Page 28 - Wound Care at End of Life Content: A Guide for Hospice Professionals - DEMO

WOUND TREATMENT GRID: Stable Eschar
Wound Care Need Stable Eschar Comments
Description Thick, leathery, black or brown crust; Stable eschar is defined as firmly adherent,
nonviable tissue, colonized with bacteria hard, non‐infected and dry
Cleanse Paint with antiseptic solution, e.g. Leave open to air
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povidone‐iodine (Betadine®)
Debridement Do not debride stable eschar (non‐ See Debridement Algorithm
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infected, dry)
Dressing If on heel, paint with povidone‐iodine
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(Betadine®) and leave open to air
Infection Not considered stable if signs of infection
present
Malodor If there’s odor, it’s probably not stable.
Dead Space N/A Cannot be determined if eschar is present.
Pruritus Not usually associated with wound, assess If patient reports pruritus, evaluate for
surrounding skin. contact dermatitis, hypersensitivity, or yeast
dermatitis
Bleeding Not considered stable if bleeding is
present
Support Surface Varies by wound location. •Group 1: Static. Mattress, pressure pad or
If on heel: elevate calves on longitudinal overlay
pillows, thereby "floating the heels"; static •Group 2: Dynamic. Powered air flotation
heel boots or foam boots‐‐not “Moon beds & pressure reducing air mattress, non‐
Boots” powered advanced pressure reducing
mattress
•Group 3: Dynamic. Air‐fluidized bed
Pain Medicate with appropriate agent for
anxiety and/or for pain.
 Neuropathic pain (burning, stabbing,
stinging, shooting pain): tricyclic
antidepressant, anticonvulsant
 Nociceptive pain (gnawing, throbbing,
tenderness): opioid or corticosteroid

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