Pressure Ulcer Management

Pressure Ulcer Management

Stage I Pressure Ulcer

■ No dressing required. ■ Prevent continued injury from pressure or shearing forces. ■ Assess frequently.

Stage II Pressure Ulcer

■ Use 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 moist environment.

Stage III Pressure Ulcer

■ Same as stage II treatment plus débride eschar, necrotic tissue. ■ Note: Heel ulcers with dry eschar and no edema, erythema, or drainage may not need to be débrided. ■ Débridement 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 Ulcer

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