Is the injury over a bony prominence or under a medical device?

1. Is the injury over a bony prominence or under a medical device? •Identify wound etiology •Apply dressing based on wound characteristics •Consult wound care if needed NO YES Implement treatment Assess wound stage •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. Intact skin with non-blanchable redness . The area may be painful, firm, soft, warmer or cooler compared to adjacent tissue Stage I •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. Presents as a shallow open ulcer with a red pink wound bed without slough. Could be an intact or ruptured blister. Stage II Subcutaneous fat may be visible. Some slough present. May include tunneling. No bone, tendon or muscle is visible. •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. Stage III Exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining or tunneling •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. Stage IV Purple or maroon localized area of discolored intact skin or blood blisters. •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. Deep Tissue Injury 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. •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. Unstageable