Pressure ulcer stage 2..what would you use?

[seks]

When I see what I think is a stage 1 pressure ulcer, I would slap on a Coloplast comfeel dressing and make sure the pt is turned q2h. Correct me if there are better options.

If you see a stage 2 (skin tear, bleeding) on a pt, what would you use before the wound care nurse has a chance to see it and provide recommendations?

[jadelpn, LPN, EMT-B]

Per TOS we can not give medical advice. However, it is never prudent to slap anything on a pressure ulcer until the nurse has had a chance to look at it, assess it, document it--regardless of stage. There are protocols, there are MD orders. Unfortunetely, when one covers a pressure ulcer, the nurse then has to uncover it to document and assess--and it can cause even more skin distress. Some protocols also require wound mapping.

Eyes and ears are invaluable parts of patient care. When you find it, tell the wound nurse-it is not a great practice to treat then tell the wound nurse.

But now I see you are in fact a nurse. My apologies. Follow your protocol, always. Reimbursements are also tied to pressure ulcers. If you have a stage 2, then get an MD order for whatever it is they would like to treat it with--and I can't stress enough to check with the protocol.

[CWONgal]

There are a variety of factors that need to be considered w/ dressing selection. As a WOCN we do like to see the PU's because of incorrect staging and product selection (SDTI confused for stage I's, moisture associated dermatitis confused w/ stage II's, etc.). As Jadelpn said staging is tied into reimbursement and incorrect staging causes a lot of confusion in the medical record. We see film dressings over skin tears, multiple layered foam dressings, you name it. I like to go with the nurse to the bedside so I can teach and discuss why a particular dressing would be better than another.

[Selfie]

Ask your manager where to find the wound care protocol. Every facility is different, and there are different names/brands of dressings recommended/preferred for each type/stage of wound. Make a copy of the protocol to keep with you. When in doubt, or until protocol is in hand, I would ask the provider.

[CWONgal]

And the provider often says, "Whatever the WOCN recommends!"

[calivianya, BSN, RN]

We have some non adherent foam dressings (our brand is Allevyn) that are pretty good about not sticking to wound beds but do stick to healthy skin, so I like slapping those on anything that looks like it needs covering, regardless of the stage of the ulcer/tear. Not only do those cover the wound bed, but they also provide cushioning so I really like to use them over bony prominences. If there is nowhere that is healthy looking skin, like a large weeping patch of cellulitis that extends all the way down the leg or something, we have a nonadherent dressing that's a thin film (Mepitel), and I will put some of that over the wound bed and cover it in a dry dressing. If it's really that big, I'll probably need a full roll of gauze to cover it. When in doubt, nonadherent dressings are always the best IMO because you don't run as big a risk of damaging the wound further as you would with really sticky dressings or dry dressings.

I get the perspective of the people who say waiting for wound care would be best, but my facility only has wound care in the building from 8-5 during the week and if someone gets admitted at 6PM with a huge ulcer, I'm not leaving that to roll across the sheets and get damaged further all night just because wound care isn't there. Just saying - I'd rather put a dressing on and it not be the best kind for the patient than to leave a wound open to get even further damaged and contaminated.

I don't know who the psychopaths are who stick the clear transparent sticky dressings (Tegaderm) over skin tears, though. I have seen that happen. Doesn't anybody realize that anything that is super STICKY and sticks to the skin is just going to rip the skin tear open even further when you take it off?! I would really like to find the people who do that in the ED and then send the poor patients up to us to be ripped open... fortunately, that doesn't happen as often where I work now as it did where I used to work!

[CWONgal]

Alas, I must admit I am one of those w/ the M-F jobs. :) For the most part you are pretty safe doing the foam dressings. It'll keep the wound covered which is better than having it exposed. The foam dressings are generally easier on the skin as many of them are silicone based. They help primarily w/ shear/friction however due to the size it is presumed it displaces pressure slightly. I will say if the dressing gets soiled from incontinence you then need to look for another option. Also, no pastes beneath them. Or double foam (I've seen 2x2's mepilex over a wound and then the PUP dressing over the top. Be careful w/ hydrocolloids as they can roll/bunch easily and can cause more damage.

[joevi]

Were using 3rd soln

[dudette10, MSN, RN]

In addition to the wound care manual on the unit, some facilities will have "wound resource nurses" on each unit who were trained by the CWON for times when the CWON is not available. They are great to assist with first assessment and care until the CWON can take a look.

All the docs where I work, even attendings, defer to nurses for non-surgical wound care.

[AJJKRN]

New product (at least for my facility) called "Mepilex". Very possible that I just miss-spelled it but it is essentially a brown in color heart-shaped dressing that provides some padding/protection with some absorption that can be peeled back to look at the area and placed back multiple times until the dressing is soiled or has been used for a week (I think...). Really cool dressing that we just started using so so far so good when in stock!

retrieved from: https://directmedicalinc.com/direct/module/documents/Mepilex%20Border%20Sacrum%20Application%20guide.jpg

[anon456, BSN, RN]

New product (at least for my facility) called "Mepilex". Very possible that I just miss-spelled it but it is essentially a brown in color heart-shaped dressing that provides some padding/protection with some absorption that can be peeled back to look at the area and placed back multiple times until the dressing is soiled or has been used for a week (I think...). Really cool dressing that we just started using so so far so good when in stock!

retrieved from: https://directmedicalinc.com/direct/module/documents/Mepilex%20Border%20Sacrum%20Application%20guide.jpg

WE use that stuff and I love it! We also use it to pad areas that could potentially get a pressure ulcer like the edges of c-collars. I once used it with success on a very leaky, nasty looking g-tube. I cut a slit in it and put it around the tube and changed it about every 4 hours. Within a couple of days the site looked a lot better. It also served to stabilize the tube from moving so much so it allowed that site to heal and the hole to get smaller.

[K+MgSO4, BSN]

My wound nurses and professor of nursing research just published an article on preventive dressings in high risk pts in a critical care area. They usec mepilex sacrum and had some really good results. If I can find the aricle I will post a link givr me a day or 2 to find it.