EUROPEAN PRESSURE ULCER ADVISORY PANEL

CLASSIFICATION
Grade 1: non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, indur-ation or hardness may also be used as indicators, particularly on individuals with darker skin.
Grade 2: partial thickness skin loss involving epider-mis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.
Grade 3: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia.
Grade 4: extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss.

GUIDELINES
Guidelines are based on the following evidence

[A] Results of two or more randomised controlled clinical trials on pressure ulcers in humans provide support.
[B] Results of two or more controlled clinical trials on pressure ulcers in humans provide support, or where appropriate, results of two or more controlled trials in an animal model provide indirect support.
[C] This rating requires one or more of the following:
         1.  results of one controlled trial,
         2.  results of a least two case series/descriptive studies on pressure ulcers in humans, or
         3.  expert opinion.

ASSESSMENT
Assessing the Pressure Ulcer
Assess the pressure ulcer(s) initially for location, grade, size, wound bed, exudate, pain and status of surrounding skin. Care should be taken to identify undermining and sinus formation. [C]
Reassess pressure ulcers when possible daily or at least weekly. If the condition of the patient or of the wound deteriorates, re-evaluate the treatment plan as soon as any evidence of deterioration is noted. [C]

History and Physical Examination
Perform a complete history and physical examination, because a pressure ulcer should be assessed in the context of the patients overall physical and psychosocial health. Address identified needs. [C]

ASSESSING COMPLICATIONS
Nutritional assessment and management
Ensure adequate dietary intake to prevent malnutrition to the extent that this is compatible with the individual's wishes or condition. [B]

Pain assessment and management
Assess all patients for pain related to the pressure ulcer or its treatment and document. [C]
Manage pain by eliminating or controlling the source of pain (e.g., covering wounds, adjusting support surfaces, repositioning).
Provide medication or other methods of pain relief as needed and appropriate. Seek specialist advice if necessary. [C]

Psychosocial assessment and management
Assess resources (e.g., availability and skill of caregivers, home conditions, equipment, patients preference) for individuals being treated with pressure ulcers in the home. [C]

MANAGING TISSUE LOADS
Managing tissue loads can be achieved in a variety of ways including:
     1) manual repositioning,
     2) use of specialist equipment,
and is a 24-hour provision whether the patient is in a bed or chair. Periods spent immobile in chairs should be limited to two hours or less per session, unless their clinical condition prevents doing so. [B]
Following assessment of the patient and pressure ulcer a plan of treatment consistent with the overall goal of therapy should be developed. [C]
Whenever possible avoid positioning patients directly on a pressure ulcer or directly on a bony prominence unless this is contra-indicated by their general treatment objectives, in which instance an adequate pressure relieving device (e.g., an alternating pressure device) should be used. [C]

THE USE OF PRESSURE ULCER PREVENTION DEVICES
There is no agreed definition of the terms of pressure:
relief - reduction - redistribution.
Therefore, for simplicity, the term pressure ulcer prevention device will be used.
Consider postural alignment, distribution of weight, balance, stability, and pressure ulcer risk reduction when positioning patients or selecting equipment. This is especially important in the sitting position whether in bed or chair. [C]
Reposition, or where possible teach the patient to reposition themselves at frequent intervals to redistribute pressure. [C]
Benefit may be derived from a variety of pressure ulcer prevention devices but information on patient outcomes and information on the cost effectiveness of any of these devices is scarce. [B]
It is necessary to develop international and European standards to which these devices should perform, e.g., similar to already existing standards in some countries. [C]

WOUND TREATMENT
Debridement is defined as the removal of devitalised tissue from a wound.
The rationale for removing such tissue is that:

• it removes a medium for infection,
• it facilitates healing,
• it aids assessment of wound depth. [C]

Remove devitalised tissue in pressure ulcers when appropriate for the patient's condition and consistent with the patients goals. [C]
With the terminally ill patient their overall quality of life should be taken into account when deciding whether to debride the wound and the manner in which it should be accomplished. [C]
Surgical, enzymatic and/or autolytic debridement techniques may be used when there is no urgent clinical need for drainage or removal of devitalised tissue. [C]
If there is an urgent need for debridement, as with advancing cellulitis or sepsis, surgical debridement* should be used. Surgical debridement must be perfor-med by a competent person. [C]
Methods of debridement include surgical, enzy-matic, autolytic, larvae or a combination.
Dry eschar need not be debrided if oedema, erythema, fluctuance or drainage are not present. Dry eschar may be removed with dressings which provide moist environment to encourage autolysis. They include hydrocolloids, hydrogels. [C]
These wounds should be assessed daily to monitor pressure ulcer complications which would require debridement. [C]
Prevent or manage pain associated with surgical debridement. [C]
* Surgical methods range from scissors and scalpel used at the bedside by a competent nurse or surgical debridement performed by a surgeon in the operating theatre.

WOUND CLEANSING
Cleanse wounds as necessary with tap water or with water which is suitable for drinking or with saline. [C]
Use minimal mechanical force when cleansing or irrigating the ulcer. Showering is appropriate. Irrigation can be useful for cleaning a cavity ulcer. [C]
Antiseptics should not routinely be used to clean wounds but may be considered when bacterial load needs to be controlled (after clinical assessment). Ideally antiseptics should only be used for a limited period of time until the wound is clean and surrounding inflammation reduced. [C]

DRESSINGS
Use a dressing which maintains a moist environment at the wound/dressing interface. [A]
Determine the condition of the wound and establish treatment objectives before selecting dressing - e.g., grade, wound bed, infection, level of exudate, pain, surrounding skin, position and patients preference. [C]
Dressings should be maintained in situ as long as is clinically appropriate, and in line with manufacturers recommendations. Frequent removal could damage the wound bed. Dressings that harden should not be used since they may cause pressure injuries. [B]
Dressings may need to be removed daily to ensure that the wound is not getting worse due to inadequate pressure relief.
If there is leakage or strike through, it causes a break in the barrier that the dressing provides to external contamination, and so it should be changed. If this occurs frequently it may be appropriate to reconsider dressing choice. [C]
The use of wound protocols based on good evidence will avoid unnecessary changes of dressing. [C]
Regular observation will demonstrate the progress of healing and if there is a need to change treatment objectives. [C]

MANAGING BACTERIAL COLONISATION AND INFECTION
Pressure ulcer colonisation and infection
Reduce the risk of infection and enhance wound healing by hand washing, wound cleansing and debridement. [A]
If purulent material or foul odour is present, more frequent cleansing and possibly debridement are required. [C]
All pressure ulcers are colonised. Therefore do not routinely take a swab. If there are clinical signs of infection present cultures may be taken. Seek advice from the pathologist / microbiologist. [C]
When there are clinical signs of infection which do not respond to treatment, radiological examination should be undertaken to exclude osteomyelitis and joint infection. [C]
Institute, where appropriate, systemic antibiotic therapy for patients with bacteraemia, sepsis, advancing cellulitis or osteomyelitis. [A]
Systemic antibiotics are not required for pressure ulcers that exhibit only clinical signs of local infection. [C]
Protect pressure ulcers from exogenous sources of contamination (e.g., faeces) [C]

Infection control
Follow body substance isolation (BSI) precautions or an equivalent system appropriate for the health care setting and the patient's condition when treating pressure ulcers. [C]
Use clean gloves for each patient. When treating multiple ulcers on the same patient, attend to the most contaminated ulcer last (e.g., in the perianal region). Remove gloves and wash hands between patients. [C]
Use sterile instruments to debride pressure ulcers. [C]

ADJUNCTIVE THERAPIES
Such therapies include Electrotherapy and low laser irradiation. However, at present, insufficient research has been completed to recommend their general use. [C]

Published in 1998.

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