Description: Unstageable pressure ulcer; 6.0 x 3.2cm; depth undetermined 2' to approximately 50% wound base with yellow/brown/purple necrotic tissue. Wound edges well defined, attached, without evidence of tunneling or undermining - even with wound base. Peri-wound erythema, edema & induration - moderate amount of serosanguinous drainage - no odor. Treatment recommendations: Surgical "cross-hatching" or conservative sharp debridement combined with enzymatic debridement.
Sample wound care recommendations: Cleanse wound with Normal Saline Solution (NSS), pat dry. Apply "skin prep" to peri-wound. Apply collagenase to wound base, cover with Polymem Max, afix with transparent dressing. Change dressing daily and PRN for strike through drainage, soiled or displaced bandage.
