Guide for Unstageable Pressure Ulcers in Hospice Care

As a hospice nurse, caregiver, or agency manager, it is essential to understand the proper management and treatment of unstageable pressure ulcers. This guide will provide up-to-date information, best practices, and valuable tips for treating these complex wounds.

Hospice nurse helping patient with Unstageable Pressure Ulcers

Understanding Unstageable Pressure Ulcers

Definition:¬†Unstageable pressure ulcers are characterized by full-thickness skin and muscle loss, with slough or eschar obstructing the wound bed. This makes it impossible to determine the true depth of the ulcer. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels is the body’s natural cover and should not be removed.

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Goals of Unstageable Pressure Ulcer Management

  1. Maintain bacterial balance: Prevent infection by keeping the wound clean and maintaining a healthy bacterial environment.
  2. Manage exudates or keep the wound moist: Optimize the wound environment to promote healing and prevent tissue damage.
  3. Attempt to prevent further tissue damage: Ensure proper pressure redistribution and offloading to minimize the risk of worsening the ulcer.

Unstageable Pressure Ulcer Treatment in Hospice Care

Always obtain a physician’s order before proceeding with treatment. The following steps are general guidelines for treating unstageable pressure ulcers:

  1. Use Standard Precautions: Wear appropriate personal protective equipment (PPE) to minimize the risk of infection.
  2. Clean the wound with Normal Saline or a Dermal Wound Cleanser for infected wounds (follow manufacturer instructions).
  3. Pat the wound dry gently.
  4. Apply skin prep to wound edges to protect the surrounding skin.
  5. Add moisture using a hydrogel to maintain a moist wound environment.
  6. Apply a foam dressing (examples include Polymem or Allevyn) to manage exudate and provide cushioning.
  7. Change the dressing every 3-7 days or per the physician’s orders.
  8. For heels, apply skin prep or betadine to protect the skin.
  9. Document the wound assessment and treatment per agency protocol.
Hospice nurse helping patient with Unstageable Pressure Ulcers

Monitoring and Reporting Unstageable Pressure Ulcers in Hospice

Monitoring the wound closely and reporting any changes to the primary physician is crucial. Notify the physician if you observe:

  • Odor
  • Necrotic tissue
  • Increase in exudate
  • Change in exudate color
  • Increase in redness, swelling, warmth, or pain

Remember, you must visualize the wound bed to stage the wound accurately. If the wound bed is not visible, the wound is considered “Unstageable due to necrotic tissue.” However, if you can visualize bone, tendon, or muscle in any part of the wound, report it to the physician.

Additional Tips for Hospice Agency Managers

  1. Ensure proper training: Regularly update your team’s knowledge and skills in pressure ulcer management through workshops, seminars, or online hospice courses.
  2. Implement a pressure ulcer prevention program: Educate staff on the risk factors, early identification, and preventive measures for pressure ulcers.
  3. Utilize a multidisciplinary approach: Collaborate with physicians, wound care specialists, and other healthcare professionals to ensure the best possible care for patients with unstageable pressure ulcers.
  4. Evaluate and update protocols: Regularly assess and update your agency’s wound care protocols to ensure they align with current best practices.

Managing unstageable pressure ulcers is a challenging but essential aspect of hospice care. By following the guidelines and best practices outlined in this guide, your hospice care team can ensure the optimal care and management of these complex wounds. 

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