1.1. Algorithms

For algorithms on identifying pressure ulcer risk and the prevention of pressure ulcers, please see part 1, ‘Prevention of pressure ulcers’.

ALGORITHM D - Management of pressure ulcers in adults (PDF, 276K)

ALGORITHM E - Management of pressure ulcers in neonates, infants, children and young people (PDF, 259K)

1.2. Key priorities for implementation

From the full set of recommendations, the GDG selected 10 key priorities for implementation. The criteria used for selecting these recommendations are listed in detail in The guidelines manual.¹³¹ The reasons that each of these recommendations was chosen are shown in the table linking the evidence to the recommendation in the relevant chapter.

• Carry out and document an assessment of pressure ulcer risk for adults
  • being admitted to secondary care or care homes in which NHS care is provided or
  • receiving NHS care in other settings such as primary and community care settings, and emergency departments, if they have a risk factor, for example:

    –

    significantly limited mobility (for example, people with a spinal cord injury)

    –

    significant loss of sensation

    –

    a previous or current pressure ulcer

    –

    nutritional deficiency

    –

    the inability to reposition themselves

    –

    significant cognitive impairment [1.1.2]

• Offer adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional (see recommendation 1.3.4). The assessment should take into account any pain or discomfort reported by the patient and the skin should be checked for:
  • skin integrity in areas of pressure
  • colour changes or discoloration^a
  • variations in heat, firmness and moisture (for example, because of incontinence, oedema, dry or inflamed skin).[1.1.5]
• Develop and document an individualised care plan for neonates, infants, children, young people and adults who have been assessed as being at high risk of developing a pressure ulcer, taking into account:
  • the outcome of risk and skin assessment
  • the need for additional pressure relief at specific at-risk sites
  • their mobility and ability to reposition themselves
  • other comorbidities
  • patient preference.[1.3.1]
• Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every 6 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.[1.1.8]
• Use a high-specification foam mattress for adults who are:
  • admitted to secondary care
  • assessed as being at high risk of developing a pressure ulcer in primary and community care settings.[1.1.13]
• Carry out and document an assessment of pressure ulcer risk for neonates, infants, children and young people:
  • being admitted to secondary or tertiary care or
  • receiving NHS care in other settings (such as primary and community care and emergency departments) if they have a risk factor, for example:

    –

    significantly limited mobility (for example, people with a spinal cord injury)

    –

    significant loss of sensation

    –

    a previous or current pressure ulcer

    –

    nutritional deficiency

    –

    the inability to reposition themselves

    –

    significant cognitive impairment. [1.2.1]

• Provide training to healthcare professionals on preventing a pressure ulcer, including:
  • who is most likely to be at risk of developing a pressure ulcer
  • how to identify pressure damage
  • what steps to take to prevent new or further pressure damage
  • who to contact for further information and for further action.[1.3.4]
• Provide further training to healthcare professionals who have contact with anyone who is assessed as being at high risk of developing a pressure ulcer. Training should include:
  • how to carry out a risk and skin assessment
  • how to reposition
  • information on pressure redistributing devices
  • discussion of pressure ulcer prevention with patients and their carers
  • details of sources of advice and support.[1.3.5]
• Discuss with adults with heel pressure ulcers and if appropriate, their carers, a strategy to offload heel pressure as part of their individualised care plan.[1.4.26]

1.3. Full list of recommendations

1. Document the surface area of all pressure ulcers in adults. If possible, use a validated measurement technique (for example, transparency tracing or a photograph).
2. Document an estimate of the depth of all pressure ulcers and the presence of undermining, but do not routinely measure the volume of a pressure ulcer.
3. Document the surface area of all pressure ulcers in neonates, infants, children and young people, preferably using a validated measurement technique (for example, transparency tracing or a photograph).
4. Document an estimate of the depth of a pressure ulcer and the presence of undermining, but do not routinely measure the volume of a pressure ulcer in neonates, infants, children and young people.
5. Categorise each pressure ulcer in adults using a validated classification tool (such as the International NPUAP-EPUAP (2009) Pressure Ulcer Classification System). Use this to guide ongoing preventative strategies and management. Repeat and document each time the ulcer is assessed.
6. Categorise each pressure ulcer in neonates, infants, children and young people at onset using a validated classification tool (such as the International NPUAP-EPUAP (2009) Pressure Ulcer Classification System) to guide ongoing preventative and management options. Repeat and document each time the ulcer is assessed.
7. Offer adults with a pressure ulcer a nutritional assessment by a dietitian or other healthcare professional with the necessary skills and competencies.
8. Offer nutritional supplements to adults with a pressure ulcer who have a nutritional deficiency.
9. Do not offer nutritional supplements to treat a pressure ulcer in adults whose nutritional intake is adequate
10. Provide information and advice to adults with a pressure ulcer and where appropriate, their family or carers, on how to follow a balanced diet to maintain an adequate nutritional status, taking into account energy, protein and micronutrient requirements
11. Do not offer subcutaneous or intravenous fluids to treat pressure ulcers in adults whose hydration status is adequate.
12. Offer an age-related nutritional assessment to neonates, infants, children and young people with a pressure ulcer. This should be performed by a paediatric dietitian or other healthcare professional with the necessary skills and competencies.
13. Discuss with a paediatric dietitian (or other healthcare professional with the necessary skills and competencies) whether to offer nutritional supplements specifically to treat pressure ulcers in neonates, infants, children and young people whose nutritinal intake is adequate.
14. Offer advice on a diet that provides adequate nutrition for growth and healing in neonates, infants, children and young people with pressure ulcers.
15. Discuss with a paediatric dietitian whether to offer nutritional supplements to correct nutritional deficiency in neonates, infants, children and young people with pressure ulcers.
16. Assess fluid balance in neonates, infants, children and young people with pressure ulcers.
17. Ensure there is adequate hydration for age, growth and healing in neonates, infants, children and young people. If there is any doubt, seek further medical advice.
18. Use high-specification foam mattresses for adults with a pressure ulcer. If this is not sufficient to redistribute pressure, consider the use of a dynamic support surface.
19. Do not use standard-specification foam mattresses for adults with a pressure ulcer.
20. Consider the seating needs of people who have a pressure ulcer who are sitting for prolonged periods.
21. Consider a high-specification foam or equivalent pressure redistributing cushion for adults who use a wheelchair or who sit for prolonged periods and who have a pressure ulcer.
22. Use a high-specification cot or bed mattress or overlay for all neonates, infants, children and young people with a pressure ulcer.
23. If pressure on the affected area cannot be adequately relieved by other means (such as repositioning), consider a dynamic support surface, appropriate to the size and weight of the child or young person with a pressure ulcer, if this can be tolerated.
24. Consider using specialist support surfaces (including dynamic support surfaces where appropriate) for neonates, infants, children and young people with pressure ulcers, taking into account their current pressure ulcer risk and mobility.
25. Tailor the support surface to the location and cause of the pressure ulcer for neonates, infants, children and young people.
26. Do not routinely offer adults negative pressure wound therapy to treat a pressure ulcer, unless it is necessary to reduce the number of dressing changes (for example, in a wound with a large amount of exudate).
27. Do not offer the following to adults to treat a pressure ulcer:
    • electrotherapy
    • hyperbaric oxygen therapy.
28. Do not routinely use negative pressure wound therapy to treat a pressure ulcer in neonates, infants, children and young people.
29. Do not use the following to treat a pressure ulcer in neonates, infants, children and young people:
    • electrotherapy
    • hyperbaric oxygen therapy.
30. Assess the need to debride a pressure ulcer in adults, taking into consideration:
    • the amount of necrotic tissue
    • the grade, size and extent of the pressure ulcer
    • patient tolerance
    • any comorbidities
31. Offer debridement to adults if identified as needed in the assessment:
    • use autolytic debridement, using an appropriate dressing to support it
    • consider using sharp debridement if autolytic debridement is likely to take longer and prolong healing time.
32. Do not routinely offer adults:
    • larval (maggot) therapy
    • enzymatic debridement.
    Consider larval therapy if debridement is needed but sharp debridement is contraindicated or if there is associated vascular insufficiency.
33. Consider autolytic debridement with appropriate dressings for dead tissue in neonates, infants, children and young people. Consider sharp and surgical debridement by trained staff if autolytic debridement is unsuccessful.
34. Do not offer systemic antibiotics specifically to heal pressure ulcers in adults.
35. After a skin assessment, offer systemic antibiotics to adults with a pressure ulcer if there are any of the following:
    • clinical evidence of systemic sepsis
    • spreading cellulitis
    • underlying osteomyelitis.
36. Discuss with the local hospital microbiology department which antibiotic to offer adults to ensure that the systemic antibiotic is effective against local strains of infection.
37. Do not offer systemic antibiotics to adults based only on positive wound cultures without clinical evidence of infection.
38. Consider systemic antibiotics for neonates, infants, children and young people with pressure ulcers with clinical evidence of local or systemic infection.
39. Discuss with a local hospital microbiology department which antibiotic to offer neonates, infants, children and young people to ensure that the chosen systemic antibiotic is effective against local strains of bacteria.
40. Do not routinely use topical antiseptics or antimicrobials to treat a pressure ulcer in adults.
41. Do not routinely use topical antiseptics or antimicrobials to treat a pressure ulcer in neonates, infants, children and young people.
42. Consider using a dressing for adults that promotes a warm, moist wound healing environment to treat grade 2, 3 and 4 pressure ulcers.
43. Discuss with adults with a pressure ulcer and, if appropriate, their family or carers, what type of dressing should be used, taking into account:
    • pain and tolerance
    • position of the ulcer
    • amount of exudate
    • frequency of dressing change
44. Do not offer gauze dressings to treat pressure ulcers in adults.
45. Do not use iodine dressings to treat pressure ulcers in neonates.
46. Consider using a dressing that promotes a warm, moist healing environment to treat grade 2, 3 and 4 pressure ulcers in neonates, infants, children and young people.
47. Consider using topical antimicrobial dressings to treat pressure ulcers where clinically indicated in neonates, infants, children and young people, for example, where there is spreading cellulitis
48. Do not offer gauze dressings to treat pressure ulcers in neonates, infants, children and young people.
49. Do not offer gauze dressings to treat pressure ulcers in neonates, infants, children and young people.
50. Discuss with adults with a heel pressure ulcer and, if appropriate, their family or carers, a strategy to offload heel pressure as part of their individualised care plan.
51. Discuss with the parents or carers of neonates and infants and with children and young people (and their parents or carers if appropriate) a strategy to offload heel pressure as part of their individualised care plan to manage their heel pressure ulcer, taking into account differences in size, mobility, pain and tolerance.

1.4. Key research recommendations

1. What is the effect of enzymatic debridement of non-viable tissue compared with sharp debridement on the rate of healing of pressure ulcers in adults?
2. Does negative pressure wound therapy (with appropriate dressing) improve the healing of pressure ulcers, compared with use of dressing alone in adults with pressure ulcers?
3. Do pressure redistributing devices reduce the development of pressure ulcers for those who are at risk of developing a pressure ulcer?
4. When repositioning a person who is at risk of developing a pressure ulcer, what is the most effective position – and optimum frequency of repositioning – to prevent a pressure ulcer developing?
5. Which pressure ulcer tools are most effective for predicting pressure ulcer risk in children?
6. In neonates, infants, children, young people and adults who have adequate nutritional status and who have a pressure ulcer, does providing further nutritional supplements improve healing of the pressure ulcer?