Page 23 - Wound Care at End of Life Content: A Guide for Hospice Professionals - DEMO

WOUND TREATMENT GRID: Pressure Ulcers Stage 1 & 2
Wound Care Need Pressure Ulcer Stage 1 or 2 Comments
Description Stage 1: Localized reddened area, non‐ Stage 1 may be difficult to detect in
blanchable patients with darker skin tones
Stage 2: Partial thickness loss of dermis,
open/broken blister
Cleanse Normal saline or commercial wound cleanser Irrigate using 4‐15 psi:
 Spray bottle: 1.2 psi (inadequate)
 Piston syringe: 4.2 psi
 Squeeze bottle with irrigation cap: 4.5 psi
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 35 mL syringe and 18 gauge needle: 8 psi
o Proper sharps precautions required if
using this method
Debridement Stage 1 or 2: N/A No debridement necessary
Dressing Stage 1: Moisturizer, barrier ointment or  Protect periwound area with a skin
cream. barrier film if an adhesive is used
Transparent film, thin hydrocolloid, foam.  Do not use hydrocolloid if infection is
present
Stage 2: Barrier ointment, Xenaderm® or
Granulex®, alginate
Transparent film, thin hydrocolloid, foam
Contact layer to protect wound bed
Infection Stage 1: N/A See Antimicrobials on Wound Care
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Stage 2: Products chart, page 42.
 Honey May treat empirically.
 Mupirocin (Bactroban®) ointment •MRSA: cadexomer iodine, mupirocin
 Silver dressing ointment, silver dressing
 Antiseptics* •Pseudomonas: acetic acid 0.25%, topical
Use topical antibiotic ≤ 14 days to reduce gentamicin
colonization • VRE: hydrofera blue (PVA+methylene
blue+gentian violet), silver dressing
*Rinse wound bed with normal saline after •MSSA: cadexomer iodine, chlorhexidine,
using any antiseptic cleanser to minimize hydrofera blue, mupirocin, silver
2
toxic effects of the antiseptic. dressing
Malodor Stage 1: N/A  Wound cleansing & debridement aid
Stage 2: odor control
 Metronidazole crushed tabs (Flagyl®) to  Change dressing more often to manage
wound bed with dressing changes; use gel odor and/or exudate.
(Metrogel®) only if wound bed is dry  Hydrocolloid dressings tend to create
 Charcoal dressings odor (doesn't mean infection is present)
 Honey  Environmental strategies:
 Cleanse with ½ strength (0.25%) sodium  In room: kitty litter, vanilla extract,
hypochlorite (Dakin’s® 0.25%) coffee grounds, dryer sheets
 Change hydrocolloid dressing every 24‐48  On dressing: essential oils
hours. (wintergreen or lavender)
Dead Space N/A N/A
Pruritus Not usually associated with wound, assess If patient reports pruritus, evaluate for
surrounding skin. contact dermatitis, hypersensitivity, or
yeast dermatitis

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