Algorithm for Pressure Ulcer Management for Professionals
ASSESS PU RISKS AS SOON AS POSSIBLE AFTER ADMISSION
PATIENT HAS
A PRESSURE ULCER
PATIENT IS AT RISK OF
A PRESSURE ULCER
PATIENT IS NOT AT RISK OF
A PRESSURE ULCER
Plan treatment interventions
• Use protocol/standard/EPUAP guideline
• Use algorithms, scales, tools, technology as appropriate
• Document
Plan preventive interventions
• Use protocol/standard/EPUAP guideline
• Use algorithms, scales, tools, technology as appropriate
• Document
Repeat the risk assessment and the tissue assessment
as stated in the local standard, protocol, EPUAP guideline, etc. Assess without delay if the patient's condition changes.
Implement planned treatment interventions
• Assess the skin damage/stage
• Clean and debride
• Apply/change dressing as per prescription/plan
• Monitor and document the wound
• Manage pain
• Use a multidisciplinary team approach
Repeat the risk assessment and the tissue assessment
as stated in the local standard, protocol, EPUAP guideline, etc. Assess without delay if the patient's condition changes.
IMPLEMENT PLANNED PREVENTIVE INTERVENTIONS IF THERE IS:
Restricted mobility/activity
• Reposition regularly
• Use supportive surfaces redistributing pressure/friction/shear
• Use preventive aids
Skin exposure to moisture
• Manage incontinence
• Keep the skin clean and dry
• Use linen and clothes made of natural materials
• Use protective products on skin
• Apply prophylactic dressings as appropriate
Nutritional deficit
• Ensure adequate nutrition rich in protein,
vitamins, minerals
• Supplement nutritional deficiency
Dehydration
• Ensure adequate hydration
• Monitor fluid intake
Pain
• Apply non-pharmacological methods of pain management
• Administer medication as prescribed
Repeat the risk assessment and the tissue assessment
as stated in the local standard, protocol, EPUAP guideline, etc. Assess without delay if the patient's condition changes.
