Pressure Sore Management

Pressure Sore Management

Stage I Pressure Sore
■ No dressing required.
■ Prevent continued injury from pressure or shearing forces.
■ Assess frequently.

Stage II Pressure Sore
■ Use a dressing that will keep ulcer bed continuously moist.
■ Keep surrounding intact skin dry.
■ Fill wound dead space with loosely packed dressing material to absorb excess drainage and maintain a moist environment.

Stage III Pressure Sore
■ Same as Stage II treatment plus debride eschar, necrotic tissue.
■ Note: Heel ulcers with dry eschar and no edema, erythema, or drainage may not need to be debrided.
■ Debridement may be done surgically, with enzymatic agents, or mechanically with wet-to-dry dressings, water jets, or whirlpool.
■ Do not use topical antiseptics.

Stage IV Pressure Sore
■ Same as Stages II and III plus remove all dead tissue, explore undermined areas and remove the skin “roof.”
■ Use clean, dry dressings for 8–24 hours after sharp debridement to control bleeding, then resume moist dressings.

Common Dressings for Pressure Sores

Transparent Dressings  (Stage I and II Pressure Sores):
■ Waterproof; maintains moisture and prevents bacterial contamination.
■ For superficial wounds, blisters, and skin tears.

Hydrogel Dressings (Stage II, III, and IV Pressure Sores):
■ Provides moist wound environment. Reduces pain and soothes.
■ For dry, sloughy wound beds; cleanses and debrides.

Hydrocolloid Dressings (Stage II and III Pressure Sores):
■ For autolytic debridement of dry, sloughy, or necrotic wounds.
■ For wounds with low to moderate amounts of exudate.

Alginate Dressings (Stage III and IV Pressure Sores):
■ Available in pads, ropes, or ribbons.
■ For wounds with moderate to heavy amounts of exudate.

Foam Dressings (Stage III and IV Pressure Sores):
■ Highly absorbent; may be left on for 3–4 days before changing.
■ For wounds with heavy exudate, deep cavities, weeping ulcers.
■ Used after debridement or desloughing of pressure sores.