Stage I Stage II PRESSURE ULCER QUICK REFERENCE Stage III Stage IV ATTACHMMENT B Nursing Standard – ICP-2 Pressure Ulcers- Treatment Unstageable Deep Tissue Injury Description: Non-blanchable erythema of intact skin or discoloration of skin, warmth, edema, induration, or hardness over bony prominence may also be indicators. Description: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater Description: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, fascia. Presents clinically as a deep crater with or without undermining adjacent tissue Description: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (i.e., tendon, joint capsule). Description: When eschar is present, accurate staging of the pressure ulcer is not possible until the eschar has sloughed or the wound has been debrided Description: Purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear. Interventions: Describe and document; Versa care, Zone air/Advanta beds; Waffle boots; turning schedule; hygiene and incontinence management; nutritional screening and assessment by dietician as needed. DO NOT MASSAGE RED AREAS! Intervention: Describe and utilize treatment for Stag I; clean wound with normal saline; xeroform/Telfa; Hydrogel dressing (Aquasorb) Note: If patient on isolation, use Silvasorb + Telfa DO NOT use Duoderm occlusive Intervention: Describe and utilize treatment for Stage I & II; Skin/Wound consult; consider specialty bed; various products (below) to wound per MD order; debridement per MD prn; cover with moist Saline gauze if using Santyl (Collagenase) Interventions: Describe and utilize treatment for Stages I & II; Skin/Wound Consult; consider specialty bed; clean with normal saline; various products (below) to wound per Wound nurse consult; debridement per MD prn; pack/cover with moist gauze if Collagenase ordered Intervention: Describe and utilize treatment for Stages I & II; Skin/Wound consult; consider specialty bed; clean with normal saline; various products to debride wound per MD order; cover with moist saline gauze if Collagenase used. Intervention: Describe; low air loss surface bed; Waffle boots; turning schedule; hygiene and incontinence management; nutrition screening and possible assessment by dietician; expect to progress to a pressure ulcer Photos of Products: Waffle Boots Photos of Products: Xeroform Photos of Products: Photos of Products: Calcium Alginate (Maxsorb) Calcium Alginate (Maxsorb) Photos of Products: Santyl Photos of Products: Waffle Boots Soothe and Cool Moisturizing Lotion AquaCel Ag (If infected) Carrington Hydrogel Occlusive dressing Moisture products: Barrier Cream A. Aquasorb Soothe and Cool Moisturizing Lotion Apply Santyl with moistened normal saline gauze SilvaSorb covered with Telfa (order from pharmacy) Carrawash Perineal Cleanser AquaCel Ag (If infected) Carrington Moisture Barrier Cream SilvaSorb covered with Telfa (order from pharmacy) Carrawash Perineal Cleanser Mepilex Border Sacrum B. Duoderm Hydroactive gel Santyl (requires MD order; from pharmacy Santyl (requires MD order; from pharmacy Any questions re: Skin and/or Wound Care, call the Skin/Wound Ostomy Nurse: Rimma Katsovskaya @ 885-5683 revised 11/2011 3M No Sting Barrier film