1. To promote tissue healing.
  2. To prevent further tissue breakdown by relieving pressure, reducing friction and shear, correcting or containing incontinence, improving nutritional status, and educating patient and/or significant other.
  3. Follow established treatment program focused on assessment of patient and pressure ulcer.
  4. Evaluate in two weeks for its effectiveness, if not improved, change course of treatment.
  5. RN or designated skin care provider may determine the need for and implement appropriate skin care treatment.


RN, LPN - treatment

RN, LPN, CNA - preventive aspects



  1. Assess pressure ulcer by using wound assessment form weekly and change in condition.
  2. Assess nutritional status.
  3. Assess need for consultants - dietitian, enterostomal therapy nurse, occupational therapist, pharmacist, physical therapist, podiatrist.
  4. Assess for pain related to pressure ulcer or its treatment.
  5. Assess for out of bed tolerances.
  6. Assess diaper and absorbent pad use.
  7. Assess for indwelling/external catheter need and/or bowel/bladder program.
  8. Assess educational needs and ability to provide treatment.


  1. Reduce or eliminate causative factors: pressure, shear, friction, moisture, circulatory impairment, neuropathy.
  2. Provide systemic support for wound healing by providing nutritional and fluid support and control of systemic condition affecting wound healing.
  3. Use appropriate topical therapy to:
    1. Remove necrotic tissue.
    2. Identify and eliminate infection.
    3. Obliterate dead space.
    4. Absorb excess exudate.
    5. Maintain moist wound surface.
    6. Provide thermal insulation.
    7. Protect the healing environment.
    8. Manage pain and discomfort.
  4. Provide education.


  1. MANAGEMENT OF TISSUE LOADS  (pressure relief, friction, shear, and moisture)
    1. Avoid positioning patient on the pressure ulcer.
    2. DO NOT use donut type devices.
    3. Establish written repositioning/turning schedule including patients on pressure reducing support surfaces.
    4. When side-lying position is used, a 30-degree turning position should be used.
    5. Use devices such as pillows and foam wedges to prevent direct contact between bony prominence.
    6. Keep head of bed elevated to less than 30-degrees except at meal times.
    7. Use lifting sheet.
    8. Encourage patient to shift their weight every 15 minutes while in wheelchair.
    9. Avoid sitting or have very limited sitting on pressure ulcer.
    10. Raise heels off the bed with pillow lengthwise to support legs.
    11. Use knee gatch when head of bed is elevated.
    12. Limit sitting time to one hour at a time, whether in bed, chair, or wheelchair.
    13. Use proper positioning, transferring, and turning techniques.
    14. Inspect skin at least once a day.
    15. Individualize bathing schedule. Avoid hot water. Use a mild cleansing agent.
    16. Use lubricant to reduce friction injuries.
    17. Avoid massage over bony prominences.
    18. Minimize environment factors such as low humidity and cold air. Use moisturizer for dry skin.
    19. Evaluate and manage urinary and/or fecal incontinence.
    20. Use protective barrier on skin if incontinent.
    21. Cleanse skin at time of soiling and at routine intervals.
    22. Use personal perineal cleanser for frequent stools.
    1. Choose appropriate support surface for patient in bed and/or chair.
    2. If patient bottoms out when hand is placed palm up under mattress overlay beneath existing pressure ulcer, or if support materials feel less than one inch thick on static support surface.
    3. Use a dynamic surface (such as a low air loss bed or an air fluidized bed) if patient cannot assume a variety of positions without bearing weight on pressure ulcer, if skin moisture is a problem, or if pressure ulcer does not show evidence of healing.
    4. Air fluidized bed is recommended for patients with multiple truncal stage 3 or 4 ulcers and for patients who have failed to heal on a low-air loss mattress.
    1. Consult dietitian to assist with nutritional assessment and planning. Implement recommendations.
    2. Obtain lab tests as recommended by dietitian and/or primary care provider.
    3. Encourage 8 - 8oz. glasses of fluids per day unless contraindicated.
    4. Patient should consume 75% of the meals from the Basic Four Food Groups.
    5. Stage I
      1. 1/2 cup orange juice or similar high vitamin C source daily.
    6. Stage II
      1. 1/2 cup orange juice or similar high vitamin C source BID.
      2. 6 oz. high protein supplement daily.
    7. Stage III
      1. Calorie counts for 3 days.
      2. 1/2 cup orange juice or similar high vitamin C source TID.
      3. 6 oz. high protein supplement BID.
    8. Stage IV
      1. Calorie counts for 3 days.
      2. 1/2 cup orange juice or similar high vitamin C source TID.
      3. 6 oz. high protein supplement TID.
    9. Adequate fluid intake (30-35 cc/kg present body weight per day).
    10. Small frequent meals.
    11. Multivitamin/mineral supplement may be considered.
    1. Consult physical/occupational therapist regarding mobility and range of motion exercise.
    2. Provide range of motion exercises BID.
    1. Prevent pain related to pressure ulcer or its treatment.
    2. Provide analgesic as needed and appropriately if cause of pain cannot be eliminated with nursing measures.
    1. Cleanse wounds initially and at each dressing change using normal saline or non-cytotoxic wound cleanser.
    2. DO NOT clean ulcer wounds with skin cleansers or antiseptic agents, such as provodine-iodine, iodophor, sodium hypochlorite, hydrogen peroxide, or acetic acid.
    3. Use enough irrigation pressure to enhance wound cleansing without causing trauma. Irrigation pressure of 4 to 15 pounds per square inch (psi) are recommended. A 35 ml syringe with a 19 gauge needle or angiocatheter delivers 8 psi.
    1. Heel ulcers with dry eschar does not need debridement unless there is edema, erythema, fluctuance, or drainage.
    2. Whirpool treatment, a form of debridement, should be used for pressure ulcers that contain thick exudate, slough, or necrotic tissue.
    3. Select appropriate method of debridement based on patient’s condition and goals.
      1. autolytic - use of synthetic dressings to cover a wound and allow devitalized tissue to self-digest from enzymes normally present in wound fluids. NOT USED if infection is present.
      2. enzymatic - topical debridement agents applied to devitalized tissue.
      3. mechanical - include wet to dry dressings; needs to be done every 4-8 hours; hydrotherapy if no improvement in 7-14 days need to discontinue and try another method; wound irrigation.
      4. sharp - use of scalpel, scissors, or other instrument to remove dead tissue. PHYSICIAN MUST PERFORM.
    4. Discontinue debridement methods when ulcer is clean.
    1. Select appropriate dressing based on condition of pressure ulcer and algorithm.
    2. Use clean technique to apply dressing after cleansing wound.
    3. Stage I
      1. Leave open to air.
      2. Transparent film dressing, foam dressing, or hydrocolloid dressing - change every 3-7 days and prn.
      3. Protective barriers.
    4. Stage II
      1. Foam dressing, hydrocolloid dressing, hydrogel dressing, transparent film dressing - change every 3-7 days and prn.
      2. Moist-to-moist saline dressing - change every shift.
    5. Stage III
      1. Moist-to-moist saline dressing - change every shift.
      2. Foam dressing, alginate dressing, hydrocolloid dressing, hydrogel dressing  change every 3-7 days and prn.
      3. Wound cleanser.
      4. Moisture barrier
    6. Stage IV
      1. Moist-to-moist saline dressing - change every shift.
      2. Alginate dressing, hydrogel dressing, hydrocolloid dressing - change every 3-7 days and prn.
      3. Wound cleanser.
      4. Moisture barrier.
    7. Choose a dressing that keeps the periulcer skin dry while keeping the ulcer bed moist.
    8. Change dressing when strike through is apparent regardless of timeframe.
    9. Loosely fill all wound cavities with dressing material. DO NOT pack wound tightly.
    10. Use water resistant dressings for perianal wounds.
    1. If purulent discharge, foul odor, or periulcer inflammation is present, ensure complete ulcer cleansing and debridement.
    2. DO NOT use swab cultures to diagnose wound infections because all pressure ulcers are colonized.
    3. Do a 2 week trial of topical antibiotics (silver sulfadizaine or triple antibiotic ointment) for clean pressure ulcers that are not healing or are continuing to produce exudate after 2-4 weeks of optimal patient care.
    4. DO NOT use topical antiseptics to reduce bacteria in wound tissue.
    5. Systemic antibiotic therapy should be used for patients with bacteremia sepsis, advancing cellulitis, or osteomyelitis.
    1. Provide audiovisual aids to enhance verbal discussion.
    2. Observe patient and/or significant other perform treatment.


  1. Monitor skin surfaces daily.
  2. Document on appropriate facility form.

ACWCP - 1998