Pressure Injury Wound care plan
Assessment for Pressure Injury
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-Wound Location
-Wound Tissue: bone, tendon, necrosis, slough, granulation, epithelium
-Dimensions: length, width, depth, tunnelling and sinuses
-Exudate: amount and type
-Wound edges: raised, rolled, undermined.
-Surrounding skin characteristic: induration, erythema, maceration, discolouration
-Pain
Stages of PI
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-Classified by the depth of tissue damage present.
Key elements of PI management
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-Relieving or reducing the pressure, friction and shear
-Minimising or eliminating the contributing factor
-Treating the pressure injury
-Education
Selection of Support Surface
-Replacement mattresses and overlays
-Seating
-Comfort/adjunct device
-Specialty beds
Treatment Goal of pressure injury
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-Promotion of granulation, wound contraction, and epithelialisation
-Management of pain
-Prevention of infection
-Protection and cushioning of the wound and skin
Dressing option for PI management●
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Stage I-Topical cream (Moisturiser, barrier cream), Protective dressing (Allevyn,
Foam), Hydrocolloid
Stage II-Hydrogel, Hydrocolloid, Foam, Calcium Alginate, Hydrofibre, Combination
dressing
Stage III & IV-Hydrogel, Interactive wet dressing, foam, calcium alginate, hydrofibre,
combination dressing, Negative pressure wound dressing