Pressure Ulcer Staging Wound Classification Chart PDF

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Summary

A chart describing how to stage pressure ulcers...

Description

Birkenhead & Wallasey Primary Care Trust

Treatment choice without a cavity

Treatment choice with a cavity

Wound Classification Chart Necrotic

Sloughy

Granulating

Epithelialising

Infected

Debride Remove Eschar

Remove slough Provide clean base for granulation tissue

Promote granulation Provide healthy base for epithelialisation

Promote epithelialisation and wound maturation

Manage infection

Primary & Secondary dressing

Primary & Secondary dressing

Primary & Secondary dressing

Primary & Secondary dressing

Primary & Secondary dressing

Fungating Malodorous

Manage complex wound e.g. bleeding, exudates, malodour, size, site

Primary & Secondary dressing

Low exudate

Hydrogel: Aquaform, Nu-gel

Hydrogel / Hydrocolloid Comfeel Duoderm

Hydrogel Hydrocolloid Foam as appropriate (1)

Not Applicable / cavity Hydrocolloid

Consider Systemic Treatment & Culture Swab Hydrocolloid Foam (1)

Medium exudate

Hydrofibre Aquacel Hydrocolloid: Comfeel, Duoderm

Cavity Filler Hydrofibre Hydrocolloid or Versiva Foam: Tielle; Biatain; Alione (1)

Hydrofibre: Aquacel, Versiva Foam Alione, Biatain or Tielle (1)

Not applicable

Aquacel AG (2) & secondary dressing Foam Hydrocolloid

Cavity Filler / carboflex Consider size location skin protectant

High exudate

Aquacel Versiva Foam (1) Likely to be mixed environment

Aquacel Ribbon Versiva. Foam

Hydrofibre: Aquacel, Versiva Foam Alione, Biatain or Tielle (1)

Not Applicable

Aquacel AG (2) & secondary dressing Skin protectant

As above Large Foam Padding Mesorb / Telfa Max

Low exudate

Hydrogel: Aquaform, Nu-Gel

Hydrocolloid Comfeel PT(3) Duoderm

Hydrocolloid: Comfeel, Duoderm Foam: Lite versions (1)

Atrauman – venous leg ulcer Hydrocolloid. Comfeel PT Post-op/ Minor lesions Cosmopore E

Consider systemic treatment & Culture swab Actisorb 220

Topical / systemic treatment Metronidazole Actisorb 220 Varying clinical & anatomical presentations

Medium exudate

Hydrocolloid Hydrofibre as above Alione

Hydrocolloid: Comfeel, Duoderm Versiva Foam: Alione, Biatain, Tielle(1)

Aquacel / Hydrocolloid Versiva Foam Tielle Biatain Alione (1)

Atrauman Venous LU Aquacel / Versiva Foam (1)

Aquacel AG (2) & secondary dressing Foam protect skin

Actisorb 220 / Carboflex

High exudate

Likely to be mixed wound bed Hydrofibre Hydrocolloid

Hydrofibre Versiva / Alione Foam: as above (1)

High exudate should not occur in clean granulating wounds

Should not occur in clean epithelialising wounds

Aquacel AG (2) & secondary dressing Mesorb / Telfa Max

Carboflex Padding Mesorb Telfa Max Skin protectant

Consider topical treatment i.e. Metronidazole Gel & cavity filler

This is a guide and should not replace clinical judgement. 1. Foam dressings possess varying fluid handling capacity please consult manufacturers instructions e.g. “Lite, Plus” 2. The use of antimicrobial / silver dressings should be limited to a maximum of 4 weeks, as the clinical picture indicates. 3 Comfeel Plus Transparent For further information please consult local trust protocols / guidelines or Ian Mansell / Maria Hughes Tissue Viability Nurse 0151-643-5329

Wound Classification Chart

Birkenhead & Wallasey Primary Care Trust

This is a guide and should not replace clinical judgement. 1. Foam dressings possess varying fluid handling capacity please consult manufacturers instructions e.g. “Lite, Plus” 2. The use of antimicrobial / silver dressings should be limited to a maximum of 4 weeks, as the clinical picture indicates. 3 Comfeel Plus Transparent For further information please consult local trust protocols / guidelines or Ian Mansell / Maria Hughes Tissue Viability Nurse 0151-643-5329...