HHC Health & Home Care Clinical Policy And

HHC HEALTH & HOME CARE Section: 7-5
Skin Care: Pressure Ulcer - Treatment of Stage III __RN
PURPOSE:
To identify dressing and treatment modality options for
Stage III pressure ulcers.
CONSIDERATIONS:
1. Obtain physician’s order for all treatment and
cleansing agents.
2. Normal saline is an acceptable agent for cleansing
pressure ulcers.
3. Use clean technique.
4. Topical treatment options for Stage III pressure
ulcers include:
a. Composite, hydrocolloid, hydrogel-impregnated,
foam, amorphous hydrogel, enhanced gauze,
moist packing gauze dressings for wounds with
light to moderate exudate and no necrosis.
b. Alginate, exudate absorbing, foam cavity,
enhanced gauze, and gauze moistened with
prescribed solution or hydrogel dressings for
wounds with moderate to heavy exudate, some
necrosis, and dead space.
5. Additional therapy modalities include:
a. Electrical stimulation.
b. Nutritional support.
c. Hyperbaric oxygen therapy
d. Support surface.
e Pulsed lavage.
f. Negative Pressure therapy
g. Ultrasound
6. When a pressure ulcer is covered with eschar, it
may not be possible to stage the ulcer accurately as
Stage III or Stage IV. (See Scoring of Eschar, No.
7.19.)
7. Continue to follow procedures for prevention and
assessment of pressure ulcers. (See Pressure
Ulcer-Prevention, No. 7.01 and Pressure Ulcer-
Assessment, No. 7.02.)
8. Certified wound consult may be indicated.
OPTION I
Topical Treatment with Dressings
(See Dressing Changes, No. 7.09.)
OPTION II
Debridement of Necrotic Tissue
CONSIDERATIONS:
1. Debridement is the removal of dead or devitalized
tissue. Sharp, mechanical, enzymatic, and/or
autolytic debridement techniques may be used for
removal of devitalized tissue per physician’s orders.
CWCN can assist in identifying appropriate wound
care products.
a. Sharp debridement involves the use of a
scalpel, scissors, or other sharp instrument to
remove the devitalized tissue. Health & Home
Care CHNs do not perform sharp
debridement in the home.
b. Mechanical debridement includes wet-to-dry
dressings, hydrotherapy, wound irrigation, and
dextranomers (fillers).
(1) Dextranomers can only be used on exuding
wounds.
(2) It is important to irrigate away all
dextranomer before reapplying.
c. Enzymatic debridement is accomplished by
applying topical proteolytic enzymes to
devitalized tissue on the wound surface.
(1) Enzymes break down necrotic tissue
without affecting viable tissue.
(2) A physician’s order and prescription are
required for use of these products.
(3) Follow manufacturer’s guidelines when
using enzymes.
d. Autolytic debridement involves the use of
synthetic dressings to cover a wound and allow
devitalized tissue to self-digest from enzymes
normally present in wound fluids.
(1) Use transparent film or hydrocolloid wafer
dressings or hydrogel to promote autolysis
in superficial wounds.
(2) Use calcium alginates and exudateabsorptive
dressings, which absorb many
times their weight, to promote autolysis.
(3) Do not use autolytic debridement if the
wound is infected.
2. Heel ulcers with dry eschar should not be debrided
if they do not have edema, erythema, fluctuance, or
drainage.
3. Pain is often associated with debridement. Use
appropriate methods to prevent or manage pain.
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