Cleansing

  1. Cleanse the pressure ulcer and surrounding skin at the time of each dressing change. (Strength of Evidence = C)
    1. Cleanse healing, clean pressure ulcers with normal saline or potable water (i.e., water suitable for drinking). (Strength of Evidence = C)
    2. Consider using cleansing solutions with surfactants and/or antimicrobials to clean pressure ulcers with debris, confirmed infection, suspected infection, or suspected high levels of bacterial colonization. (Strength of Evidence = C)
    3. Cleanse surrounding skin. (Strength of Evidence = B)
  2. Cleanse the pressure ulcer using an irrigation solution, and apply sufficient pressure to cleanse the wound without damaging tissue or driving bacteria into the wound. (Strength of Evidence = C)
    Generally, irrigation pressure between 4 and 15 pounds per square inch (PSI) should be adequate to clean the surface of the pressure ulcer without causing trauma to the wound bed.
  3. Contain and properly dispose of used irrigation solution to reduce cross-contamination. (Strength of Evidence = C)