Is this an unstageable ulcer?

[coltonk1234]

New to HHC so not used to staging and choosing my own treatment plan for patients until I get a doctors order. I'm pretty sure this would be a unstageable d/t the yellow. I'm realizing now I maybe should have put calcium alginate or something. She has a very clear stage 2 a little lower. I cleaned and I put barrier cream and a sacral border foam dressing that covered both. I realized when I went to go do my charting that this may not have been the best treatment plan, better than nothing, but what do you think?

[Tenebrae, BSN, RN]

Its hard to tell until you get rid of the slough. The size of it would make me think stage 2 with a layer of slough/biofilm

I love iodosorb for  autolytic debridgement, it comes in a sheet with gauze each side but you can pull off a piece and make it fit the wound. Can stay on for 2-3 days. 

Minor downers, it can be intially quite warm when first applied to the wound, but it settled within an hour or so. And if the patient is allergice to iodine, then don't use . hydrosorb also works on the same principle. Probably not as effective but doesnt have iodine. 

https://www.hauoratairawhiti.org.nz/assets/Uploads/Pressure-Injury-Grading-Chart-April-2019.pdf This is what I use for staging a pressure injury

[vampiregirl, BSN, RN]

I would agree this is unstageable:) The slough completely obscures the wound bed.

Pressure injuries are either over a bony prominence or caused by pressure from a medical device/ something else. 

It takes time to consistently accurately stage pressure injuries and sometimes it isn't easy.

Treatment plans depend on agency policies - I encourage you to be familiar with yours as well as your scope of practice. For example - I can not apply anything beyond a dry dressing for protection without orders for HH patients where I work. For hospice patients, our medical director has some basic standing orders for wound care while we await further orders. 

Effective wound care treatment plans address moisture management in a wound bed to promote healing/ repair. Too dry or too moist won't heal well. Calcium alginate absorbs drainage so it is typically used with wounds with higher exudate.

Different agencies may also have formularies. If yours does, take time to learn about the products available so you are using them to their best potential. Most of us have our favorite products. 

Any effective wound care treatment plans also include non-pharmacological interventions. Education to promote skin integrity - avoiding pressure, shearing etc. Offloading pressure. Nutritional status. Patient/ caregiver education on how other co-morbidities affect the wound. It also depends on patient goals and patient/ caregiver abilities.