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Provide Local Wound Care



Assess the Stage of the Pressure Ulcer

The National Pressure Ulcer Advisory Panel (NPUAP) Staging System for Pressure Ulcers (Updated 2007) with Fruit Analogy and Photographic Examples

Remember - you can never “back-stage” an ulcer –e.g. once a stage IV, always a stage IV.


NPUAP Stages NPUAP Description Analogy of Fruit & Photographic Example
Cross-section illustration of skin with a red wound on the surface
Stage 1
  • Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
  • Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
  • May be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
  • May indicate "at risk" persons (a heralding sign of risk)
Photo of an intact red applePhoto of a stage 1 pressure ulcer

When you touch a red apple, you cannot make the colour less red or disappear. With a Stage I pressure ulcer, pressing your thumb or finger onto the reddened area cannot make the colour “blanche” or disappear.

Cross-section illustration of skin with a shallow open ulcer on it
Stage II
  • Partial thickness loss of dermis.
  • Shallow open ulcer with a red pink wound bed, without slough, or
  • Intact or open/ruptured serum-filled blister.
  • Shiny or dry shallow ulcer without slough or bruising.
  • This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
  • Bruising indicates suspected deep tissue injury (DTI) not Stage II.
Photo of a partially peeled red apple, with peel still attachedPhoto of a stage II pressure ulcerPhoto of a stage II pressure ulcerPhoto of a stage II pressure ulcer

When you peel an apple, you want to take only the skin off so that you are not wasting the flesh. In a Stage II pressure ulcer, only the dermis or the outside layer of the skin has been removed or damaged.

Cross-section illustration of skin with a deep open ulcer
Stage III
  • Full thickness tissue loss.
  • Subcutaneous fat may be visible but bone, tendon or muscle are not exposed or directly palpable.
  • Slough may be present but does not obscure the depth of tissue loss.
  • May include undermining and tunneling.
  • Depth varies by anatomical location: shallow on bridge of the nose, ear, occiput and malleolus, extremely deep in areas like the buttocks
Photo of a red apple with a bite taken out of itPhoto of a stage III pressure ulcer

Taking a bite out of the apple takes us through the skin into the flesh, like a Stage III pressure ulcer.

Cross-section illustration of skin with a deep open ulcer exposing bone and tendon
Stage IV
  • Full thickness tissue loss with exposed bone, tendon or muscle.
  • Slough or eschar may be present on some parts of the wound bed
  • Often include undermining and tunneling
  • The depth of a stage IV pressure ulcer varies by anatomical location:
  • The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow.
  • Can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible.
  • Exposed bone/tendon is visible or directly palpable.
Photo of an apple corePhoto of a stage IV pressure ulcer

The core of the apple is similar to underlying structures in the body, which are exposed with Stage IV ulcers.

Cross-section illustration of skin with a deep tissue injury
Suspected Deep Tissue Injury (DTI)
  • Evolution of DTI may include a thin blister over a dark wound bed → becomes covered by thin eschar
  • May heal or → evolution may be rapid, exposing additional layers of tissue even with optimal treatment.
  • Blood blisters are included in DTI & represent a deeper level of injury than a serum-filled blister, yet the true depth of tissue damage is not known.
Photo of an intact but bruised red applePhoto of a suspected deep tissue injury

Even though the skin of this apple is not broken, you know that there is bruising in all of those areas of darker colour. You DON’T know if it is just on the surface or if it goes deeper.

Cross-section illustration of skin with a black ulcer exposing bone
Unstageable
  • Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
  • Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.
  • Other information: Goal is stable dry, adherent eschar that is intact without erythema or softness under the surface on the heels serves as "the body's natural (biological) cover" and should not be removed.
Photo of a caramel applePhoto of an unstageable pressure ulcer

Just as a caramel covering may hide many blemishes and bruises in an apple, necrotic tissue hides the true depth or degree of tissue damage.

Reproduction of the National Pressure Ulcer Advisory Panel (NPUAP) materials in this document does not imply endorsement by the NPUAP of any products, organizations, companies or statements made by any organization or company. The NPUAP definitions are available online at http://www.npuap.org. The Apple analogy idea is from http://mkt.medline.com/clinical-blog/clinical-solutions/apples-to-ulcers-tips-for-staging-pressure-ulcers/. The wound photographs are © Red Cross Care Partners and used with permission.

All pressure ulcers are identified and staged using the National Pressure Ulcer Advisory Panel (NPUAP) criteria.
Level of Evidence – IV

If pressure ulcers are identified, utilization of the RNAO best practice guideline Assessment and Management of Stage I to IV Pressure Ulcers is recommended.
Level of Evidence – IV


RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 1.10
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 3.2b

Healing Trajectory

Determine if the wound is “Healable, Maintenance, or Non-Healable"
Wound healing is impacted by many factors and can be complex depending on available resources, changing health status, and lifestyle choices. The healing trajectory whether a wound is healable or not, forms the treatment and intervention. The healing wound trajectory includes: healable, maintenance, and non-healable wounds1.

  • Healable Wound: have the potential to heal: Have sufficient vascular supply, underlying cause can be corrected, & health can be optimized2. The goal is for closure of the wound with ongoing functional integritry.

    If pressure ulcer is on the lower leg, a lower leg assessment and ankle brachial pressure index should be performed; if it has not been done in the last 3-6 months. vascular assessment table
  • Maintenance Wound: have the healing potential, but various patient factors are compromising wound healing at this time. For example, necessary resources cannot be included in the treatment plan such as pressure relief devices cannot be purchased. The goal is to reduce the risk of further deterioration and infection, and to promote client self-management and client independence of wound care regime.
  • Non-healable wound: has no ability to heal due to untreatable causes such as terminal disease or end-of-life3. The goal is to promote comfort and reduce risk of infection and if possible to prevent further deterioration.

Wound and Peri-wound Assessment

Wound and Peri-wound Assessment is best performed using a validated and reliable wound assessment tool such as the Bates Jensen Wound Assessment Tool (click here to download as a PDF). Where using a rating or scoring system is not feasible, the vocabulary used to describe the wound characteristics and the education provided to clinicians should align with those of a validated and reliable tool.

First page of Bates-Jensen Wound Assessment Tool

The Bates Jensen Wound Assessment Tool (BWAT) Pictorial Guide is available at http://cawc.net/index.php/resources/store/wound-assessment-pocket-guide/

Best Practice Local Wound Care: DIME Principle

Once the cause of the pressure ulcer has been identified and patient’s concerns have been discussed, the team will apply best practice principles of local wound care. The wound bed preparation framework is a holistic approach to assess, diagnosis, and treat wounds while considering client-patient concerns4. Best practice local wound care includes treating local wound care consisting of four components using the mnemonic of DIME: Debridement, Infection/inflammation, Moisture and Edge5.

  • Debridement of a healable or stalled wound is important to remove infected, devitalized tissue because they are a media for bacterial proliferation.
  • Infection/inflammation is assessed at every visit for superficial critical colonization and deep infection using the mnemonic of NERDS and STONEES (xiii).
  • Moisture helps facilitate the cells to function normally and promotes wound healing. However, excessive moisture can cause damage to the surround peri-wound and lead to maceration and potential breakdown of the skin.
  • Edge of the wound is considered if all above components have been corrected and the edge of the wound is not migrating or non-advancing in consultation with the interprofessional wound team. Active wound therapies such as a skin graft and biological agents (growth factors, fibroblasts, epithelial cell, or matrix components) are to be considered prior to advanced modalities therapies (electrical stimulation or Negative Pressure Wound Therapy). Biological agents will stimulate new tissue growth to improve wound strength and decrease inflammatory cells needed for tissue repair. Surgical repair or reconstruction such as a skin graft is another standard treatment for a stalled chronic wound6.
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendations 3.2a - 3.2g
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 3.3a

Wound Cleansing and Dressing Selection for Pressure Ulcers

If Healing Treatment Goal:

Principles of wound bed preparation and moist wound healing: debridement, bacterial balance, exudate control, protect periwound skin IF wound requires debridement7, determine which method of debridement is most appropriate for this individual, and in conjunction with interdisciplinary team (if necessary) initiate debridement interventions.

If Maintenance/Non-Healing Goal

Avoid higher cost advanced wound treatment and focus on exudate and odour management, quality of life issues.

Wound Cleansing and Product Selection:

RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendations 3.3a - 3.3f
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendations 3.5a - 3.5e

Each organization may use the PDF Fillable CAWC Product Picker to list the products available within their organization.

Wound Cleansing and Product Selection Table

Dressing Exudate Handling Capacity:
Each dressing type suggested in this table has been assigned with their estimated absorbing capacity: Small [1+], Moderate [2+], Large [3+], Copious [4+].
Clinical Principle & Photographic Examples Suggested Interventions
1. Clean Epithelializing Wound
Goal:
Provide environment conducive to wound healing without trauma
Cleansing: DO NOT irrigate with pressure higher than 7 PSI - pour room or body temperature solution over the wound bed; cleanse the periwound skin. Do not use antimicrobial solutions.
Choice of Dressing: Choose a dressing that can be left insitu as long as possible to avoid disruption of the migrating epithelium. If the wound depth is <1-2 mm with minimal exudate consider:
  • Transparent Film Membranes [1+] (some exudate will evaporate-can be used over alginate dressings)
  • Hydrogel [1+] only if very dry (use under other dressings)
  • Absorbent Clear Acrylic Dressing [2+] q 7-14 days or more (Retains moisture and growth factors, decreased need for frequent dressing changes)
  • Thin hydrocolloid [1+] q 5-7 days (Retains moisture and growth factors)
  • Non-adherent foam border dressing [2+]
2. Clean Granulating Wound decreasing in size 20-30% in 3-4 weeks*
Goal:
Provide environment conducive to wound healing without trauma
Cleansing: DO NOT irrigate with pressure higher than 7 PSI - pour room or body temperature solution over the wound bed; cleanse the periwound skin.
Do not use antimicrobial solutions.
Primary Dressing:
  • Hydrofibres and alginates [1+ to 2+] - form a gel-like mass on the wound surface (require secondary dressing)
  • NPWT [2+ to 4+]
Secondary (Cover) Dressing:
  • Composite dressings [2+ to 3+] (can be primary or secondary)
  • Foams border dressings [2+ to 3+] (can be primary or secondary) (Not appropriate for daily dressing changes)
  • Hydrocolloids [1+ to 2+] (can be primary or secondary)
  • Ultra-absorbent dressings [3+ to 4+]
3. Clean Granulating Wound NOT decreasing in size 20-30% in 3-4 weeks*
*May have a localized infection or chronic inflammation
Cleansing: Irrigate with 7-15 PSI using at least 150 ccs of solution or a smaller amount of a commercial spray wound cleanser with surfactants at room or body temp. Cleanse and protect the periwound skin.
Primary Dressing: Antimicrobial dressings with ‘pro-inflammatory’ actions to “kick-start” acute inflammation:
  • Cadexomer iodine ung. [1+]
  • Povidone iodine [0]
  • Manuka Honey [all <1+ to 2+] (all require secondary dressing)
  • Gentian Violet/ Methylene blue dressings [2+]
Chronic inflammation:
  • Calcium Alginates [2+] (contribute to the initial inflammatory response required to start healing)
  • Protease Inhibitor dressings [<1+] (remove or reduce chronic inflammatory cells from wound surface and provide growth factors)
Secondary (Cover) Dressing:
Do NOT use occlusive dressings if infected
  • Composite dressings [2+ to 3+]
  • Foams border dressings [2+ to 3+] (Not appropriate for daily dressing changes)
  • Hydrocolloid dressings [1+ to 2+]—but not if on a plantar foot surface
  • Ultra-absorbent dressings [3+ to 4+]
4. Necrotic healable wound (debridement is appropriate; ABPI >0.5,co-morbidities are optimized)
Goal:
debridement of necrotic tissue, prevent infection, and support healing.

Cleansing: Irrigate with 7-15 PSI using at least 150 ccs of solution or a smaller amount of a commercial spray wound cleanser at room or body temperature. Cleanse and protect the periwound skin. Foul odour indicates aneorobes.
Primary Dressing: If slough:
  • Hydrocolloid [1+ to 2+] (Promotes autolytic debridement & granulation- doesn’tt require secondary dressing, but hydrofiber [2+] can be used under it)
  • Hydrogels [1=] (Add moisture to support autolytic debridement with correct secondary dressing)
  • Hypertonic Gauze [1+] (Supports autolytic debridement- may be increase in the amount of drainage and the size of the wound during initial treatment)
  • NPWT (Supports autolytic debridement but wounds should be reasonably debrided prior to starting (check organizational policy & procedure for % of necrotic tissue allowed))
If eschar:
Have ET or WCS nurse cross-hatch hard eschar before applying hypertonic gel [0] and cover with woven gauze dressing (not non-woven gauze or absorbent pads)
Secondary (Cover) Dressing:
  • Composite dressings [2+] with water-proof or occlusive outer layer (Support autolytic debridement)
  • Foams [2+ ]with transparent film or waterproof outer layer (Support autolytic debridement)
5. Necrotic non-healable wound where debridement is NOT appropriate (ABPI<0.5; co-morbid factors)
Goal:
stabilize and dry necrotic tissue to allow gradual auto-amputation or epithlialization under the eschar, without extension or infection.

Cleansing: If there is exudate, cleanse the periwound skin. Pat dry. The intent is to allow the necrotic tissue to dessicate and remain stable; a topical application of povidone-iodine solution (not detergent scrub) or Chlorhexidine is appropriate. Conservative Sharp Wound Debridement may be necessary to decrease the bacterial load.
Primary Dressing: Warning- “Application of moisture retentive dressings in the context of ischemia and or dry gangrene can result in a serious life- or limb-threatening infection”.
If a non-stick surface is not required, simply saturate a gauze with either povidone-iodine or chlorhexidine and place it to cover the necrotic tissue and the wound edges. As the necrotic tissue dries and dessicates over time, there will be less absorption of the antiseptic solution. If a non-stick dressing is needed, povidone-iodine non-adherent dresssing can be used. Or, leave open to air after ‘painting’ with antiseptic, or cover with a loose non-woven gauze that will not be occlusive or adhere to tissue.
6. Tunneling or Undermined Wound
Goal:
Gradual contraction of tunnel or undermining and growth of healthy granulation tissue from base until dead space is gone and epithelialization can occur.

Cleansing: Irrigate using a 5Fr catheter or “soft-cath” with a 30-35 cc. syringe and 150 to 500 cc. solution at room or body temperature. Irrigate until returns are clear. Gently palpate over undermined or tunneled areas to express any irrigation solution that is retained. Do not force irrigation when resistance is detected. Consult physician if sharp debridement needed.
Primary Dressing: General Principles: Both have the potential for infection and abscess formation.
Wound packing must be firm enough to prevent premature bridging of granulation tissue in the base, causing pockets and future abscesses, yet:
  • allow the wound to contract and heal from the base and
  • serve as a conduit or wick to allow the exudate to drain.
Avoid packing tightly at the opening, as this can plug the exit leading to increased pressure within the cavity as the exudate volume increases, causing painful extension of the cavity (Birchall & Taylor 2003).
Fill "dead space" with filler dressings such as:
  • Hypertonic Gauze [1+] (Helps to reduce edema and exudate)
  • Hydrofibres and Calcium alginates [2+] (Form a gel-like mass on the wound surface in combination with exudate but must retain integrity so that they can be removed in one piece - Lee et al. 2009 recommend that you not use hydrofibers in tunnels where you cannot see the bottom)
  • NPWT [4+] –does not require a secondary dressing
If biolfilm or localized infection is suspected or present:
  • AMD ribbon packing [<1+] or kerlix [1+]
  • Gauze ribbon packing [<1+] buttered with Cadeomer iodine
  • Hypertonic Gauze [1+] (Helps to reduce edema and exudate)
  • Hydrofiber/aginate Ag [2+] (Form a gel-like mass on the wound surface in combination with exudate but must retain integrity so that they can be removed in one piece - Lee et al. 2009 recommend that you not use hydrofibers in tunnels where you cannot see the bottom)
  • Nanocrystalline AG [1+]
Secondary (Cover) Dressing:
  • Composite dressings [2+ to 3+]
  • Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes)
  • Ultra-absorbent dressings [3+ to 4+]
7. Localized & Spreading Infection
Goal:
Resolve infections and prevent recurrence. Prevent strike-through of secondary dressings (where exudate soaks through or leaks from sides, creating a pathway for bacteria).
NOTE****
Deep or Spreading infection
will need systemic antibiotics in addition to thorough wound cleansing and antimicrobial dressings

Cleansing: Two-week challenge: May use a 10 – 14 day cleansing regime with an antimicrobial solution (prolonged use of antiseptics is NOT recommended but may be appropriate for maintenance wounds). Irrigate with 7-15 PSI using at least 150 mls of solution or a smaller amount of a commercial spray wound cleanser at room or body temperature. **NB- do not use Chlorhexidine near the ear due to the danger of hearing loss if the product enters the ear canal****
Cleanse and protect the periwound skin. May need to increase dressing frequency until S&S of infection decrease.
Primary Dressing: Localized infection: use topical antimicrobial dressings:
  • Povidone Iodine mesh [0] dressings not for highly exudative wounds)
  • AMD antimicrobial - packing strips [<1+], kerlix roll [ 1+]
  • Hydrofiber Ag [2+] (may need to be pre-moistened)
  • Nan0oystalline Ag [1+]
  • Ag Hydrofiber-Alginate [2+]
  • Cadexomer iodine ung. [1+] care to be taken on bone or tendon which may be at risk of dehydration with lower exudate levels)
  • AMD antimicrobial transfer foam [1+] (may require a non-adherent contact layer)
  • Methylene Blue/ Gentian Violet dressing [2+]
Secondary (Cover) Dressing: Do not use occlusive dressings in with/ suspected anerobic infections.
  • Composite dressings [2+ to 3+]
  • Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes). Use with caution on plantar foot dressings where increased exudate may cause maceration and extension of wound.
  • Ultra-absorbent dressings [3+ to 4+]
8. Painful Wounds
Goal:
Assess and manage pain WITH dressing change, pain AFTER dressing change and pain BETWEEN dressing changes.
Cleansing: Painful tissue may not tolerate irrigation with 7-15 PSI or hand-held shower. Warm the solution to body temperature to decrease discomfort, may have to use pour or compress method of cleansing until pain is controlled.
Primary Dressing: Protect painful wounds from trauma at dressing removal:
  • Clear Acrylic dressing [2+]
  • Foam with silicone contact layer [2+]
  • Hydrocolloid [1-2+] May need to add absorbent layer (hydrofiber or alginate) – does not require secondary dressing
  • Non-Adherent (soft silicone wound contact layer, Petrolatum, non-adherent mesh, Mylar perforated polyester film) [0]
Pain Control Dressing:
  • IBU foam [2+] Releases ibuprofen in the presence of exudate for shallow wounds not extending into the subcutaneous tissue
Topical Analgesia:
  • Morphine can be prescribed mixed with Intrasite gel to use topically for extremely painful palliative wounds evidently without risk of systemic absorption. A treatment guideline can be found at http://www.elht.nhs.uk/pdf/10.pdf
  • Topical lidocaine preparations can also be used in painful wounds at dressing change, or injected into the tubing going to the dressing of topical negative pressure wound therapy prior to the dressing change. Systemic absorption is high when applied to wound surfaces, and should only ever be used under physician or nurse practitioner orders
Secondary (Cover) Dressing:
  • Composite dressings [2+ to 3+]
  • Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes)
  • Hydrocolloiod [1-2+] or Ultra-absorbent dressings [3+ to 4+]


Infection and/or Inflammation

Pressure ulcers, like most chronic wounds, can become infected with superficial or spreading bacteria. The validated mnemonics “NERDS” and “STONEES” classify the signs and symptoms (s&s)8 9 of localized infection. (NERDS) include Non-healing, Exudate increased, Red friable tissue (caused by damage to the structure of the collagen matrix and increased blood vessels in the tissue), Debris or discolouration of the wound bed: dark, dull red or grey/green, raw, red or salmon colouration with gelatinous texture and Smell. Spreading infection s&s (STONEES) include Size, Temperature, Osteomyelitis, New areas of satellite breakdown (beyond the original wound) and/ or recurrence of wounds within a short period of time, Erythema and Smell. Waterloo Wellington CCAC has provided education to their Nursing Service Providers and they have been using the mnemonics for some time.

Signs, Symptoms and Actions for Superficial and Spreading Wound Infection (All Etiologies), Care Partners, Oct 20, 2014

Page 3 of Red Cross Care Partners document on Signs, Symptoms and Actions for Superficial and Spreading Wound Infection (All Etiologies) Page 4 of Red Cross Care Partners document on Signs, Symptoms and Actions for Superficial and Spreading Wound Infection (All Etiologies) Page 5 of Red Cross Care Partners document on Signs, Symptoms and Actions for Superficial and Spreading Wound Infection (All Etiologies)

RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 3.3f

Levine Method for Culture and Sensitivity (c&s)

In addition to recognizing the signs and symptoms of infection in pressure ulcers, it is very important that culture and sensitivity (c&s) be done using a validated method of sampling to quantify bacteria in wounds. Tissue biopsies are considered the gold standard10 but are not practical in many settings. Fortunately, a linear relationship between quantitative tissue biopsy and swab for c&s taken using the Levine method of sampling has been validated11 and is recommended for assessing any open wound12 13 14. Swabs for c&s are important in determining the type of bacteria and the appropriate antibiotics, but are not necessary to confirm the presence or absence of infection. The c&s results may not reflect the presence or absence of biofilm.


RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendations 3.3a - 3.3e
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 3.3g
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendations 3.1a - 3.1b

Measurements including Percentage of Healing

Wound Measurements (Length x Width x Depth) should be recorded on admission and at least weekly, with a calculation performed weekly to calculate the percentage reduction in wound size since admission.

The information about whether to measure head-to-toe and side-to-side (PUSH tool) or longest length x widest width (BWAT) can be confusing if you are not using a validated tool. If nurses are not measuring using a consistent method within an organization or agency, there can be huge variation in the measurements.

The two most important points are that measurements are done weekly, and using a standardized method within each organization to calculate the percentage of healing.

V (Initial) – V (Current) x 100 = % reduction in volume
            V (Initial)
(V = volume of wound calculated as Longest Length x Perpendicular Widest Width x Depth straight in)
(Adapted from Sussman and Bates-Jensen 2007)

Individuals with pressure ulcers who have adequate blood supply, are able to have their nutritional or co-morbid factors corrected, and receive pressure redistribution and moist wound healing, should begin to show healing of the pressure ulcer within 2-4 weeks. A good indicator of healing is 30% healing within 4 weeks with expectation to heal in 12 weeks15). Pressure ulcers may also need to have sharp debridement before the wound measurements start to reduce. Ulcers with a surface area decrease of at least 39% after 2 weeks healed more quickly than those with a smaller % decrease in size16 in a 1993 study, and the numbers have not changed significantly. Studies in 2003 and 2009 confirmed that pressure ulcers with <20% to 40% change in size over the initial 2 to 4 weeks is a reliable indicator that the wound is not responding well to treatment17 18. A biopsy is recommended to rule out other pathology such as malignancy.

If the wound cannot heal (Maintenance/ Non-healing), the goal of treatment is to maintain current wound status is maintained if possible and to prevent an infection. It is still important to measure and assess the wounds in these circumstances.

The PUSH TOOL (The Pressure Ulcer Scale for Healing) (click here to download as a PDF) was developed by the National Pressure Ulcer Advisory Panel (NPUAP) as a quick, reliable tool to monitor the change in pressure ulcer status over time.


Adjunctive Modalities or Biologically Active Dressings

RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 2.5
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 2.6
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendations 3.6a - 3.6b
RNAO BPG Assessment & Management of Stage I to IV Pressure Ulcers - Recommendation 3.7

If all components of the local wound bed have been corrected and the wound is still stalled, consider: Edge effect19. If the edge of the wound is not migrating or non-advancing, then active therapies should be considered. Active wound therapies such as biological agents (growth factors, fibroblasts, epithelial cell, or matrix components) are to be considered. Biological agents will stimulate new tissue growth to improve wound strength and decrease inflammatory cells needed for tissue repair. Advanced modalities may need to be considered such as Electrical Stimulation and Negative Pressure Wound Therapy. It is important to note that the client will be an active participant in the decision-making process for active therapies. The chart bellows illustrates the local wound bed paradigm for a healable and stalled wound.

Chronic Pressure Ulcers
Edge effect Biological Agents
  • growth factors, fibroblasts, epithelial cell, or matrix components
Cellular Therapies: Skin Grafting
  • Autologous epidermis, allografts, living skin equivalents
Advanced Therapeutic Modalities
  • Electrical Stimulation

The NPUA and EPUA have recommended using electrical stimulation for the treatment of chronic pressure ulcers that have not healed by conventional methods20. Electrical stimulation principle of action is to improved circulation of the wound by directing cell migration, regulating the frequency and direction of cell division and promoting re-epithelization and angiogenic phases of wound healing21.

Provide Organizational Support
  1. Sibbald RG, Goodman L, Woo KY, Krasner DL, Smart H, Gulnaz T, Ayello EA, Burrell RE, Keast DH, Mayer D, Norton L. Special considerations in wound bed preparation 2011: An update. In: Krasner DL, Rodeheaver GT, Sibbald RG, Woo KY, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 5th ed. Vol 1. Malvern, PA: HMP Communications, 2012: 173-197.
  2. Sibbald RG, Goodman L, Woo KY, Krasner DL, Smart H, Gulnaz T, Ayello EA, Burrell RE, Keast DH, Mayer D, Norton L. Special considerations in wound bed preparation 2011: An update. In: Krasner DL, Rodeheaver GT, Sibbald RG, Woo KY, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 5th ed. Vol 1. Malvern, PA: HMP Communications, 2012: 173-197.
  3. Despatis, M., Shapera, L., Parslow, N. Woo, K. (2008) Complex Wounds WCC 8(2):24-25.
  4. Sibbald RG, Goodman L, Woo KY, Krasner DL, Smart H, Gulnaz T, Ayello EA, Burrell RE, Keast DH, Mayer D, Norton L. Special considerations in wound bed preparation 2011: An update. In: Krasner DL, Rodeheaver GT, Sibbald RG, Woo KY, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 5th ed. Vol 1. Malvern, PA: HMP Communications, 2012: 173-197.
  5. Sibbald, Orsted, Coutts, Keast, 2006. Best Practice Recommendations for preparing the wound bed: update 2006. Wound Care Canada. 4(1): 15-29.
  6. Sibbald RG, Goodman L, Woo KY, Krasner DL, Smart H, Gulnaz T, Ayello EA, Burrell RE, Keast DH, Mayer D, Norton L. Special considerations in wound bed preparation 2011: An update. In: Krasner DL, Rodeheaver GT, Sibbald RG, Woo KY, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 5th ed. Vol 1. Malvern, PA: HMP Communications, 2012: 173-197.
  7. Keast D.H. , Parslow, N. Houghton, PE., Norton,L. and Fraser, C. (2006) Best Practice Recommendations for the Prevention and Treatment of Pressure Ulcers: Update 2006. Wound Care Canada 4(1):R19-29.
  8. Sibbald, R.G., Woo, K., Ayello, E. Increased bacterial burden and infection: The story of NERDS and STONES Adv Skin Wound Care 2006; 19 (8): 447-461.
  9. Woo, K.Y.; Sibbald, R.G. A Cross-sectional Validation Study of Using NERDS and STONEES to Assess Bacterial Burden Ostomy Wound Manage 2009: 55(8):40 –48.
  10. Landis, S., Ryan, S., Woo, K. & Sibbald, R.G. Infections in chronic wounds. In: Krasner D.L., Rodeheaver G.T., Sibbald R.G. editors. Chronic Wound Care Fourth Edition. Health Management Publications, Inc. Malvern, PA. 2007:299-321.
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