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I have a question about a pressure ulcer. When a stage 1 opens to a stage 2, do you measure the entire area-even the stage 1 area or just the open area that is now open??
(I hope I explained this right!)
Measure the entire area. Since stg 1 is nonblanchable redness, stg 2 is an open area.
Measure wound using the clock method; measure the redness surrounding, because this
could open up even further since the tissue is already damaged. Describe your wound, is
the wound bed moist or dry, does it have slough, if so , what color? Does it have drainage: what color
and how much? Dont forget the depth of the wound and also if odor is present or absent.
The entire wound is now classified as a stg 2. Charting well is drawing a picture of what you
see. Hope this helps
Hmm, I measure the open area, and the surrounding, stage one separately. For example length 5cm, width 4cm, depth 4cm. The peri skin is reddened and intact measuring 2cm around the wound.
It is possible that the open area can heal, while the reddened skin remains the the same. If that happened you could have charting reading width reading 6cm, for weeks, while in reality the open area is now only 2cm, with 4cm of reddened peri skin.
Thanks guys! We are having some disputes about what is what. Our "wound nurse" only measures the open areas and not the nonblanchable areas so measurements are not correct. She is also reverse staging pressure ulcers as they heal. Which I was taught NOT to do.