Questionnaire/history:

Location? Category/Stage?

- I: Nonblanchable Erythema?

- II: Partial Thickness Skin Loss?

- III: Full Thickness Skin Loss?

- IV: Full Thickness Tissue Loss?

- Unstageable: Depth Unknown?

- Suspected Deep Tissue Injury: Depth Unknown?

Size?

Tissue type(s)?

Color?

Periwound condition?

Wound edges?

Sinus tracts?

Undermining?

Tunneling?

Exudate?

Oodor?

Pain?

Management:

Risk of developing a pressure ulcer: position change at least every 6 hours

Hight risk of developing a pressure ulcer:

- Position change at least every 4 hours

- High-specification foam mattress

- Barrier preparation (eg 3M™ Cavilon™)

- Prophylactic dressings with polyurethane foam dressing to bony prominences

Cleanse most pressure ulcers with potable water (i.e., water suitable for drinking) or normal saline

Debride devitalized tissue within the wound bed or edge of pressure ulcers when appropriate to the individual’s condition and consistent with overall goals of care

Debride the wound bed when the presence of biofilm is suspected or confirmed

Dressings:

Hydrocolloid: clean stage II or shallow stage III pressure ulcers in body areas where they will not roll or melt

Transparent Film: as a secondary dressing for pressure ulcers treated with alginates or other wound filler that will likely remain in the ulcer bed for an extended period of time (eg 3-5 days)

Hydrogel: shallow,minimally exuding pressure ulcers

Alginate: moderately and heavily exuding pressure ulcers

Foam: exuding stage II and shallow stage III pressure ulcers

Silver-Impregnated: pressure ulcers that are clinically infected or heavily colonized

Honey Impregnated: stage II and III pressure ulcers

Cadexomer Iodine: moderately to highly exuding pressure ulcers

Gauze: when other forms of moisture-retentive dressing not available

Silicone: prevention of periwound tissue injury when periwound tissue is fragile or friable

Collagen Matrix: nonhealing stage III and IV pressure ulcers

Resource(s):

European Pressures Ulcer Advisory Panel (EPUAP): Prevention and Treatment of Pressure Ulcers: Quick Reference Guide

NICE CG179: Pressure ulcers: prevention and management