Page 25 - Wound Care at End of Life Content: A Guide for Hospice Professionals - DEMO

WOUND TREATMENT GRID: Pressure Ulcers Stage 3 & 4
Wound Care Need Pressure Ulcer Stage 3 or 4 Comments
Description Stage 3: Full thickness ulcer with Stage 3 and 4 ulcers have highest infection
subcutaneous tissue visible risk
Stage 4: Full thickness ulcer with exposed Osteomyelitis risk if bone is exposed
muscle, tendon, and/or bone
Cleanse Normal saline, commercial wound cleanser, Irrigate with 4‐15 psi to remove debris.
*antiseptics: acetic acid 0.25%, chlorhexidine,  Spray bottle: 1.2 psi (inadequate)
hydrogen peroxide, povidone‐iodine  Piston syringe: 4.2 psi
(Betadine®), ½ strength sodium hypochlorite  Squeeze bottle with irrigation cap: 4.5 psi 1
(Dakin’s solution 0.25%)  35 mL syringe and 18 gauge needle: 8 psi
o Proper sharps precautions required if using
this method
*Rinse wound bed with normal saline after
using any antiseptic cleanser to avoid toxic
effects.
Debridement •Autolytic: transparent dressing, hydrocolloid,  See Debridement Algorithm
alginate; hydrogel if wound is dry.  Silver inactivates collagenase; do not use
•Chemical: collagenase (Santyl®) (change 1‐2 silver dressing and collagenase together.
times per day); Full‐strength sodium  Only leave full‐strength Dakin’s® solution
hypochlorite (Dakin’s® solution, 0.5%) 5 in contact with wound bed if intent is
applied to gauze and packed in wound debridement.
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• Biosurgical: Larval therapy
Dressing Hydrocolloid (do not use if infection is  Protect periwound area with a skin
present), alginate, foam barrier film if an adhesive is used
Contact layer to protect wound bed.
Infection  Silver dressing See Antimicrobials on Wound Care Products
 Honey chart, page 42.
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 Antiseptics May treat empirically.
 Cleanse with ½ strength sodium •MRSA: cadexomer iodine, silver dressing
•Pseudomonas: acetic acid
hypochlorite (Dakin’s® solution0.25%), then
rinse with normal saline • VRE: hydrofera blue, silver dressing
 Use topical antibiotics ≤ 14 days to reduce • MSSA: cadexomer iodine, chlorhexidine,
colonization hydrofera blue, silver dressing
*Rinse wound bed with normal saline after
using any antiseptic cleanser to minimize
toxic effects
Malodor  Metronidazole crushed tabs (Flagyl®) to  Wound cleansing & debridement aid in
wound bed with dressing changes; use gel odor control
(Metrogel®) only if wound bed is dry  Change dressing more often to manage
 Charcoal dressing odor and/or exudate
 Honey  Hydrocolloid dressings tend to create odor
 Cleanse with ½ strength Dakin’s® solution, (doesn't mean infection is present)
then rinse with normal saline  Do not use hydrocolloid if infection is
 Change hydrocolloid dressing every 24‐48 present
hours.  Environmental strategies:
 In room: kitty litter, vanilla extract,
coffee grounds, dryer sheets
 On dressing: essential oils
(wintergreen or lavender)
Dead Space Alginate roping; foam; wound fillers; collagen; Dressing materials placed into open wounds
hydrogel to eliminate dead space, absorb exudate, or
maintain moisture
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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