Stage II - Interruption of epidermis, dermis, or both.
- Presents as abrasion, blister, or very shallow crater.
| - Use dressing that will keep ulcer bed moist.
- Keep surrounding intact skin dry.
- Fill wound dead space with loosely packed dressing to absorb excess drainage and maintain moist environment.
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Stage III - Full-thickness crater.
- Involves damage and/or necrosis down to, but not penetrating, fascia.
| - Same as stage II plus debride eschar and necrotic tissue.
- Note: Heel ulcers with dry eschar and no edema, erythema, or drainage may not need to be debrided.
- Debridement may be done surgically, with enzymatic agents, or mechanically with wet-to-dry dressings, water jets, or whirlpool. Do not use topical antiseptics.
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Stage IV - Full-thickness crater.
- Similar to stage III, but penetrates fascia and involves muscle and bone.
- May involve undermining.
| - Same as stages II and III plus remove all dead tissue, explore undermined areas, and remove skin "roof."
- Use clean, dry dressings for 8-24 hr after sharp debridement to control bleeding; then resume moist dressings.
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