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Pressure ulcer

Key sources
The following summarized guidelines for the evaluation and management of pressure ulcer are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the European Pressure Ulcer Advisory Panel (EPUAP/PPPIA/NPIAP 2019), the Wound Healing Society (WHS 2016), and the American College of Physicians (ACP 2015).


1.Classification and risk stratification

Risk assessment: as per AAFP 2023 guidelines, use a structured, repeatable approach, including risk assessment tools, to identify patients at risk of PUs.
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2.Diagnostic investigations

History and physical examination: as per AAFP 2023 guidelines, perform skin examinations to assess for skin integrity, erythema, firmness, moisture, pain, and variations in heat in patients at high risk for PUs.

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  • Evaluation for wound infection

3.Diagnostic procedures

Bone biopsy: perform bone biopsy for culture and histology in patients with suspected osteomyelitis associated with a PU.

4.Medical management

Topical antimicrobials
As per EPUAP 2019 guidelines:
Apply topical antiseptics in tissue-appropriate strengths to control microbial burden and to promote healing in pressure injuries showing delayed healing.
Apply topical antiseptics active against biofilm in tissue-appropriate strengths in conjunction with regular debridement to control and eradicate suspected (or confirmed) biofilm in pressure injuries showing delayed healing.

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  • Systemic antibiotics

  • Management of osteomyelitis

  • Management of distant infections

  • Growth factor therapy

  • Management of pain

5.Nonpharmacologic interventions

Offloading: elevate the heels using a specifically designed heel suspension device in patients with stages 1-2
and stage ≥ 3 PUs,
or a pillow/foam cushion in patients with stages 1-2 PUs, offloading the heel completely to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein.

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  • Nutritional support

6.Therapeutic procedures

Electrical stimulation: as per EPUAP 2019 guidelines, offer pulsed current electrical stimulation to facilitate wound healing in patients with recalcitrant stage 2 pressure injuries and stage 3-4 pressure injuries.

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  • Negative pressure wound therapy

  • Hyperbaric oxygen therapy

  • Ultrasound therapy

7.Perioperative care

Perioperative management: as per EPUAP 2019 guidelines, monitor the wound regularly and immediately report signs of flap failure.
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8.Surgical interventions

As per EPUAP 2019 guidelines:
Debride the pressure injury of devitalized tissue and suspected or confirmed biofilm and perform maintenance debridement until the wound bed is free of devitalized tissue and covered with granulation tissue.
Avoid disturbing stable, hard, dry eschar in ischemic limbs and heels unless an infection is suspected.

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  • Wound cleansing

  • Wound dressings

  • Surgical closure

  • Fecal and urinary diversion

  • Amputation

9.Specific circumstances

Pediatric patients: obtain an age-appropriate nutritional screening and assessment in neonates and pediatric patients at risk of pressure injuries.
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  • Seated patients

  • Patients with medical devices

10.Preventative measures

Skin care: implement a skin care regimen including:
keeping the skin clean and appropriately hydrated
cleansing the skin promptly after episodes of incontinence
avoiding the use of alkaline soaps and cleansers
protecting the skin from moisture with a barrier product
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  • Pressure-relieving surfaces

  • Repositioning

  • Offloading

11.Follow-up and surveillance

Serial clinical assessment: reassess the pressure injury at least weekly to monitor progress toward healing.
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  • Management of chronic ulcers

12.Quality improvement

Documentation: document wound history, recurrence, and characteristics (location, staging, size, base, exudates, infection condition of surrounding skin, and pain).