| Recommendation |
Level of Evidence |
| 3.2a Lower extremity ulcers or wounds in patients who are gravely palliative with dry eschar need not be debrided if they do not have edema, erythema, fluctuance or drainage. Assess these wounds daily to monitor for pressure ulcer complications that would require debridement.
|
IV |
| 3.2b Prior to debridement on ulcers on the lower extremities, complete a vascular assessment (e.g., clinical assessment, palpable pedal pulses, capillary refill, ankle/brachial pressure index and toe pressure) to rule out vascular compromise. |
IV |
| 3.2c Determine if debridement is appropriate for the patient and the wound. |
IV |
3.2d If debridement is indicated, select the appropriate method of debridement considering: Level of Evidence IV
- Goals of treatment (e.g., healability);
- Client´s condition (e.g., end of life, pain, risk of bleeding, patient preference, etc.);
- Type, quantity and location of necrotic tissue;
- The depth and amount of drainage; and
- Availability of resources.
|
IV |
| 3.2e Sharp debridement should be selected when the need is urgent, such as with advancing cellulitis or sepsis, increased pain, exudate and odour. Sharp debridement must be conducted by a qualified person. |
IV |
| 3.2f Use sterile instruments to debride pressure ulcers. |
IV |
| 3.2g Prevent or manage pain associated with debridement. Consult with a member of the healthcare team with expertise in pain management. Refer to the RNAO Best Practice Guideline Assessment and Management of Pain (Revised) (2007). |
IV |
| Recommendation |
Level of Evidence |
| 3.3a The treatment of infection is managed by wound cleansing, systemic antibiotics, and debridement, as needed.
|
Ib |
| 3.3b Protect pressure ulcers from sources of contamination, e.g., fecal matter. |
IV |
| 3.3c Follow Body Substance Precautions (BSP) or an equivalent protocol appropriate for the healthcare setting and the client´s condition when treating pressure ulcers. |
IV |
| 3.3d Medical management may include initiating a two-week trial of topical antibiotics for clean pressure ulcers that are not healing or are continuing to produce exudate after two to four weeks of optimal patient care. The antibiotic should be effective against gram-negative, gram-positive and anaerobic organisms.
|
Ib |
| 3.3e Medical management may include appropriate systemic antibiotic therapy for patients with bacteremia, sepsis, advancing cellulitis or osteomyelitis. |
Ib |
| 3.3f To obtain a wound culture, cleanse wound with normal saline first. Swab wound bed, not eschar, slough, exudate or edges. |
IV |
| 3.3g The use of cytotoxic antiseptics to reduce bacteria in wound tissue is not usually recommended. |
IIb |
| Recommendation |
Level of Evidence |
| 3.4a Do not use skin cleansers or antiseptic agents (e.g., povidine iodine, iodophor, sodium hypochlorite solution, hydrogen peroxide, acetic acid) to clean ulcer wounds.
|
III |
| 3.4b Use normal saline, Ringer´s lactate, sterile water or non-cytoxic wound cleansers for wound cleansing. |
IV |
| 3.4c Fluid used for cleansing should be warmed at least to room temperature. |
III |
| 3.4d Cleanse wounds at each dressing change.
|
IV |
| 3.4e To reduce surface bacteria and tissue trauma, the wound should be gently irrigated with 100 to 150 milliliters of solution. |
IV |
3.4f Use enough irrigation pressure to enhance wound cleansing without causing trauma to the wound bed. Safe and effective ulcer irrigation pressures range from 4 to 15 psi. Pressure of 4 to 15 psi is achieved by using:
- 35 milliliter syringe with a 19 gauge angiocath, or
- single-use 100 milliliter saline squeeze bottle.
|
IIa |
| Recommendation |
Level of Evidence |
3.5a For comprehensive wound management options, consider the following:
- Etiology of the wound;
- Client´s general health status, preference, goals of care and environment;
- Lifestyle;
- Quality of life;
- Location of the wound;
- Size of the wound, including depth and undermining;
- Pain;
- A dressing that will loosely fill wound cavity;
- Exudate: type and amount;
- Risk of infection;
- Risk of recurrence;
- Type of tissue involved;
- Phase of the wound healing process;
- Frequency of the dressing change;
- Comfort and cosmetic appearance;
- Where and by whom the dressing will be changed;
- Product availability; and
- Adjunctive therapies.
|
IV |
| 3.5b Moisture-retentive dressings optimize the local wound environment and promote healing. |
Ia |
| 3.5c Consider caregiver time when selecting a dressing. |
Ib |
3.5d
- Consider the following criteria when selecting an interactive dressing: Level of Evidence Ia-IV
- Maintains a moist environment (Level of Evidence Ia)
- Controls wound exudate, keeping the wound bed moist and the surrounding intact skin dry (Level of Evidence IV)
- Provides thermal insulation and wound temperature stability (Level of Evidence IV)
- Protects from contamination of outside micro-organisms (Level of Evidence IV)
- Maintains its integrity and does not leave fibres or foreign substances within the wound (Level of Evidence IV)
- Does not cause trauma to wound bed on removal (Level of Evidence IV)
- Client/patient preference (Level of Evidence IV)
- Is simple to handle, and is economical in cost and time (Level of Evidence IV).
|
Multiple |
| 3.5e Monitor dressings applied near the anus, since they are difficult to keep intact. Consider use of special sacral-shaped dressings. |
Ib |
