Have you ever missed a pressure ulcer during assessment?

angel4gramma · Oct 14, 2008

Don't be so hard on yourself. Just use this as a lesson learned and make sure you do a full assess on everyone. I have learned to not believe everything in report and do my own assessment. I learned the hard way early in my career. :)

CHATSDALE · Oct 14, 2008

i liked angel's post, set standards for yourself you will never regret it

pressure ulcers can progress quickly because as has often been stated it is like an iceberg and the bottom is larger than the top a pressure ulcer can be a small spot and it can become larger in a very short time

ChristineN, BSN, RN · Oct 14, 2008

If she was young and in good health (ie eats well, repositions self) I probably wouldn't have even looked, might have asked her if there was an issue. Don't beat yourself up, it's a mistake any of us easily could have made.

hnt1987 · Oct 14, 2008

i see a lot of pressure ulcer around the buttock area in my clinical setting. Stupid hospital bed

TopazLover, BSN, RN · Oct 14, 2008

Depending on the surgery she may have been in one position for a long time. Sometimes these things seem to develop quickly. It is possible to miss one, especially early in the progression.

Like others have said, don't beat yourself up, just learn from it.

RNsRWe, ASN, RN · Oct 14, 2008

Several days ago I admitted a post-op lady from surgery (I work in med-surg). She was relatively young and looked in good health. I got no report of a pressure ulcer. So during my assesssment, I very quickly looked at her backside but not thoroughly. Anyway, several days later a nurse pulls me aside and says "You missed a pressure ulcer on your admission! Be careful!" I guess fortunately, another nurse found it a few shifts later. It was a Stage II and her entire bottom area was red. Today it looks much better. I feel like a moron for not catching it... and also because I just assumed. They all pointed their fingers back at me. (But of course the pre-op and surgery people get off). Have you ever missed one?? I'll feel better if you share your similar stories. =-)

Yup. Morbidly obese woman who could barely move in the bed for an assessment. You can only do so much!

lpnflorida, LPN · Oct 14, 2008

I would not be hard on yourself. You learned a valuable lesson. While I do head to toe examination of my patients. I will share the day I had little old frail thin lady. I had observed her entire body at the very beginning of the shift when she was in her bed. Two hours later her bell turned on, she was sitting in her unpadded wheelchair. She wanted to go to the bathroom, I was so surprised to now see a large area of red/unblanchable skin on her bottom. I know for a fact this was not there 2 hours earlier. I informed the RN who initiated pressure ulcer care plan. Of course I made sure that this patient was repositioned more frequently, dietitian called to go over her nutritional needs. There was no albumin level to go by at that time.

Seeing her pressure ulcer with my eyes, smacked me in the head and impressed it is no exaggeration when it is said a pressure ulcer can develop in a two hour time period. A padded seat cushion, ended up being used to relieve pressure. Pt got involved as did all other disciplines to help this person's skin. Fortunately as it was caught quickly, it never developed to stage 2 and beyond. I am so glad I happened to be the person to answer that light, what if it was another staff member who was not aware her skin had been clear only 2 hours earlier. I realize this was an extreme due to the condition of the particular patient , but as I said gave a whole new meaning to head to toe see, feel, reposition every 2 hours, nutrition, etc.

CoffeeRTC, BSN, RN · Oct 14, 2008

I've learned my lesson on this one. Even if they appear to be in good health and ambulatory, cont B and B, etc...I still check every one on admit. Granted, I do LTC and they might have been in the hospital for a while, but those are the ones that creep up on you.

Depending on the surgery, how long they were imobile, health status before admit...you might be right and the decub wasn't there on admit or it could have been a stage one.

morte, LPN, LVN · Oct 14, 2008

Several days ago I admitted a post-op lady from surgery (I work in med-surg). She was relatively young and looked in good health. I got no report of a pressure ulcer. So during my assesssment, I very quickly looked at her backside but not thoroughly. Anyway, several days later a nurse pulls me aside and says "You missed a pressure ulcer on your admission! Be careful!" I guess fortunately, another nurse found it a few shifts later. It was a Stage II and her entire bottom area was red. Today it looks much better. I feel like a moron for not catching it... and also because I just assumed. They all pointed their fingers back at me. (But of course the pre-op and surgery people get off). Have you ever missed one?? I'll feel better if you share your similar stories. =-)

it is quite possible you didnt miss a darn thing.....reread what you wrote...a few shift later.....well what happened to all the nurses inbetween?? was the patient compliant with turning? etc

ktwlpn, LPN · Oct 14, 2008

it is quite possible you didnt miss a darn thing.....reread what you wrote...a few shift later.....well what happened to all the nurses inbetween?? was the patient compliant with turning? etc

Exactly----it does not take long for a stage II to form....

mondkmondk · Oct 14, 2008

I don't know about pressure ulcers (too long ago to remember), but I did miss 2-3 stasis ulcers between someone's toes once. I didn't get wrote up for it but we had a big inservice about head to toe assessment not too long afterwards...and everyone knew it was because of me...a great learning experience!

Blessings, Michelle