Pressure Ulcer, Stages 3 and 4

Clinical Protocol Title & Number: Pressure Ulcer – Treatment of Stage 3 and 4 - #6356 Section: Provider of Choice Clinical Service Area/Dept.: Patient Services Profession/Discipline: Nursing Principle Title & Number: Professional Practice #6300 Approved By: Vice President, Patient Services Approval Date: August 2003 Effective Date: August 2003 Review/Revisions:

Implementation Considerations: 1. Assess cause of the pressure ulcer and initiate interventions to eliminate underlying cause such as pressure off loading, nutrition, education, etc. 2. Following principles of wound healing applied: a) Moist wound healing b) Preserve optimal temperature for healing c) Microbial load d) Wound bed preparation – surgical debridement performed by a physician may be needed. e) Adequate nutrition - dietician consultation 3. Ensure adequate pain control during dressing change. 4. Selection of dressing appropriate to the amount of drainage balances the moisture in the wound and prevents skin maceration (refer to the implementation process). 5. Protect wound edges of highly exuding wound with skin protectants such as: Zinc oxide, skin-prep, no-sting film spray, hydrocolloid. 6. Consider using montgomery ties or hydrocolloid under the tapes to protect the skin for high exuding wounds requiring frequent dressing changes. 7. If infection is suspected, clean wound with normal saline and send a wound swab for C&S. 8. If infection is confirmed, notify physician for possible antibiotic therapy. 9. If wound drainage is copious, consider a wound pouch to contain the drainage. 10. Refer to VAC protocol if VAC dressing is indicated. 11. Doctor’s order is required for any topical antibacterial or antiseptic dressings such as Acticoat or Cadexomer iodine (refer to guidelines for acticoat, and iodosorb) respectively. 12. Ensure proper circulation to area before initiating moist wound healing especially in perpherial vascular disease. ABI is recommended or toe pressures in know diabetics.

Written Consent Required: Yes_____No 

© Pressure Ulcer – Treatment of Stage 3 and 4 Page 1 of 4 Implementation Process: Wound assessment: 1. Depth of the wound at deepest part 2. Width and length at longest points and perpendicular to each other. 3. Wound bed: granulating tissue, slough 4. Odour 5. amount of exudate 6. color of the drainage 7. presence of fistula /sinus opening 8. Condition of the surrounding skin of the wound

Clean/irrigate wound with normal saline to remove the loose slough, debris, residual materials such as hydrogel, threads from the previous dressing, and drainage.

Use a 35cc syringe and an Irrigation 18-gauge needle/angiocath, Or 100 ml amp of NS - 6” away from the wound.

Swab for C&S to rule out infection with sudden increase in exudate

Very Heavy drainage Moderate drainage None to minimal drainage: Heavy Pack wound with Pack wound with either Pack wound with one of the drainage either: one of the following: following: or fistula  hydrofiber  hydrofiber  Saline soaked gauze Use a  foam cavity  foam cavity/foam  Hydrogel impregnated wound  Sodium  Saline soaked gauze. drainage chloride gauze. pouch to impregnated Secondary dressing: collect gauze. Secondary dressing: 4x4 dry gauze or abdominal drainage. Foam or abdominal pad pad. Secondary dressing: If wound is shallow: Foam or Cover with either © Pressure Ulcerabdominal – Treatment pad of Stage 3 and 4 hydrocolloidPage 2 ofor 4transparent film dressing. Definition: Wound healing by secondary intention: An open wound healing is achieved by having the granulating tissues gradually filling in from the base of the wound.

Teaching: 1. Patient education regarding the general cleanliness around the wound dressing. 2. Patient education around home care

Documentation: 1. Progress note/24-hr patient record 2. Wound progress flow sheet

Quality Monitoring: Chart audit

References:

Ballard, K; Baxter, H (2000). Developments in wound care for difficult to manage wounds. British Journal of Nursing 9 (7) pg. 405 – 412.

Hadcock, J. L. (2000). The development of a standardized approach to wound care in ICU. British Journal of Nursing 9 (10) pg. 614 – 624.

Harding K. Cutting K. Price P. (2000). The cost-effectiveness of wound management protocols of care. British Journal of Nursing, 9(19 Tissue Viability Supplement).

Krasner, Diane et al (2001) Chronic Wound Care: A clinical source book for health care professionals.

Parker, L. (2000) Applying the principles of infection control to wound care. British Journal of Nursing 9(7). pg. 394 – 404.

Perry, A. G. & Potter, P. A. (2002). Clinical Nursing Skills & Techniques (5th Edition).

Russell, L. (2000). Understanding physiology of wound healing and how dressings help. British Journal of Nursing 9(1). pg. 10 – 21.

905 Wound Management Protocols, Skin Care Committee, 2003.