Is the injury over a bony prominence

or under a medical device?

NOYES

Intact skin with non-blanchable redness .

The area may be painful, firm, soft, warmer or cooler

compared to adjacent tissue

Presents as a shallow open ulcer with a red

pink wound bed without slough. Could

be an intact or ruptured blister.

Subcutaneous fat may be visible. Some

slough present. May include tunneling. No

bone, tendon or muscle is visible.

Exposed bone, tendon or muscle.

Slough or eschar may be present. Often

include undermining or tunneling

Presence of slough or eschar at the base obscuring the true

depth . Stage cannot be determined. May be yellow, tan, gray,

green, brown or black.

Purple or maroon localized area of

discolored intact skin or blood blisters.

Assess wound stage Implement treatment

Stag

e I

Stag

e II

Stag

e III

Stag

e IV

Uns

tage

able

Deep

Tiss

ue In

jury

•Identify wound etiology •Apply dressing based on wound characteristics •Consult wound care if needed

•Cover & protect : Consider product that will maintain moist wound environment and control exudate •Hydrate if wound is dry: Consider ordering wound gel •Prevent friction and shear: Every shift inspect areas such as elbows, scapulas, sacrum and heels •Control moisture from incontinence •Place an order to turn patient q2h and consult dietitian if intake is poor •Notify attending physician GOAL: Promote re-epithelialization. Should heal in 5-14 days.

•Protect & moisturize when covering is contraindicated •Apply transparent dressing, foam or hydrocolloid if not contraindicated •Place an order to turn patient q2h and consult dietitian if diet intake is poor •Notify attending physician GOAL: Prevention of skin breakdown. Should resolve in 2-5 days.

•Consult wound care team •In the interim, cover and protect with normal saline moistened gauze & dry dressing to secure •Order specialty bed and consult dietitian if nutrition is poor •Place an order to turn patient q2h GOAL: Protect and provide clean, moist wound healing environment. May require surgical intervention.

•Consult wound care team •In the interim, cover and protect with normal saline moistened gauze & dry dressing to secure •Order specialty bed and consult dietitian if nutrition is poor •Place an order to turn patient q2h GOAL: Protect and provide clean moist wound healing environment. May require surgical intervention.

•Consult wound care team •In the interim, cover and protect with normal saline moistened gauze & dry dressing to secure. •Order specialty bed and consult dietitian if nutrition is poor •Place an order to turn patient q2h GOAL: Protect tissue from further deterioration . May require surgical intervention.

•Consult wound care team •In the interim, cover and protect with foam, or hydrocolloid dressing •Order specialty bed and consult dietitian if nutrition is poor •Place an order to turn patient q2h GOAL: Protect tissue from further deterioration. Once pressure is off loaded, may take 3-4 days to determine extent of injury.