How to Treat a Stage 2 Pressure Ulcer

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Definition

Partial thickness skin loss involving the dermis. May present as an open blister or shallow crater without slough or bruising. Stage 2 pressure ulcers happen because of pressure: therefore, the term/description stage 2 pressure ulcer should not be used to describe skin tears, tape burns, maceration, excoriation. Stage 2 Pressure Ulcers can show improvement within 1 – 2 weeks.

Goal

  • Maintain moist environment
  • Attempt to minimize causing factors

Treatment

Obtain a physician order:

  1. Use Standard Precautions
  2. Clean wound with Normal Saline or with Dermal Wound Cleanser for infected wounds
  3. Pat dry
  4. For blisters: cover with protective non adherent dressing
  5. For an open wound: apply thin film of wound gel (examples include saf-gel or Duo derm gel) and a thin hydrocolloid (Duo Derm Extra Thin) or foam dressing (PolyMem or Allevyn) (Also
  6. see Wound Care: Shallow Dry and Shallow Wet for more information)
  7. Change twice a week and/or PRN
  8. Document per agency guidelines

Mattress Recommendation

  • Foam /Gel Cushion for chair

* Note: These are wound care guidelines only. Consult with the primary physician for specific orders.

 

 

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