Charting Wounds

Go to www.npuap.org

There is lots of helpful information on staging wounds on this site. We used it to revamp our wound care policy and protocols..

We use a wound classification chart written by one of the NHS trusts in the UK. I love it because it gives a protocol for for treatment as well.

Wound Classification Chart

Thanks for that one,Sharrie.I've printed that one off.Looks really useful.

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!!!!!!!!!!

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.

leslie

We aren't allowed to document the size of a wound or stage ulcers. When we find something that we are concerned about we can put in a consult with the wound nurse and she does all of those things. She also starts a treatment plan, does the dressing changes, and takes pictures during the initial assessment and during treatment.

We are only able to say where it is and what it looks like (red, black, drainage, smell, etc.). I was told it is done this way because everyone classifies the wounds or stages the ulcers differently and one person may say it's a stage 2 while someone else stages it a 3.

I am an inactive nurse, however, I wanted to ask what is your line of report? You did report it to the preceptor. I would think that you would just chart what you observed and noted. Also, say that preceptor was notified. Always chart who you report to. As an LPN, I would chart that I reported to unit RN. Also, I would put them down on list for dr. consult for whatever reason. We learned in nursing school not to chart stages, however, in the facility that I worked at, we did stage them. However, I do agree that staging is quite subjective.

And, don't beat yourself up over this. We all learn through our mistakes, and we all make them. Especially being new, you will have a lot of learning. What we learn along the way makes us better nurses. And, someday you may be able to pass all of your knowledge on to a newbie.:wink2:

Just remember to CYA by documenting everything!

Thanks for resonding! You all are the best!

Without a doubt there was an open wound, which is which I thought it was a stage 2. I did document the shearing it in the skin/wound assessment and there was a picture of a body and I circled the sacral area on the picture. I guess when I think of shearing I do think of a break in skin, but not really an open wound which is what my patient had. And to be honest, it's not like this patient is going to get better any time soon as I work in the ICU and it seems like everyday when I go into work she gets worse and worse.

I don't know what to do now. I just wanted to cover my butt, but I guess it's too late for that.