How to Treat a Stage 4 Pressure Ulcer

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Definition

  • Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle bone, or supporting structures
  • Exposed bone, tendon or muscle
  • Slough or eschar can be present on some parts of the wound
  • Undermining and sinus tract may be present

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. Apply skin prep or barrier cream to wound edges (thin layer)
  5. To add moisture: hydrogel
  6. Apply foam (examples include Polymem or Allevyn) Dressing (also see Wound Care-Deep Dry and Deep Wet Wounds for more information)
  7. Change every 3-7 days
  8. Document per agency protocol

Mattress Recommendation

  • Air Powered System – consult 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.” An exception to this is if you can visualize bone, tendon or muscle in any part of the wound. 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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