TREATMENT OF STAGE I PRESSURE AREA
Stage I – Non-Heel Area
1.
Relieve pressure from affected area.
2.
Apply moisture barrier q 8 hours and PRN, d/c when healed.
3.
Assess affected area with treatment for changes, and/or signs and symptoms of infection.
4.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
5.
Document appearance and measurements initially and weekly.
6.
Notify provider of any wound that has not changed in status in 1 week for re-evaluation.
Stage I – Heel
1.
Relieve pressure from affected area.
2.
Apply Skin Prep BID, d/c when healed.
3.
Assess affected area with treatment for changes, and/or signs and symptoms of infection.
4.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
5.
Document appearance and measurements initially and weekly.
6.
Notify provider of any wound that has not changed in status in 1 week for re-evaluation.
STAGE II PRESSURE AREA
Stage II – Shallow Crater
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1.
Relieve pressure from affected area.
2.
Assess resident for pain related to presence of wound and wound treatment. Notify MD if order for treatment needed.
3.
Cleanse gently with Normal Saline, pat dry.
4.
Apply Hydrogel (ex. Intrasite gel) to open area and cover with foam dressing (ex. Mepilex, Allevyn) daily and PRN, d/c when healed.
5.
Assess affected area with treatments for changes, and/or signs and symptoms of infection.
6.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
7.
Document appearance and measurements initially and weekly.
8.
Notify provider of any wound that has not changed in status in 1 week for re-evaluation.
Stage II – Intact Blister
1.
Relieve pressure from affected area.
2.
Apply Skin Prep to area BID.
3.
Assess affected area with treatments for changes, and/or signs and symptoms of infection.
4.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
5.
Document appearance and measurements initially and weekly.
6.
Notify provider of any wound that has not changed in status in 1 week for re-evaluation.
Stage II – Open Blister
1.
Relieve pressure from affected area.
2.
Cleanse with Normal Saline, pat dry.
3.
Apply Hydrogel (ex. Intrasite) to open area and cover with foam dressing (ex. Mepilex/Allevyn) daily and PRN, secure with paper tape, and d/c when healed.
4.
Assess affected area with treatments for changes, and/or signs and symptoms of infection.
5.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
6.
Document appearance and measurements initially and weekly.
7.
Notify provider of any wound that has not changed in status in 1 week.
Additional Recommendations:
If area is located in an area at risk for friction or shear, apply foam dressing to protect area.
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STAGE III PRESSURE AREA
Stage III – Dry to Light Exudates
1.
Relieve pressure from affected area.
2.
Cleanse with Normal Saline, pat dry.
3.
Apply Hydrogel (ex. Intrasite) to open area and cover with foam dressing (ex. Mepilex, Allevyn) daily and PRN, secure with paper tape, and d/c when healed.
4.
Assess affected area with treatments for changes, and/or signs and symptoms of infection.
5.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
6.
Document appearance and measurements initially and weekly.
7.
Notify provider of any wound that has not changed in status in 2 weeks.
Stage III – With Moderate to Heavy Exudates
1.
Relieve pressure from affected area.
2.
Cleanse with Normal Saline, pat dry.
3.
Cover with calcium alginate product (Algisite), cover with foam dressing (Mepilex, Allevyn) daily and PRN, and d/c when healed.
4.
Assess affected area with treatments for changes, and/or signs and symptoms of infection.
5.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
6.
Document appearance and measurements initially and weekly.
7.
Notify provider of any wound that has not changed in status in 2 weeks for re-evaluation.
Additional Recommendations:
Stage III – Dry to Light Exudates – If slough or eschar are visualized, apply Santyl in place of
Hydrogel
Stage III – With Moderate to Heavy Exudates – If slough or eschar are visualized, apply Santyl prior to calcium alginate
Use ABD pad instead of foam dressing for copious drainage
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STAGE IV PRESSURE AREA
Stage IV – Dry to Light Exudates
1.
Relieve pressure from affected area.
2.
Cleanse with Normal Saline, pat dry.
3.
Apply Hydrogel (Intrasite) to open area and cover with foam dressing (Mepilex, Allevyn) daily and
PRN, d/c when healed.
4.
Assess affected area with treatments for changes, and/or signs and symptoms of infection.
5.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
6.
Document appearance and measurements initially and weekly.
7.
Notify provider of any wound that has not changed in status in 2 weeks for re-evaluation.
Stage IV – With Moderate to Heavy Exudates
1.
Relieve pressure from affected area.
2.
Cleanse with Normal Saline, pat dry.
3.
Cover with Calcium Alginate product (Algisite), cover with foam dressing (Mepilex, Allevyn) daily and PRN, secure with paper tape, and d/c when healed.
4.
Assess affected area with treatments for changes, and/or signs and symptoms of infection.
5.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
6.
Document appearance and measurements initially and weekly.
7.
Notify provider of any wound that has not changed in status in 2 weeks for re-evaluation.
Additional Recommendations:
Stage IV – Dry to Light Exudates – If slough or eschar are visualized, apply Santyl in place of
Hydrogel
Stage IV – With Moderate to Heavy Exudates – If slough or eschar are visualized, apply Santyl prior to calcium alginate
If tunneling and undermining are present, pack wound loosely with Calcium Alginate pad or rope
Use ABD pad instead of foam dressing for copious drainage
10/29/10

SUSPECTED DEEP TISSUE INJURY (UNSTAGEABLE)
Deep Tissue Injury – Closed with Eschar in Non-Mucous Membrane Area
1.
Relieve pressure from affected area.
2.
Apply Skin Prep BID, d/c when healed.
3.
Assess affected area q shift for changes, and/or signs and symptoms of infection.
4.
Notify physician, responsible party, therapy and registered dietician. Document notifications.
5.
Document appearance and measurements initially and weekly.
6.
Notify provider when eschar’s perimeter separates from surrounding tissue.
7.
Notify provider of any wound that has not changed in status in 2 weeks for re-evaluation.
Deep Tissue Innjury – Open Area, Dry to Light Exudates
1.
Relieve pressure from affected area.
2.
Cleanse with Normal Saline, pat dry.
3.
Apply Santyl, cover with foam dressing daily and PRN.
4.
Assess affected area with treatments for changes, and/or signs and symptoms of infection.
5.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
6.
Document appearance and measurements initially and weekly.
7.
Notify provider of any wound that has not changed in status in 2 weeks for re-evaluation.
Suspected Deep Tissue Injury
1.
Relieve pressure from affected area. (If area involves heels, off-load heels.)
2.
Assess resident for pain related to presence of wound and wound treatment. Notify MD if order for treatment needed.
3.
Avoid topical agents until would has fully evolved, eschar is present, and/or drainage is present.
4.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
5.
Assess for change DAILY. Document appearance and measurements initially and DAILY.
6.
Notify provider of any wound that has not changed in status in 2 weeks for re-evaluation.
Additional Recommendations:
Use ABD pad instead of foam dressing for copious drainage
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SKIN TEAR, ABRASION, LACERATION
Abrasion/Skin Tear, Without Flap
1.
Assess for resident for pain related to presence of wound and wound treatment. Notify MD if order for treatment needed.
2. Cleanse wound with Normal Saline using cotton tipped applicator, pat dry with dry gauze.
3. Apply Bacitracin Ointment, cover with dry sterile dressing daily and PRN, d/c when healed.
4. Assess area with treatments for changes, and/or signs and symptoms of infection.
5. Notify provider, responsible party, therapy and registered dietician. Document notifications.
6. Document appearance and measurements initially and weekly.
7. Notify provider of any wound that has not changed in status in 2 weeks for re-evaluation.
Skin Tear/Shallow Laceration, With Skin Flap, No Tissue Loss
1. Assess for resident for pain related to presence of wound and wound treatment. Notify MD if order for treatment needed.
2.
Cleanse wound with Normal Saline using cotton tipped applicator, pat dry with dry gauze.
3.
Use cotton tipped applicator, moistened with Normal Saline, to gently roll flap back into place and approximate edges.
4.
Pat dry with dry gauze.
5.
Apply Steri-Strips to approximate edges.
6.
Assess area with treatments for changes, and/or signs and symptoms of infection.
7.
Notify provider, responsible party, therapy and registered dietician. Document notifications.
8.
Document appearance and measurements initially and weekly.
9.
Notify provider of any wound that has not changed in status in 2 weeks for re-evaluation.
Partial Tissue Flap Loss/Complete Tissue Flap Loss
1. Assess resident for pain related to presence of wound and wound treatment. Notify MD if order for
treatment needed.
2. Cleanse wound with Normal Saline using cotton tipped applicator, pat dry with dry gauze.
3. Use cotton tipped applicator, moistened with Normal Saline, to gently roll flap back into place and
approximate edges (partial flap loss only).
4. Pat dry with dry gauze.
5. Apply primary dressing:
Partial Thickness – Apply Oil Emulsion Gauze (ex. Adaptic)
Full Thickness – Apply Hydrogel Sheet or Cellulose (ex. Aquacell)
6. Cover with non-bordered foam dressing and secure with Stretch Gauze and tape. Do not apply
adhesives to “AT RISK” skin.
7. Assess area with treatments for changes, and/or signs and symptoms of infection.
8. Notify provider, responsible party, therapy and registered dietician. Document notifications.
9. Document appearance and measurements initially and weekly.
10. Notify provider of any wound that has not changed in status in 2 weeks for re-evaluation.
10/29/10