Any wound nurses out there?


  • Specializes in Long Term Care, Pediatrics. Has 1 years experience.

We have a patient who recently developed a stage 1 pressure ulcer: the skin was intact, pinkish grey and slightly mushy. My nursing interventions were foam boots to decrease pressure on her heel and keep pressure off by off loading lower extremeties. Then I went home. The next nurse put medi honey and duoderm on the wound to debride it. The next day when I came back, the medi honey and duoderm were gone and the skin was no longer intact. It showed no s/s of infection, so I cleaned it and put on a tegraderm.

I went home and researched and only found that you don't debride eschar tissue on a heel, otherwise, everything I read said that a pressure ulcer should be debrided.

But...I was thinking that as long as the skin is intact, it's protecting her from infection, right?

Any wound nurses out there? What am I missing? Should I be debriding all stage 1's?


131 Posts

Specializes in ER, LTC, IHS. Has 4 years experience.

A stage one is only red skin, nothing to debride as far as I know


147 Posts

No, you should not be debriding Stage 1--anywhere on the body. And you should also not be debriding any unstageable's on the heels--you are getting into very merky waters there, I have seen them down to the bone once they open up on their own. So, you were correct in floating the heels and trying to offload pressure. But they should be left alone entirely if the skin is intact, Stage 1 or Unstageable or Deep Tissue Injury. They are very difficult to heal, thus opening them up creates problems and some will resolve themselves on their own. I am not a WOCN, but do work very closely with the WOCNs in my practice, and have never seen them attempt to debride a Stage One or open up any heel eschar, and have always been told to leave that tissue to do it's own thing.

tewdles, RN

3,156 Posts

Specializes in PICU, NICU, L&D, Public Health, Hospice. Has 31 years experience.

It is generally not a good idea to advance a stage 1 intentionally, IMHO.

Specializes in LTC. Has 18 years experience.

Wound doc when I was still a student: "What do you do when you see eschar that's intact? LEAVE IT ALONE. Eschar is Mother Nature's dressing."

Not to say your wound had any eschar, as it was a stage one heel which was merely gray and mushy. I have no idea what the other nurse was thinking by doing anything but floating the heel and moisturizing the intact skin. Perhaps he/she thought the MediHoney would prevent infection, but again, intact skin does a fine job doing that on its own.

Nope, you didn't miss a thing. I like to put extra protective cream on higher risk skin.

Too bad you now have an open wound to deal with. :uhoh3:


683 Posts

Specializes in Geriatrics, WCC.

Never debride on the heels. That is what i was taught by an WOCN. Use only dry dressings for protection and keep pressure off.