Quote from doglvr
Speaking of documenting wounds, I have a question. I'm a new nurse and have been on orientation for a few weeks. My preceptor was helping me get my patient washed up and we both noticed what I thought was a small early stage 2 on the patient's sacral area. My preceptor however called it shearing. I questioned her twice about it, and then figured okay, well she's been a nurse for over 20 years and I've only been a nurse for a month so she obviously knows what she's talking about and called it shearing in my documentation. Now I'm starting to worry because I realized what I did was wrong. Maybe I'm freaking out, but if the patient's family takes anyone to court it will be me, because I documented and signed all the paper work, not my preceptor. God I feel so bad for the patient. And I'm so scared. How would you define "shearing"? Please help! Thank you!!!!!!!!!!
what your preceptor referred to, was 'how' the lesion occured...
shearing forces is when the skin lifts up as the sheets/surface area goes down.
whenever you see a break in tissue integrity, you note its characteristics.
etiology (which preceptor is stating is shearing) isn't known unless it's directly observed.
we can hypothesize that it's r/t pressure, shearing, malnutrition, bony prominences, and intervene accordingly, but what is important, is what you see.
if there was a break in the skin, it's a stage II and warrants treatment.