ClearChoice PRESSURE ULCER GUIDELINES FOR - Elta.Net

ClearChoice PRESSURE ULCER GUIDELINES FOR TOPICAL TREATMENT
The following are suggested guidelines for treatment of pressure ulcers using Swiss-American Products’ Clear Choice formulary and are intended
to supplement facility protocols and may be incorporated into the facility’s specific plan of care for treatment of pressure ulcers. Be sure to
refer to your facility’s pressure management protocols & Risk Assessment Tool! ClearChoice Clinical
Support is available. Call our 24-hour desk at 1-800-224-0646 to request a consult.
Pressure Ulcer Wound Depth Wound Description Treatment & Frequency Rationale
Stage 1
(Partial Thickness)
Stage II
(Partial Thickness)
Stage III - IV
(Full Thickness/Deep
Tissue Injury/DTI)
Note: If necrotic tissue
is present, refer ttissue
No visible depth
Blister-small amount of
fluid contained
Blister-large amount of
fluid contained
Non-blanchable erythema or
boggy feel (fluctuance)
Note: If boggy feel or fluctuance
present, monitor for signs/symptoms
of Deep Tissue Injury (DTI)
Top layer of skin intact
Top layer of skin intact
Abrasion/shallow crater No to light exudate
Abrasion/shallow crater Moderate to heavy exudate
Shallow Depth No to light exudate
Stage III – IV (continued) Shallow Depth Moderate to heavy exudate
Cleanse area & pat dry. Apply Nuvase & gently rub into the area
2 x day.
–OR—
If friction & shear is a factor: Apply Askina Derm Transparent
Film Dressing- Change every 7 days or as necessary. Assess
daily.
Cover with protective dressing i.e. Elta Soft Touch
Composite Island Dressing-assess daily
–OR—
Askina Derm Transparent Film Dressing –assess daily,
change Q 5-7 days
Apply non-adherent non-bordered dressing to area, (depending
on location) secure with roll gauze. Change every 2-3 days.
Assess daily
B BraunThinSite hydrogel dressing- Change every 3-5 days or as
necessary
-OR-
Askina hydrocolloid Dressing - Change every 3-5 day or as
necessary
B BraunThinSite hydrogel dressing for more flexible areas.
Change every 3-5 days or as necessary.
-OR-
Askina Hydro hydrocolloid dressing. Change every 3-5 days or as
necessary.
-OR-
B Braun Transorbent hydrogel dressing. Change every 3-5 days
or as necessary
Infection MUST be ruled out; consult with MD or NP.
Apply B BraunThinSite hydrogel dressing for flexible areas.
Change every 3-5 days or as necessary
-OR-
Braun Transorbent hydrogel dressing. Change every 3-5 days
or as necessary.
B BraunTransorbent hydrogel dressing; Change every 2-3 days
or as necessary.
-OR-
Promote dermal & epidermal repair.
Protect area from friction & shear
Consider pillows and/or heel-lift
devices to properly “off-load”
pressure areas.
Epidermis is compromised & fragile;
fluid to be reabsorbed
If blister ruptures, wound bed will be
protected and drainage will be
contained.
Promotes moist wound healing
environment, protects wound bed
Promotes moist wound healing
environment, protects wound bed;
absorbs exudate
Promotes moist wound healing
environment, protects wound bed;
absorbs exudate.
Absorbs exudate

ClearChoice PRESSURE ULCER GUIDELINES FOR TOPICAL TREATMENT
The following are suggested guidelines for treatment of pressure ulcers using Swiss-American Products’ Clear Choice formulary and are intended
to supplement facility protocols and may be incorporated into the facility’s specific plan of care for treatment of pressure ulcers. Be sure to
refer to your facility’s pressure management protocols & Risk Assessment Tool! ClearChoice Clinical
Support is available. Call our 24-hour desk at 1-800-224-0646 to request a consult.
Pressure Ulcer Wound Depth Wound Description Treatment & Frequency
Askina Sorb calcium alginate, cover with Elta Soft Touch
Composite Island Dressing. Change every 1-2 days as necessary
Infection MUST be ruled out; consult with MD or NP.
Rationale
Stage III – IV (continued)
Moderate Depth No to light exudate
Stage III – IV (continued) Moderate Depth Moderate to heavy exudate
Stage III – IV (continued) Deep Crater No to light exudate
Stage III – IV (continued) Deep Crater Moderate to heavy exudate
Elta Dermal hydrogel impregnated gauze to wound bed, cover
with Elta Soft Touch Composite Island Dressing; Change daily or
as necessary
Askina Sorb calcium alginate dressing; if exudate is very heavy,
cover with Elta Soft-Touch Bordered Hydrophilic Foam Dressing.
Protect periwound area with Elta Seal zinc oxide moisture barrier
ointment. Change Change daily or as necessary.
--OR—
For malodorous or heavily draining wounds, apply dry hypertonic
sodium chloride-impregnated dressing to wound bed & cover with
Elta Soft-Touch Bordered Hydrophilic Foam Dressing. Change
daily or as necessary
Infection MUST be ruled out; consult with MD or NP.
Apply Elta Dermal Hydrogel, cover with Elta Soft Touch
Composite Island Dressing. Change daily or as necessary.
–OR—
Apply Hydrovase hydrogel, cover with Elta Soft Touch Composite
Island Dressing. Change daily or as necessary.
--OR—
Apply Elta Dermal Hydrogel-impregnated gauze to wound bed,
cover with Elta Soft Touch Composite Island Dressing.
Change every day or as necessary
Apply Askina Sorb calcium alginate, cover with Elta Soft Touch
Composite Island Dressing. Change daily.
–OR-
Apply Elta Seal zinc-oxide moisture barrier to protect peri-wound
skin from possible maceration. Apply Askina Sorb calcium
alginate to wound, cover with Elta Foam dressing. Change daily.
–OR-
For malodorous, heavily draining wounds, apply dry hypertonic
sodium chloride-impregnated dressing to wound bed & cover with
Elta Soft-Touch Bordered Hydrophilic Foam Dressing. Change
daily.
Infection MUST be ruled out; consult with MD or NP.
Donates moisture to wound bed,
Protects wound bed, Absorbs small
amount of exudate
Wicks and contains exudate.
Enhances autolytic debridement
Decreases inflammation.
Donates moisture to wound bed,
promotes moist wound healing
environment.
Wicks & absorbs exudate
Protects wound bed
Promotes moist wound healing
environment

ClearChoice PRESSURE ULCER GUIDELINES FOR TOPICAL TREATMENT
The following are suggested guidelines for treatment of pressure ulcers using Swiss-American Products’ Clear Choice formulary and are intended
to supplement facility protocols and may be incorporated into the facility’s specific plan of care for treatment of pressure ulcers. Be sure to
refer to your facility’s pressure management protocols & Risk Assessment Tool! ClearChoice Clinical
Support is available. Call our 24-hour desk at 1-800-224-0646 to request a consult.
Pressure Ulcer Wound Depth Wound Description Treatment & Frequency Rationale
Non-viable tissue
Stage III
Stage IV
Full Thickness
Non-viable tissue
Stage III
Stage IV
Full Thickness
Slough / Eschar (depth
unknown or to be
determined)
Stable eschar on an
arterial insufficiency
compromised limb (depth
unknown or to be
determined)
Infected Wounds Variable depth(s)
White, yellow or brown/black
appearance.
Note: Do not apply occlusive
dressings if infection is
present.
Note: Do not debride stable
eschar heel ulcers.
Stable (dry, intact) on arterial
insufficiency compromised limb
Moderate to heavy exudate; May
have purulent drainage, may be
foul smelling or may be a clean
wound that is unresponsive to
treatment
If the area is not infected and is dry, apply small amount of Elta
Hydrovase hydrogel and cover with B BraunThinSite hydrogel
dressing. Change every 2-3 days and as necessary. Assess daily.
-OR-
Utilize enzymatic debriding agent [RX], cover with gauze
dressing. Change daily.
-OR-
Sharp debridement (Performed by Qualified Clinician): Use
sterile instruments; assess pain, labs (PT/PTT as indicated) and
Circulatory status first.
Stable “heel ulcers with dry eschar need not be debrided if
they do not have edema, erythema, fluctuance, or drainage”
AHCPR/AHRQ Clinical Practice Guideline # 15 ”Treatment of
Pressure Ulcers” p. 49. Assess status of eschar daily. Keep area
dry and offloaded.
May protect wound with dry dressing and roll gauze. Do NOT
attempt debridement of ANY kind.
Assess wound and eschar status daily; if dressing used, change
as necessary
Physician involvement is essential for possible systemic
antibiotic therapy
DO NOT apply occlusive dressing. Monitor daily for signs and
symptoms of sepsis and worsening condition.
Consider two-week trial of topical antimicrobial treatment.
Change daily.
-OR-
For malodorous, heavily draining wounds, apply dry
hypertonic sodium chloride-impregnated dressing to wound
bed & cover with Elta Soft-Touch Bordered Hydrophilic
Foam Dressing. Change daily.
Autolysis promotes “self digestion”
of non-viable tissue.
Enzymatic agent promotes
sloughing of non-viable tissue and
clean wound bed
Sharp/Conservative debridement
must be done by a qualified
clinician.
Stable heel ulcers are usually not
debrided because the covering
provides protection to the heel.
Always offload heels, and debride
once the area becomes unstable,
pending circulation assessment.
No debridement should be
attempted without adequate
circulation for healing.
Do not use occlusive dressings on
infected wounds because they
promote growth of anaerobic
bacteria.
Please note: foam dressings are not
considered “offloading devices”-

General Wound Care Information:
ClearChoice PRESSURE ULCER GUIDELINES FOR TOPICAL TREATMENT
♦ FOR ALL PRESSURE ULCERS: DO NOT MASSAGE AFFECTED AREAS.
♦ Turn and reposition per facility protocol. Provide preventive and treatment surfaces per facility policy.
♦ Manage pain and prevent painful dressing changes. Promote analgesic and non-analgesic pain relief prior to
dressing changes.
♦ For wounds with moderate to heavy exudate: Apply Elta Seal moisture barrier cream or Elta Creme to periwound
tissue to protect fragile skin and prevent maceration
♦ Apply Elta Crème melting moisturizer to dry skin in all non-affected areas. This will provide prevention of further
skin breakdown.
♦ Cleanse all wounds with Elta Dermal Wound Cleanser. This product is non-cytotoxic and delivers a therapeutic
irrigation at a range of 4-8 psi.
♦ Please note: foam dressings are not considered “offloading devices”- please consider pillows and/or heel-lift
devices to properly “off-load” pressure areas.
♦ Date and initial all wound dressings with a permanent marker and document dressing changes appropriately per
facility policy.
♦ When performing a dressing change, utilize facility infection control guidelines with Standard Precautions. ♦ Reassess all wounds at least weekly and reassess the Risk Scale per facility policy.