Management of Wounds, Decubiti, or Pressure Ulcers Care and Treatment


To develop treatment guidelines for the clinician (skilled nurse) to manage and treat wounds, decubiti, or pressure ulcers.


The agency has developed guidelines to assist the skilled nurse in managing and treating wounds, decubiti, and pressure ulcers to promote healthy, intact, and infection-free tissue.


• The patient's skin is routinely assessed for breakdown, with special attention to skin folds, bony prominences, and areas of pressure or reduced circulation.

• Wounds are staged based on the amount of tissue involved. The staging system has four stages:

Stage 1: Redness that does not disappear within 30 minutes of relief of pressure.

Stage 2: Partial loss of skin, involves the epidermis and sometimes the dermis. This wound may be a blister, pink in color and may be painful.

Stage 3: This wound is deeper, and enters the tissue beneath the top layers (epidermis and dermis). It may have a thick scab covering it or may be concave in appearance. Tissue may be black, infected or both. It is not usually painful because the nerves are damaged.

Stage 4: Wound extends deep into the tissue and may encompass the muscle, joint capsule, and bone. The wound usually has a deep cavity, may be black, infected or both and is without pain.

• Wounds are to be measured at least weekly noting width, length and depth, color, drainage, and condition of surrounding tissue.

• All Stage 3 and 4 wounds should be photographed upon discovery of the wound, and every 62 days for ongoing dressing changes.

• The nurse shall obtain consent to photograph. A consent need only be obtained one time per admission per wound site.

• The wound care flowsheet is to be used on all wounds needing dressing changes three times a week or more (one visit must be documented on sheet). The flowsheet is always used for multiple wound sites or daily dressing changes.

• All patients with wounds will be assessed weekly for effectiveness of wound care treatment, pressure relieving devices, wound care prevention techniques (patient positioning), and individual dietary intake with appropriate documentation of patient/caregiver teaching.

• Types of wound care treatment are listed in Appendix A. This is to be used as a resource only and not considered all-inclusive.

• An Enterostomal Therapist (ET) consult and follow-up is recommended as a standard of practice in the following situations:

— If a wound fails to make significant progress in 21 days.

— On long-term wounds (six weeks of service).

— Wounds that are difficult to stage.

— Any Stage 3 or 4 wound admissions.

— Any wounds progressing to Stage 3 or 4.

• Recommendations by the ET will be communicated to the primary nurse by the ET directly or through the coordinator within 24 hours of the consult/visit by the ET.

• Any recommendations by the ET for changes in wound care treatment shall be called to the MD by the ET for follow-up by the primary nurse. Orders are written for the change in treatment by the nurse who receives the orders from the physician. Any new wounds identified during current treatment need additional orders written for the new wound, even through the treatment parameters may be the same.

• Regular communication (every 62 days) informing the physician about the status of the wound should take place and be documented on the patient progress form. The clinical visit note or the communication note shall be used to update the MD, caregiver, family or other home care team members about the status if changes are occurring more frequently.

• Documentation should include the availability of willing caregivers, the teaching and follow-through by caregivers in the dressing procedure or why your attempts for self-care management have been unsuccessful.

• Discharge should be communicated to the patient and family with recommendations to prevent further complications and routine physician follow-up.