RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Nursing Best Practice GuidelineBiological debridement involves the use of sterile larvae of Lucilia seicata (greenbottle fly) to digestnecrotic tissue from the wound bed. Supported by recent studies, this therapy is gaining popularity but hasstill yet to find general acceptance in Canada (Sibbald, Orsted et al., 2006).Mechanical debridement includes the use of wet-to-dry dressings at specific intervals, hydrotherapy(whirlpool) and wound irrigation. All of these methods can be utilized alone, or in preparation for surgical(sharp) debridement (AHCPR, 1994). Mechanical debridement is a slow process, can be painful and shouldbe discontinued when necrotic tissue has been removed (Consortium for Spinal Cord Medicine, 2000). Wet-to-drydressings in particular are nonselective in that they remove both viable and necrotic tissue, and arepotentially damaging to granulation and epithelial tissue. It is important to ensure that appropriate andadequate pain management is incorporated into the plan of care when this method is utilized (AHCPR, 1994;Maklebust & Sieggreen, 1996; Ovington, 2002).Control Bacteria/InfectionRecommendation 3.3aThe treatment of infection is managed by wound cleansing, systemic antibiotics anddebridement, as needed.Level of Evidence – IbRecommendation 3.3bProtect pressure ulcers from sources of contamination, e.g., fecal matter.Level of Evidence – IIaRecommendation 3.3cFollow Body Substance Precautions (BSP) or an equivalent protocol appropriate for the healthcaresetting and the client’s condition when treating pressure ulcers.Level of Evidence – IVRecommendation 3.3dMedical management may include initiating a two-week trial of topical antibiotics for cleanpressure ulcers that are not healing or are continuing to produce exudate after two to four weeks ofoptimal patient care. The antibiotic should be effective against gram-negative, gram-positive andanaerobic organisms.Level of Evidence – IbRecommendation 3.3eMedical management may include appropriate systemic antibiotic therapy for patients withbacteremia, sepsis, advancing cellulitis or osteomyelitis.Level of Evidence – Ib37