AAWC Pressure Ulcer Guideline Algorithm Presentation 8.13

AAWC Pressure Ulcer Guideline
Content Validated, Evidence Based
“Guideline of Pressure Ulcer Guidelines”
Using the AAWC Pressure Ulcer (PU)
Guidelines to Manage Pressure Ulcers
• 3 Steps to manage a PU patient:
– Assess and document patient, skin & PU
– Prevent PU with care plan focused on reducing risk
– Treat patient and PU to heal and prevent recurrence
• For guideline details, references, implementation
tools, patient brochure and evidence please see:
Fonts Used in This PPT and in the
AAWC PU Guideline Checklist
• Recommendations in bold font are
– Ready to Implement :
• A-level evidence support
• + Content validity index (CVI)>0.75
• Recommendations in bold italics
– Need more Education
• Content validity index (CVI) <0.75 (Raters say not relevant to PU)
• A-level evidence support
• Recommendations in normal font
– Need more research to be considered evidence-based ,
but have a CVI of at least 0.75,
– i.e. 75% of independent raters or more believed this
recommendation was clinically relevant for PU practice.
Using the AAWC Pressure Ulcer Guidelines
to Prevent/Manage Pressure Ulcers
• Assess and document patient’s skin
• Prevent pressure ulcers (PU) as feasible.
– Focusing on those at risk of developing a PU
• Treat patient and PU to heal as feasible
Pressure Ulcer Management
• If feasible manage with a interdisciplinary
wound care team or appropriate consults as
needed by the individual receiving care.
Assess the Patient’s Skin
• Trained staff regularly assess skin sites at risk
– By 72 hours after admission or per setting protocol
– Usually weekly and on change in patient status
Pay special attention to more darkly pigmented
• Document and plan care to address skin
• Assess skin areas where devices may cause
pressure, e.g. splints, casts, tubes as feasible.
Evaluate and document patient
medical/surgical history
• Physical Exam
– Include whole-body visual and tactile skin inspection within
72 h or protocol-specified time and regularly after
admission identifying PU present on admission
Psychosocial condition
Goals, including quality of life
PU risk using clinical judgment + reliable, valid scale:
– Braden, Norton, Waterlow +
• Assess other validated risk factors:
– Body mass index (BMI) extremes
– Diabetes
– Extremes of age
Document Progress
• Document pressure ulcer progress weekly
– using reliable, valid measures, e.g.
• length x width to estimate area.
• Partial- or full-thickness depth assessment
• Ensure formal assessments are accessible to
those providing or consulting on PU care
Pressure Ulcer Prevention
Address all patient PU risk factors identified
1. Limited mobility, activity, cognition, sensation
• Redistribute pressure every 4 hr or as indicated or feasible
• Properly trained staff select and use indicated pressure
redistribution devices for beds, chairs and wheelchairs that
meet psychological, social, anatomic and physiologic needs
for those at PU risk, if appropriate for patient.
• Use patient-appropriate positioning standards of care per
institution protocol.
• Implement appropriate exercise program as needed/feasible
• Consistently train patient and care providers on PU
prevention and treatment as appropriate and feasible
Pressure Ulcer Prevention
Address all patient PU risk factors identified
2. Manage skin moisture:
• Protect skin from excess moisture with barrier
• Wick excess fluid away from skin
Patient-appropriate incontinence plan and skin-fold
management if needed and feasible
Clean and gently dry skin after incontinence episodes
Pressure Ulcer Prevention
Address all patient PU risk factors identified
3. Nutrition, circulation, infection:
• Consult(s) as needed to identify/reduce PU risk
• Consistent with patient and family goals and
consult advice, restore, maintain good:
– Hydration
– Nutrition
– Circulation
– Infection control
Pressure Ulcer Prevention
4. Protect skin
• from chemical or physical pressure or trauma
Avoid friction, shear, pressure on transfers
Special attention to splints, casts, tubes
Avoid vigorous massage
Moisturize dry skin to prevent cracking
• Protect skin from excess moisture and heat
– Attend to areas affected by incontinence or
perspiration, and skin folds in bariatric patients
Treat Patient and Pressure Ulcer (PU)
To Optimize Healing as Feasible
• Continue or implement appropriate measures to
prevent PU
• Select and use appropriate effective pressure
redistribution product(s) as feasible
– For use on pressure sites for individuals with a PU
– To avoid positioning directly on PU when on bed , chair or
wheel chair surface, e.g. use cushions
Treat Patient and Pressure Ulcer (PU)
To Optimize Healing
• Manage local and systemic factors per institutional protocols
and to meet patient and family needs and goals as feasible
 Infection
 Other, such as neuromuscular spasticity, contractures
• Cleanse PU with water or saline or non-toxic cleanser at 4-15 psi
• Debride nonviable tissue
 autolytically surgically enzyme
• Evaluate PU at each dressing change for signs and symptoms of
clinical infection
Treat Patient and Pressure Ulcer (PU)
To Optimize Healing
• Dress/treat PU to maintain a moist environment,
protect PU and local skin from friction, shear,
pressure, trauma, irritation and excess exudate
(e.g. fiber, foam or hydrocolloid dressings)
• Manage PU-related pain to meet patient needs.
• Identify and address all nutrient deficiencies.
• 4 weeks if there is no PU area ,
– Re-evaluate and improve care plan
– Consider adjunct therapy such as electrical stimulation

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