Evidence-Based Practice in Wound Care

Instructor: Justine Fritzel

Justine has been a Registered Nurse for 10 years and has a Bachelor's of Science in Nursing degree.

Pressure ulcers are a huge burden on patients and on the healthcare system. In this lesson, we will learn more about pressure ulcers and evidence-based practice in managing them.

Prevention of Skin Breakdown

When a person is ill, injured, or debilitated they are often bed bound or at the very least less active than they used to be. They may be hospitalized, in a nursing home or cared for at home. Regardless of the specific situation, many of these people are at risk for skin breakdown, commonly known as bed sores.

As bed sores can become very severe, studies agree that prevention of bed sores is key. Preventing them is much easier than healing them.


Nursing assessment is important in helping to identify the risk for skin breakdown and aid in prevention. It's important to take into consideration the patient's age and health conditions including previous bed sores. Reviewing their medications can also identify any risks. Regular assessment of a patient's skin is essential. There are also several tools that can be used to assess a patient's risk for skin breakdown.

Braden Scale

One commonly used tool is the Braden Scale. This scale rates sensory and perception, moisture, activity, mobility, nutrition, and friction/shearing. For example, a 93 year old lady is no longer able to walk and spends most of her time in bed. She often slides down in bed and is unable to reposition herself independently. She is incontinent of urine and is unaware when she is. She is very thin and frail and eats very little. She would be at high risk for skin breakdown on the Braden Scale.

Prevention is focused on the same factors as the Braden Scale. Interventions include repositioning the person at least every few hours and providing extra cushioning for their chair or bed, keeping the skin dry for incontinence care, encouraging mobility, improving nutrition and avoiding friction or shearing such as sliding in bed. Meticulous care can help avoid skin breakdown.

Pressure Ulcers

Pressure ulcer is the medical term for a bed sore. Any part of the body with a bony prominence is a common area for pressure ulcers and should be closely assessed. Examples are the hips, ankles, shoulders, and lower back over the sacrum. Pressure ulcers are categorized through staging according to the National Pressure Ulcer Staging System. A simplified description of each stage is below.

Stage 1 pressure ulcer is a an area that is reddened and when light pressure is applied it doesn't change color.

Stage 2 pressure ulcer is a superficial skin loss, like a popped blister.

Stage 3 has full thickness skin loss and extends down into subcutaneous tissue.

Stage 4 extends even deeper and can go to the bone.

Learning a little bit about the staging may now help you understand how significant pressure ulcers can be.


If a person does develop a pressure ulcer, appropriate treatment is necessary. Research identifies steps for treatment which include cleansing, assessment and staging, debridement, managing bacteria, managing exudate, improving nutrition, managing pain, and ongoing assessment of the wound.

Nurses will assess the wound and determine the stage of the wound. Cleansing the wound with normal saline cleans the wound of debris and bacteria that may otherwise delay healing.

The wound may have necrotic tissue which is essentially dead tissue that will prevent healing. Debridement is the removal of this tissue to promote healing. There are different ways to debride which include sharp, mechanical, autolytic, enzymatic and biosurgery.

Bacteria is going to be present in a wound but when the bacteria content increases the wound may become infected and again healing can be delayed. Research shows that swab cultures are not recommended and instead tissue biopsies should be done. Treatment can include oral or topical antibiotics to control the bacteria growth.

Keeping the wound moist is important in healing but at the same time if there is heavy drainage, or exudate, you need a non-gauze dressing.

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