pressure sore

[kunni]

I visited a patient who was previously been seen by one of the senior nurses. The sacral wound was graded as grade 1. I documented that the wound has sloughy patches (in description).

The patient was later admitted to hospital due to chest infection. I have been told that I should have done a datix because I had stated that there were sloughy patches on the wound. I do understand that yes I should have done a datix but my question is, shouldn't the first person who said the wound was grade 1 do a datix as well.

Please I need an answer as pressure sore is not my specialty.

[Jensmom7, BSN, RN]

First of all, any open wound is not a Stage I.

Second, any open wound that has slough cannot be staged-because you can't see the wound bed and you can't guess at what might be under it.

That wound should probably have been classified "Unstageable, due to slough covering the wound bed."

[anh06005, MSN, APRN, NP]

Maybe it was a stage 1 when the previous nurse saw it. A lot can change in a few hours if a deep tissue injury (closed) has been festering a while.

[Wicked Wahine]

I don't know if this is a woundcare specific thing or what, but the woulda-coulda-shoulda game is strong in this field (IMO). The thing is, there are so many products out there and modalities for wound healing... combine that with a field that is changing so quickly that products 5 years old are considered old fashioned and products from 20 years ago are considered the gold standard. It's a topsy turvy field, to say the least. So, don't let the "You should have..." get to you. Accept it as a learning opportunity because that's what it can be.

For clarification, as long as you can visualize the wound bed and therefore the depth, slough in a pressure ulcer would automatically make it at least a grade III. If the slough is fibrous, covers the entire wound bed and you are therefore unable to visualize the wound bed at all to determine the depth, then it is unstageable and definitely not a stage I. Staging is not a diagnosis but an assessment (someone please correct me if I'm incorrect!), so you can document the ulcer as whatever stage your assessment finds.