Wound Care Plan

Pressure Injury – (Stage 4)

Last Updated
05 July 2025
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Quick Overview

Reference ID Number: TWS-WCP-81

Categories

Pressure Injury

Scope of Practice (ScOP) Designation

Medical Officer,Registered Nurse (RN),Enrolled Nurse (EN)

Treatment Goals

Minimise further pressure the the heel area whilst aiding granulation tissue to occur

Aim of Dressing

Provide a moist wound bed environment whilst protecting the skin's integrity. By raising and supporting the heels this will reduce the chances of further insult to the area.

Frequency of Dressing Change

3 Days(s) Min - 5 Days (Max)

Consult(s) / Diagnostic Test Required

Wound Care expert

References

Shopping List

Dressing Pack (Small),Normal Saline,Aquacel Ribbon (2cm x 45cm),Zetuvit Plus (10cm x 10cm),Hypafix (5cm x 10m),Heel Elevator (ILS)
Page Table of Contents

    Product Selection Disclaimer:

    The wound care products being currently used are a suggestion ONLY. They do not take into account your patient's individual needs which you must assess. No funding from medical companies has been provided and wound care products are chosen on their merit and what is available on the NSW Health State Wound Care Contract. Where an exact brand name product is not available we suggest you review the alternative tab or use another wound care product from its category eg. Hydrofibre

    Photo Gallery

    Care Plans

    Stage 4 Heel Pressure Injury

    Where the heel has suffered a pressure injury and there has been complete dermal tissue loss with the injury extending into the subcutaneous structures and down into bone

     Swipe 
    Step 1

    Setup sterile field

    Setup your sterile field with all your sterile products
    Products Used
    Step 2

    Clean the wound bed

    Clean the wound gently to agitate the wound bed
    Products Used
    Step 3

    Apply aquacel ribbon

    Gently pack the wound with the aquacel ribbon. You can slightly overpack the wound cavity as the hydrofibre will shrink
    Products Used
    Step 4

    Apply Heel dressing

    When applying the dressing minimise any creases
    Products Used
    Step 5

    Secure

    Assess the skin. If there is good skin turgor use tape if not use an appropriately sized tubular dressing
    Products Used
    Step 6

    Elevate the heels

    Obtain a heel elevator from ILS
    Products Used
    Step 6

    Recheck

    Recheck area at shift handover
    Products Used

    Stage 4 Scapula/Sacrum Pressure Injury

    Where the scapula/Sacrum has suffered a pressure injury and there has been complete dermal tissue loss with the injury extending into the subcutaneous structures and down into bone

     Swipe 
    Step 1

    Setup sterile field

    Setup your sterile field with all your sterile products
    Products Used
    Step 2

    Clean the wound bed

    Clean the wound gently to agitate the wound bed
    Products Used
    Step 3

    Apply aquacel

    Gently pack the wound with the aquacel. You can slightly overpack the wound cavity as the hydrofibre will shrink
    Products Used
    Step 4

    Apply Scapula/sacral dressing

    When applying the dressing minimise any creases
    Products Used
    Step 5

    Secure

    Assess the skin. If there is good skin turgor use tape if not use an appropriately sized tubular dressing
    Products Used
    Step 6

    Elevate the heels

    Obtain a heel elevator from ILS
    Products Used
    Step 7

    Recheck area

    Recheck the pressure injury at shift handover
    Products Used