Confused

[smithand]

Hello,

I am having some issues with my skin assessments. We have a patient with gluteal wounds, on the first skin assessment nurses just describe it as wound. " patient with wound on his left gluteal fold. Now they are describing it as pressure "pressure ulcer of right gluteal fold, stage 3." Can wound change to pressure ulcer?.

Thank you for your time and help

Smith

[BSN-to-MSN, ADN, BSN, RN]

No, the pressure ulcer can change to a wound. Pressure ulcers are stage 1,2,3,4. First stage is closed, a non-wound, but starting at stage 2 it can be called a wound. Usually, if something is charted as a pressure ulcer, it has to have a stage number next to it.

[BSN-to-MSN, ADN, BSN, RN]

Look up pressure ulcer staging to get an idea.

[mtjoanna]

The facility that I have just left does not allow the floor nurses to declare whether a wound is a pressure ulcer or not. We are to describe its size, shape, location and characteristics, but only the DON is allowed to state whether it's a pressure ulcer. Typically, if the resident comes to the facility with it, she's fine with calling it a pressure ulcer, but if it develops under our care (which doesn't actually happen often--a miracle with how short-staffed we've been), it's never a pressure ulcer.

[Adele_Michal7, ASN, RN]

From my understanding where I work, whoever does the initial assessment- does the best they can do with their knowledge base. Then when the wound care nurse goes to do THEIR assessment, they determine if the initial assessment was on target or if it needs to be re-classified. For example- an I.A. that states a wound is a stage 2; but the WCN declares it a sDTI. Does that help?