Wound Care Plan

Pressure Injury – (Unstageable) – Shepparton Retirement Village

Last Updated
05 July 2025
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Quick Overview

Reference ID Number: SRV-WCP-11

Categories

Pressure Injury

Scope of Practice (ScOP) Designation

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

Treatment Goals

To stop wet necrosis (gangrene) setting in and sepsis occuring

Aim of Dressing

To dry out the tissue that has become boggy and is non-viable

Frequency of Dressing Change

Everyday

References

Shopping List

Dressing Pack (Small),Iodine (100ml) (AKA Betadine),Adhesive Allevyn – (10cm X 10CM) – Shepparton Retirement Village
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

    Necrotic heel

    Where a pressure injury has progressed where the tissue has become non-viable and has dried out and the depth of the injury is unknown.

     Swipe 
    Step 1

    Prepare Sterile Field

    Prepare your sterile field and sterile
    Products Used
    Step 2

    Clean the affected area very well

    Clean the heel very well. You will need to touch the necrotic tissue and move it to see what is currently attached to healthy tissue and if there is any undermining
    Products Used
    Step 3

    Allow to dry

    Allow the iodine to dry (5min) and then re-apply.
    Products Used
    Step 4

    Keep open to the air

    If possible do not put a dressing on. If the necrotic tissue forms a complete cap on the heel then leaving it open will allow it to dry faster. If there is open tissue then place a zetuvit or mepilex border over the affected area
    Products Used
    Step 5

    Raise the heels off the matress

    Call and order a heel elevator
    Products Used
    Step 6

    Repeat and recheck

    Repeat the painting of the area until the area is stable and no sign of moisture can be seen. Recheck area at each shift change.
    Products Used

    Necrotic Scapula/Sacrum

    Where a pressure injury has progressed where the tissue has become non-viable and has dried out and the depth of the injury is unknown.

     Swipe 
    Step 1

    Prepare Sterile Field

    Prepare your sterile field and sterile
    Products Used
    Step 2

    Clean the affected area very well

    Clean the heel very well. You will need to touch the necrotic tissue and move it to see what is currently attached to healthy tissue and if there is any undermining
    Products Used
    Step 3

    Allow to dry

    Allow the iodine to dry (5min) and then re-apply.
    Products Used
    Step 4

    Keep open to the air

    If possible do not put a dressing on. If the necrotic tissue forms a complete cap on the heel then leaving it open will allow it to dry faster. If there is open tissue then place a zetuvit or mepilex border over the affected area
    Products Used
    Step 5

    Raise the heels off the matress

    Call and order a heel elevator
    Products Used
    Step 6

    Repeat and recheck

    Repeat the painting of the area until the area is stable and no sign of moisture can be seen. Recheck area at each shift change.
    Products Used