Page 179 - Clinical Managers Orientation Binder

4/11/2019

Pressure Ulcer/Injury Unstageable

 Full thickness tissue loss

 Base of the ulcer is covered by slough
and/or eschar

 Re Stage the ulcer after debridement
NPUAP 2016

Incontinence Associated Skin Damage

Inflammation of the skin associated with exposure to
leaked urine or stool

Goal - Prevention
 Cleanse perineal skin after each incontinent episode
and daily with a no rinse cleanser close to 5.5 ph
 Avoid urea, glycerin, alpha hydroxyl acids and lactic
acid products- add too much moisture to the skin.
 3 in 1 products/sprays that cleanse/moisturize and
have skin protectant properties
 Fecal- requires skin protectant ointment
/paste/dimethicone, liquid clear barrier film,
petroleum, zinc oxide.

Wound,Ostomy and Continence Nurses Society, Continence
Committee
Incontinence Associated Dermatitis , Best Practice for Clinicians.
Wound Ostomy Continence Nurses Society.2011; pp 6-9.

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