Stage I Stage II Stage III Stage IV

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