Pressure Ulcer

[fabiusgile]

I'm writing up my careplan on a pt I had at the beginning of the semester. he had a stage 4 coccyx pressure ulcer with tunnelling granulated tissue around edges with measurements 2x3 3x6 and tunneling. Serosanguinous drainage.

I don't remember what the 2x3 3x6 was is there a standard for measuring wounds that l can't find try googling it.

[Daytonite, BSN, RN]

we usually measure wounds by mm, cm or inches. it doesn't matter which units you use, just keep them consistent and use the same unit of measurement throughout. in other words, don't say 2 inches by 3 cm. say 2 inches by 1.5 inches.

your nursing diagnosis for a stage iv ulcer should be impaired tissue integrity. impaired tissue integrity

[fabiusgile]

so l don't remember if the 2x3cm was width by 3x6. I wasn't the one who measured it l took it from the nurses note I was wondering if there was a standard where the first set of numbers were width by depth or width by tunneling?

[Daytonite, BSN, RN]

??? This is what happens when you don't do your own assessments.