Sample Pressure Ulcer Protocols
Sample Pressure Ulcer Protocols
STAGE I
Definition: Non-blanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.
Goals: Protect, prevent further injury
Treatment
• Decrease pressure to site; elimination of all pressure is the ideal.
• Gently cleanse site, rinse, and dry well, daily. Keep site clean and dry.
• Apply topical sprays, per manufacturer’s instructions.
• Dressings such as thin hydrocolloid, foam or hydrogel also may be used according to manufacturer’s recommendation.
STAGE II
Definition: Partial thickness skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Goals: Cover, protect, hydrate, insulate, absorb
Treatment
A. Wounds with no exudate
• Irrigate wound with saline.
• Cover wound with a dressing, such as foam.
• Change dressing PRN.
• Consult the package insert to determine the manufacturer’s recommendations and instructions.
OR
• Apply topical sprays per manufacturer’s instructions.
B. Minimal amount of exudate
• Irrigate any debris from wound with normal saline.
• Clean and dry skin around wound, cover with dressing, such as foam, hydrogel, or hydrocolloid.
• Change dressing PRN.
OR
• Apply topical sprays per manufacturer’s instructions.
C. Moderate amounts of exudate
• Irrigate any debris from wound with normal saline.
• Apply appropriate size calcium alginate.
• Apply appropriate size secondary dressing, such as gauze.
• When barrier protection is required, use a foam.
• Change when strike through occurs or PRN, according to manufacturer’s recommendation.
STAGE III
Definition: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Goals: Cover, protect, hydrate, insulate, absorb, cleanse, prevent infection, promote granulation
Treatment
A. Minimal to moderate amounts of exudate
• Irrigate any debris from the wound with normal saline.
• Gently fill cavities with calcium alginate packing or dressings and cover with a dry dressing such as gauze, thin film, or foam. Foams provide barrier protection.
• Change dressing daily or when strike through occurs.
OR
• Irrigate any debris from the wound with normal saline.
• Apply appropriate size hydrocolloid or hydrogel.
• Change PRN according to manufacturer’s recommendations.
B. Moderate to heavy amounts of exudate
• Irrigate any debris from wound with normal saline.
• Gently fill cavities with calcium alginate packing or dressings.
• Cover with a bulk dresser, such as ABD pad or ExuDry. When barrier protection is required, foams may be used.
OR
• Irrigate any debris from the wound with normal saline.
• Apply appropriate size hydrocolloid.
• Change when first strike though or leakage occurs, at least every five days.
STAGE IV
Definition: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts may be associated with Stage IV pressure ulcers.
Goals: Cover, protect, hydrate, insulate, absorb, cleanse, prevent infection, obliterate dead space, promote granulation
Treatments
A. Minimal to moderate amounts of exudate
• Irrigate any debris from the wound with normal saline.
• Gently fill cavities with calcium alginate packing or dressings and cover with a dry dressing such as gauze, thin film, or foam. Foams provide barrier protection.
• Change dressing daily or when strike through occurs.
OR
• Irrigate any debris from the wound with normal saline.
• Apply appropriate size hydrocolloid or hydrogel.
• Change PRN according to manufacturer’s recommendations.
B. Moderate to heavy amounts of exudate
• Irrigate any debris from wound with normal saline.
• Gently fill cavities with calcium alginate packing or dressings. Cover with a bulk dressing, such as ABD pad or ExuDry. When barrier protection is required, Telfa pads may be used.
OR
• Irrigate any debris from the wound with normal saline.
• Apply appropriate size hydrocolloid.
• Change when first strike though or leakage occurs, at least every five days.
SKIN TEAR
Definition: A skin tear is a traumatic wound occurring principally on the extremities of older adults as a result of friction and/or shearing forces, which separate the epidermis from the dermis (partial thickness wound) or which separate both the epidermis and the dermis from underlying structures (full thickness wound).
Treatment
• Assess, categorize, and measure the skin tear.
• Gently cleans site. Pat wound margins dry with gauze.
• Debride any small pieces of detached epithelium.
• Return viable skin tissue gently back into position.
• Dress area with appropriate size Flexzan dressing.
• Dressing should remain in place undisturbed, however site should be monitored for complications.
• If the dressing should need replacing, remove in the direction of the flap and not against it, as this may disrupt any healing that has taken place.
WOUND WITH ESCHAR
Debridement of eschar and necrotic tissue must be accomplished before the wound can be staged or healing occur.
• Sharp debridement involves the use of a scalpel, scissors, or other sharp instrument to remove devitalized tissue. As the most rapid form of debridement, sharp debridement is urgently indicated when there are signs of advancing cellulitis or sepsis. Those performing sharp debridement should have demonstrated the necessary clinical skills and should meet licensing requirements.
• Mechanical debridement includes the use of wet-to-dry dressings at prescribed intervals, hydrotherapy, forced wound irrigation, and dextranomers. All these methods can be used as the initial or sole form of debridement.
• Wet-to-dry dressings adhere to devitalized tissue. Once the dressings are dry — usually within four to six hours — they can be removed and the devitalized tissue will be removed along with them.
The debriding function of the dressing is at least partly defeated if the dressing is moistened prior to removal. One disadvantage of wet-to-dry dressings is that they are nonselective; they remove both nonviable and viable tissues and are therefore potentially traumatic to granulation tissue and especially to new epithelial tissue.
• Hydrotherapy and wound irrigation can be used to debride wounds and soften eschar. Wound irrigation with a safe and effective device such as a 35-ml syringe with a 19-gauge angiocatheter attached to it will provide enough force to remove eschar, bacteria, and other debris.
• Dextranomers are beads that are placed into a wound bed to absorb exudate, bacteria, and other debris. One disadvantage of their use is that they may be difficult to apply and remove. In addition, the beads are expensive.
• Enzymatic debridement is accomplished by applying topical debriding agents to devitalized tissues on the wound surface. This option should be considered when individuals cannot tolerate surgery or are in long-term care facilities or receiving care at home and when the ulcer does not appear to be infected. If infection spreads beyond the ulcer (e.g., advancing cellulitis, sepsis), there is urgent need for sharp debridement.
• Autolytic debridement involves the use of synthetic dressings to cover a wound and allow devitalized tissue to self-digest from enzymes normally present in wound fluids. Although autolytic debridement takes longer than other methods, expert clinical opinion indicates that it is an appropriate choice for patients who cannot tolerate other forms of debridement and who are not likely to become infected if their wound is not debrided by other, more rapid means. Autolytic debridement is contraindicated if the ulcer is infected.
Source: Mylan Pharmaceuticals Inc., Morgantown, WV. 1997.
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