Gluteal Wounds

verdeacres · Mar 15, 2016

I am not a wound nurse but am looking into getting certified through one of the programs. Staging wounds is a tricky business and there seems to be a lot of subjectivity in it. I was shadowing several wound care nurses and they commented on how suddenly one of the nurses staged a wound and how the change can look poorly on the hospital as it looks like the patient received it while being there. It definitely is worth following up so that the patient gets proper care but also, the history of the injury is correct.

TallRN,WCC · Mar 16, 2016

Hi smith. It sounds to me like the nurse who did the initial assessment did not document correctly. If the wound is indeed pressure related, it should have been staged, measured and described at the time of assessment. It is not really okay to just document, "wound" well is it a stab wound? A laceration? A surgical wound? Etc. Sounds like the next nurse determined it was pressure related. Let me give you an easy run down of how to stage pressure ulcers.

Stage 1- A non blanching red area, that does not go away. Usually over a bony prominence.

Stage 2- The 3 P's! Pink, Partial, Painful! Stage 2 wounds are partial thickness and often resemble a very shallow ulcer with a reddish-pink wound bed. NO SLOUGH. If there is slough present, it must be staged as a Stage 3.

Stage 3- Full thickness wound. This is why there is slough in the wound bed. These wounds may have undermining and tunneling but there is NO muscle, tendon or bone exposed. If there is, it should be documented as a Stage 4.

Stage4- Full thickness tissue loss with exposes bone, muscle or tendon. It usually will have slough or eschar as well. These wounds can tunnel and undermine as well.

Unstageable- These wounds are completely covered with eschar or slough and the wound bed is not visible. For this reason, you cannot stage them because you don't know what is under all that gunk!

I hope this helps!