Assess for signs of pressure injury.

Stage 1

Stage 2, stage 3, or stage 4

End

Remediate other factors, if possible.

Wash gently with warm water or commercial skin cleanser, pat dry.

Remove area from pressure sources.

Assess other contributing factors to break in skin integrity.

Choose type of ulcer treatment. (Add moisture, remove moisture, use antibacterial, fill cavity, support autolysis of debris, totally occlude, partially occlude?)

Choose method of debridement (Surgical or nonsurgical).

Choose care for periwond skin. (keep dry, use protective barrier, avoid adhesives?)

Choose a dressing. (Primary with separate secondary, combination?) Initiate and maintain pressure preventive measures and remediation of any other contributing factors, if possible.

Regularly reassess effectiveness of interventions.

Irrigate wound bed with normal saline solution or ordered solution. Wash around wound bed with normal saline solution; pat dry.

Assess color, odor, and amount of drainage on old dressing.

Assess ulcer color, length, width, depth, and drainage.

Assess for necrotic areas.

Assess skin around wound. (Is it intact, macerated, inflamed, tunneled?)