Wound Care


Ok i need a refresher please. The only wounds you stage are pressure ulcers right? Venous/Arterial Ulcers are just measured, No stage,right? Also I know once a Stage IV always a Stage IV it can just become a healing stage IV or healed stage IV. But what about a Stage III? Still always a stage III because there was full thickness loss? Any advice, refreshers, answers would be greatly appreciated. :) Thanks


204 Posts

Specializes in Med/Surg and ANCC RN-BC. Has 4 years experience.

Funny you asked this today. I had to take a test for this today for my new grad orientation stuff. I know that pressure ulcers cannot be staged down. For example a stage 3 to a stage 2. You are right that it needs to be stated a healed stage 3. you only have to stage pressure ulcers. the others you measure and should have a diagnosis attached to it. I hope this helps.


1,246 Posts

Has 36 years experience.

You are correct. Once an ulcer is correctly staged, it remains that 'stage'. No other wounds/ulcers/trauma can be staged. Measured - - always from top to bottom, and side to side.

If there is an open wound across the abdomen it may be "1.7 cm x 12 cm x 2.3 cm"

If it is a vertical wound from below the sternum towards the pubis it might be "12 cm x 1.7 cm x 2.3 cm"

Everyone should chart the same way. If a wound is somewhat circular, it can still be measured as above, with clock interfacing as needed. Tunneling and undermining are frequently noted using clock 'measurements' as well. "At approx 4 o'clock there is a 2.4 cm tunnel, and undermining noted , 0.4cm from 9 o'clock to 1 o'clock"

Hope this helps! Best wishes!