Pressure Ulcers

Stage II

no eschar or slough; skin loss involving epidermis, dermis, or both; ulcer is superficial and presents as abrasion, blister, or shallow crater

hydrogel dressings

partial and full thickness with light exudate; water or glycerin-based sheet to allow packing into wounds; wounds with necrosis or slough; deep crater wounds, tunneling; *don't use on infected wounds

calcium alginate dressing

partial and full-thickness with moderate to heavy exudate; good for really bad wounds; absorbs heavy amounts of exudate; maintains wound surface moist; necrotic tissue wounds, wounds with undermining or sinus tracts; USE WITH INFECTED WOUNDS; excellent for packing

hydrocolloid dressings

partial thickness STAGE II and shallow full thickness STAGE III with light to moderate exudate; impermeable to O2 (may promote anaerobic growth); contraindicated for infected wounds; wounds with necrosis or slough

polyurethane foam

partial thickness stage II to full thickness stage III; absorbent and non-adhering to wound edge; may be used with infected wounds; may be used with topical agents

Suspected deep tissue injury

purple localized area of discolored intact skin or blood-filled blister that rapidly exposes additional layers of injured tissue; pressure develops in deep tissue and works its way up.

Unstageable pressure ulcer

full-thickness loss in which the base is covered by slough or eschar that interferes with staging

Stage IV

down into muscle and possibly into the bone; skin loss with extensive destruction, tissue necrosis, or damage to bone, muscle, or supporting structures; may have undermining and sinus tracts

Stage I

falls under partial thickness; red and non-blanchable; skin is intact but has non-blanchable erythema

transparent film

use for partial thickness wounds; permeable to oxygen and water vapor but is waterproof; provides moist environment; transparent to assess wound; don't use on infected wounds *stage I or II with little to no exudate

Stage III

will have scar and have permanent damage; skin loss involving damage to or necrosis of sub-Q tissue; may extend down to, but not through underlying tissue; presents as deep crater; may or may not have undermining