How to Treat a Stage 3 Pressure Ulcer

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Definition

  • Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to but not through the underlying fascia
  • Bone/tendon is not visible or directly palpable
  • Presents as deep crater with or without undermining of adjacent tissue

Goal

  • Remove necrotic tissue
  • Maintain bacterial balance
  • Manage exudates or keep wound moist

Treatment

Obtain a physician order:

  1. Use Standard Precautions
  2. Clean wound with Normal Saline or with a Dermal Wound Cleanser for infected wounds. (Follow manufacturer instructions if using a Dermal Wound Cleanser.)
  3. Pat dry
  4. To add moisture: hydrogel (such as saf-gel)
  5. Apply foam (examples include Polymem or Allevyn) dressing (also see Wound Care -Deep Dry and Deep Wet Wounds for more information)
  6. Change every 3-7 days
  7. Document per agency protocol

Mattress Recommendation

  • Air Powered System – collaborate with your team manager

Notes

You must be able to visualize the wound bed in order to stage the wound. If you cannot see the wound bed, the wound is considered not able to be staged and is documented “Unstageable due to necrotic tissue.” Monitor for and notify MD for odor, necrotic tissue, increase in exudates, and change in color of exudates, an increase in redness, swelling, warmth or pain.

 

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

 

 

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