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| A Stage IV pressure ulcer involves muscle, bone, or supporting structures. Undermining or sinus tracts may also be present. |
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| Goals of Care: Restore skin integrity and avoid infection. |
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| Wound and Skin Care Objectives: Protect intact periwound skin, cleanse wound, manage wound exudate, debride wound, hydrate wound, manage wound odor, and fill in dead space. |
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| EXUDATE? DRY WOUND? NECROTIC? ODOR? DEPTH OR UNDERMINING? PERIWOUND SKIN AT RISK OR IMPAIRED? |
| Protect intact skin: Skin protectant, skin sealant, skin cleanser, transparent film, thin hydrocolloid, skin barrier, heel and elbow protectors |
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| Cleanse wound: Wound cleanser |
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Manage wound exudate:
- Minimal: transparent film, thin hydrocolloid, thin foam, absorptive gauze
- Moderate: hydrocolloid, foam, calcium alginate, collagen, absorptive gauze
- Heavy: calcium alginate, foam, absorptive gauze, combinations of dressings, wound beads, pastes or powders
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Debride wound:
- Dry: transparent film, hydrogel, moist saline gauze, hydrating impregnated gauze
- Moist/wet: hydrocolloid, foam, calcium alginate, absorptive gauze
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| Hydrate wound: Hydrogel, hydrating impregnated gauze, moist saline gauze |
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| Manage wound odor: Wound cleanser, odor absorbent dressing, room deodorizer, more frequent dressing changes, antimicrobial topical agent |
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| Fill in dead space: Calcium alginate, hydrating or absorptive gauze, moist saline gauze, foam cavity dressing, wound beads, pastes or powders, collagen |
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| HOLLISTER PRODUCTS FOR IMPROVED OUTCOMES |
Skin Care
- Restore Cleanser & Moisturizer
- Hollister Skin Cleanser
- Restore DimethiCreme
- Hollister Skin Conditioning Creme
- Hollister Moisture Barrier Ointment
- Hollister Skin Gel
- Premium Skin Barrier
- Flextend Skin Barrier
- EpiFlex Heel and Elbow Protectors
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Wound Care
- Restore Wound Cleanser
- Restore Plus Hydrocolloid
- Restore Hydrogel (gel, sponge, packing strip)
- Restore CalciCare Calcium Alginate
- Hollister Odor-Absorbent Dressing
- Hollister Deodorizer Germicide
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