Staging questions

[Turtle in scrubs]

1. You assess a wound for the first time and it is 100% covered with adherent slough. You cannot see the wound bed. Unstageable. You apply santyl and with two weeks you can see the wound bed and there clearly is no bone, tendons, etc. How do you stage it now? Stage III or healing Unstageable?

2. You have a DTI; dark purple with dry, intact skin. A week later you assess and it is opened up with that dark, moist slough and exudate. How do you stage it now? Evolving DTI or Unstageable?

Feedback please! Thanks!

[RachRN11]

Good questions. I'm not sure if my answer is the correct one but for the first one I would document something like "previously unstageable, now stage III ulcer presents with...etc" And same with the 2nd one "previously suspect deep tissue injury has evolved into unstageable with wound bed 100% covered with slough...etc."

[Turtle in scrubs]

Thanks RachRN11!

In my reassessment I can (and do) write out a description, and I agree with what you said. Problem is, we expect the nurses on the unit to be documenting the PU's in a EMR with little drop down boxes that don't allow for all that. Also if it is a HAPU, Risk Management is involved and they want a definitive answer... as do our billing coders.

As a staff nurse I was sometimes frustrated when the WOCN's would evaluate my patient and in the consult would write out what I saw as an ambiguous description.... meaning I still didn't know how to fill in my little boxes. Now as a WOCN I find I am doing the same thing in an attempt to best describe the history and current state of the ulcer. As a WOCN I want to provide the best assessment and yet at the same time be of the most help to my staff. I'm finding a disconnect here that I'm not sure how to bridge.