Unstageable Wounds (A Pressure Ulcer Stage)

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Definition

  • Full thickness skin, muscle loss with slough and/or eschar present in the base of the pressure ulcer, preventing you to see the true depth of the ulcer.
  • Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

Goals

  • Maintain bacterial balance
  • Manage exudates or keep wound moist
  • Attempt to prevent further tissue damage

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 to wound edges
  5. To add moisture: hydrogel
  6. Apply foam (examples include Polymem or Allevyn)
  7. Change every 3-7 days
  8. For heels, apply skin prep or betadine
  9. Document per agency protocol

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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