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RNAO Recommendations


Assessment

Recommendation 1.1

Conduct a history and focused physical assessment.

Recommendation 1.2

Conduct a psychosocial assessment to determine the client’s goals and IV their ability and motivation to comprehend and adhere to the treatment plan of care options.

Recommendation 1.3

Assess quality of life from the client’s perspective.

Recommendation 1.4

Ensure adequate dietary intake to prevent malnutrition or replace existing deficiencies to the extent that this is compatible with the individual’s wishes.

Recommendation 1.5

Prevent clinical nutrient deficiencies by ensuring that the patient is provided with optimal nutritional support through one or more of the following:

  • Consultation with a Registered Dietitian for assessment
  • Consultation with a speech language pathologist for swallowing assessment
  • A varied, balanced diet to meet clinical requirements for healing and co-existing diseases (e.g., renal failure and diabetes)
  • Nutritional supplements if needed
  • Multivitamin and mineral preparations
  • Enteral tube feeding
  • Parenteral nutrition
  • Ongoing monitoring of nutritional intake, laboratory data and anthropometric data

Recommendation 1.6

Assess all patients for pain related to the pressure ulcer or its treatment.

Recommendation 1.7

Assess location, frequency and intensity of pain to determine the presence of underlying disease, the exposure of nerve endings, efficacy of local wound care and psychological need.

Recommendation 1.8

Recommendation 1.9

If the patient remains at risk for other pressure ulcers, a high specification Ia foam mattress instead of a standard hospital mattress should be used to prevent pressure ulcers in moderate to high risk patients.

Recommendation 1.10

Vascular assessment (e.g., clinical assessment, palpable pedal pulses, capillary refill, ankle/brachial pressure index and toe pressure) is recommended for ulcers in lower extremities to rule out vascular compromise.


Management of causative/contributing factors

Recommendation 2.1

Choose the support surface which best fits with the overall care plan for the client considering the goals of treatment, client bed mobility, transfers, caregiver impacts, ease of use, cost/benefit, etc. Ensure ongoing monitoring and evaluation to ensure that the support surface continues to meet the client’s needs and that the surface is used appropriately and is properly maintained. If the wound is not healing, consider the total care plan for the client before replacing the surface.

Recommendation 2.2

Pressure management of the heels while in bed should be considered independently of the support surface.

Recommendation 2.3

Use pressure management for clients in the Operating Room to reduce the incidence of pressure ulcers post operatively.

Recommendation 2.4

Obtain a seating assessment if a client has a pressure ulcer on a sitting surface.

Recommendation 2.5

Refer patients at RISK to appropriate interdisciplinary team members (Occupational Therapist, Physiotherapist, Enterostomal Therapist, etc.). Utilize those with expertise in seating, postural alignment, distribution of weight, balance, stability and pressure management when determining positioning for sitting individuals. Ensure support surfaces are used appropriately and are properly maintained.

Recommendation 2.6

A client with a pressure ulcer on the buttocks and/or trochanter should IV optimize mobilization. If pressure on the ulcer can be managed, encourage sitting as tolerated.


Local Wound Care

Assessment

Recommendation 3.1a

To plan treatment and evaluate its effectiveness, assess the pressure ulcer(s) initially for:

  • Stage/Depth;
  • Location;
  • Surface Area (length x width) (mm², cm²);
  • Odour;
  • Sinus tracts/Undermining/Tunneling;
  • Exudate;
  • Appearance of the wound bed; and
  • Condition of the surrounding skin (periwound) and wound edges.
Recommendation 3.1b

Debridement

Recommendation 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.

Recommendation 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.

Recommendation 3.2c

Determine if debridement is appropriate for the patient and the wound.

Recommendation 3.2d

If debridement is indicated, select the appropriate method of debridement considering:

  • 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.
Recommendation 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.

Recommendation 3.2f

Use sterile instruments to debride pressure ulcers.

Recommendation 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).

Control Bacteria/Infection

Recommendation 3.3a

The treatment of infection is managed by wound cleansing, systemic antibiotics, and debridement, as needed.

Recommendation 3.3b

Protect pressure ulcers from sources of contamination, e.g., fecal matter.

Recommendation 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.

Recommendation 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.

Recommendation 3.3e

Medical management may include appropriate systemic antibiotic therapy for patients with bacteremia, sepsis, advancing cellulitis or osteomyelitis.

Recommendation 3.3f

To obtain a wound culture, cleanse wound with normal saline first. Swab wound bed, not eschar, slough, exudate or edges.

Recommendation 3.3g

The use of cytotoxic antiseptics to reduce bacteria in wound tissue is not usually recommended.

Wound Cleansing

Recommendation 3.4a
Recommendation 3.4b
Recommendation 3.4c
Recommendation 3.4d
Recommendation 3.4e
Recommendation 3.4f

Management Approaches

Recommendation 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.
Recommendation 3.5b

Moisture-retentive dressings optimize the local wound environment and promote healing.

Recommendation 3.5c

Consider caregiver time when selecting a dressing.

Recommendation 3.5d

Consider the following criteria when selecting an interactive dressing:

  • Maintains a moist environment (Ia)
  • Controls wound exudate, keeping the wound bed moist and the
  • surrounding intact skin dry (IV)
  • Provides thermal insulation and wound temperature stability (IV)
  • Protects from contamination of outside micro-organisms (IV)
  • Maintains its integrity and does not leave fibres or foreign substances within
  • the wound (IV)
  • Does not cause trauma to wound bed on removal (IV)
  • Client/patient preference (IV)
  • Is simple to handle, and is economical in cost and time (IV).
Recommendation 3.5e

Monitor dressings applied near the anus, since they are difficult to keep intact. Consider use of special sacral-shaped dressings.

Adjunctive Therapies

Recommendation 3.6a

Refer to physiotherapy for a course of treatment with electrotherapy for Stage III and IV pressure ulcers that have proved unresponsive to conventional therapy. Electrical stimulation may also be useful for recalcitrant Stage II ulcers.

Recommendation 3.6b

Chronic pressure ulcers may be treated by:

  • Electrical stimulation (Ib)
  • Ultraviolet light C (IIa)
  • Warming therapy (Ib)
  • Growth factors (Ib)
  • Skin equivalents (IV)
  • Negative pressure wound therapy (IV)
  • Hyperbaric oxygen (IV)

Surgical Intervention

Recommendation 3.7

Possible candidates for operative repair are medically stable, adequately nourished and are able to tolerate operative blood loss and postoperative immobility.


Discharge/Transfer of Care Arrangements

Recommendation 4.1

Recommendation 4.2



Patient Education

Recommendation 5.1



Education Recommendations

Recommendation 6.1

Recommendation 6.2

Recommendation 6.3

Recommendation 6.4



Organization & Policy Recommendations

Recommendation 7.1

Recommendation 7.2

Recommendation 7.3

Recommendation 7.4

Recommendation 7.5

Recommendation 7.6

 

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