Based Support Surface Algorithm ( http://algorithm.wocn.org) to identify the appropriate support surface for adults (≥16 years) and bariatric patients in care settings where the length of stay is 24 hours or more.
  • Utilize seating redistribution support surfaces that meet the needs of sitting individuals who have a pressure ulcer.
  • Establish an individualized bowel/bladder management program for the patient with incontinence.
  • Screen for nutritional deficiencies at the patient's admission to the care setting, when their condition changes, and/or if the pressure ulcer is not healing. 
  • Provide daily calorie and protein intake for adult patients with pressure ulcers: 30-35 kcal/kg and protein 1.25-1.5 g/kg.
  • Consider evaluation of laboratory tests such as albumin and prealbumin as only one part of the ongoing assessment of nutritional status. 
  • Cleanse the wound and periwound at each dressing change, minimizing trauma to the wound. 
  • Choose appropriate solutions for cleaning pressure ulcers, which may include potable tap water, distilled water, cooled boiled water, or saline/salt water.
  • Determine the bacterial bioburden by tissue biopsy or Levine quantitative swab technique.
  • Consider a 2-week course of topical antibiotics for nonhealing, clean pressure ulcers.
  • Consider use of antiseptics for "maintenance wounds," which are defined as wounds that are not expected to heal, or for wounds that are critically colonized.
  • Use systemic antibiotics in the presence of bacteremia, sepsis, advancing cellulitis, or osteomyelitis. 
  • Debride the pressure ulcer of devitalized tissue, or when there is a high index of suspicion that biofilm is present (i.e., wound fails to heal despite proper wound care and antimicrobial therapy), and when consistent with the patient's condition and goals of therapy.
  • Modify the type of dressing as appropriate due to changes in the wound during healing or if the pressure ulcer deteriorates. Monitor and assess the wound on a regular basis and at every dressing change to determine if the type of dressing is appropriate or should be modified. 
  • Consider adjunctive therapies as indicated: platelet-derived growth factor (PDGF); electrical stimulation; negative-pressure wound therapy (NPWT).
  • Evaluate the need for operative repair for patients with stage 3 and 4 ulcers that do not respond to conservative medical therapy.
  • Implement measures to eliminate or control the source of pressure ulcer pain.
  • Implement appropriate treatment of pressure ulcers to optimize healing, recognizing that complete healing may be unrealistic in some patients.
  • Educate the patient/caregiver(s) about strategies to prevent pressure ulcers, promote healing, and prevent recurrences of ulcers; and emphasize these are lifelong interventions.

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