STAGE 1 PRESSURE ULCER
Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area differs in characteristics such as thickness and temperature compared to adjacent tissue. Stage 1 may be difficult to detect in individuals with dark skin tones. It may indicate “at risk” persons (a heralding sign of risk).
OPTION 1: If the wound is on a pressure point or extremity
Barrier ointment: Medline Remedy® Phytoplex™ Z-Guard® (Apply with each episode)
Optifoam® or Optifoam® Genite (q 1-7 days depending on drainage)
OPTION 2: If the wound is on an extremity in a miction area
Transparent dressing: Suresite® (q 1-7 days)
OPTION 3: If the wound is on the buttocks and may become soiled by incontinence
Second generation barrier cream: Medline Remedy® Phytoplex™ Z-Guard® (Apply with each episode)
Sureprep® No-Sting (Apply with each episode)
OPTION 4: If the wound is on any pressure point, high friction area, or is exposed to moisture
Liquid cyanoacrylate technology: Marathon® Liquid Skin protectant (q 1-3 days. Reapply as needed)
Stage 2 Pressure Ulcer
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
OPTION 1: If the wound is on a pressure point or extremity
Barrier ointment: Medline Remedy® Phytoplex™ Z-Guard® (Apply with each episode)
Optifoam® or Optifoam® Genite (q 1-7 days depending on drainage)
OPTION 2: If the wound is on an extremity in a miction area
Transparent dressing: Suresite® (q 1-7 days)
OPTION 3: If the wound is on the buttocks and may become soiled by incontinence
Second generation barrier cream: Medline Remedy® Phytoplex™ Z-Guard® (Apply with each episode)
Sureprep® No-Sting (Apply with each episode)
OPTION 4: If the wound is on any pressure point, high friction area, or is exposed to moisture
Liquid cyanoacrylate technology: Marathon® Liquid Skin protectant (q 1-3 days. Reapply as needed)
STAGE 3 PRESSURE ULCER
A stage 3 pressure ulcer represents a more severe level of skin and tissue damage compared to stages 1 and 2. It is characterized by full-thickness skin loss, potentially extending into the underlying tissue.
OPTION 1: If the wound is on a pressure point or extremity
Barrier ointment: Medline Remedy® Phytoplex™ Z-Guard® (Apply with each episode)
Optifoam® or Optifoam® Genite (q 1-7 days depending on drainage)
OPTION 2: If the wound is on an extremity in a miction area
Transparent dressing: Suresite® (q 1-7 days)
OPTION 3: If the wound is on the buttocks and may become soiled by incontinence
Second generation barrier cream: Medline Remedy® Phytoplex™ Z-Guard® (Apply with each episode)
Sureprep® No-Sting (Apply with each episode)
OPTION 4: If the wound is on any pressure point, high friction area, or is exposed to moisture
Liquid cyanoacrylate technology: Marathon® Liquid Skin protectant (q 1-3 days. Reapply as needed)
STAGE 4 PRESSURE ULCER
A stage 4 pressure ulcer is the most severe form of pressure injury, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle.
Full-Thickness Tissue Loss: This stage involves the complete loss of skin and extensive destruction of deeper tissues, extending down to muscle, bone, or supporting structures like tendons or joint capsules.
OPTION 1: If the wound is on a pressure point or extremity
Barrier ointment: Medline Remedy® Phytoplex™ Z-Guard® (Apply with each episode)
Optifoam® or Optifoam® Genite (q 1-7 days depending on drainage)
OPTION 2: If the wound is on an extremity in a high miction area
Transparent dressing: Suresite® (q 1-7 days)
OPTION 3: If the wound is on the buttocks and may become soiled by incontinence
Second generation barrier cream: Medline Remedy® Phytoplex™ Z-Guard® (Apply with each episode)
Sureprep® No-Sting (Apply with each episode)
OPTION 4: If the wound is on any pressure point, high friction area, or is exposed to moisture
Liquid cyanoacrylate technology: Marathon® Liquid Skin protectant (q 1-3 days. Reapply as needed)
