Pressure ulcer assessment continues to be an area of struggle for many nurses. How many times have you felt uncertain about how to accurately determine the stage of a wound or the etiology of a pressure ulcer? Because of this, many care facilities designate a specific nurse to be the wound care specialist.  By doing so, the goal is to have consistency and accuracy when staging the wound.  While this may provide consistency, it often leads to wounds being documented only when the wound nurse is available, which may not be at admission and can lead to reduced accuracy in reporting.

 

In many long-term care facilities, admissions often come late on Friday afternoon, during a time when the wound nurse may not be available. In some cases, the specialist may not be available until Monday to complete the formal documentation.  The admitting nurse visualizes the wound and puts interventions into place, however the documentation may not accurately reflect the correct staging of the wound. In some instances, correct assessment and documentation does not take place until three or four days after admission. 

 

The same is true when a pressure ulcer is first noticed.  The nurse who discovers the area may not feel comfortable doing the formal assessment and may end up waiting until the wound nurse is available.  Therefore, the documentation may reflect a false delay in assessment and intervention.

 

It is important that all your nurses, including the LPN's, have the proper training and ability to document the characteristics of a pressure ulcer.  This training should include the etiology of a pressure ulcer so other wounds, such as macerated skin or vascular ulcers, are not tracked and staged as a pressure ulcer.  All nurses should be capable of staging, measuring, describing the wound bed, the surrounding skin, drainage, odor, tunneling and undermining.  This will ensure that when an individual with a wound is admitted or discovered that the documentation process starts immediately.  From there the designated wound care nurse can help monitor and track the healing progress of the wound.  It is recommended that when the specialized wound nurse rounds he/she always have the floor nurse and/or nurse manager present.  This will help ensure consistency in observation and documentation of the area and help train others in the event the wound nurse is not present.

 

Pathway Health Services is in the process of developing a Pressure Ulcer Assessment and Documentation on-line training module that nurses can complete.  This training will cover how to complete a comprehensive assessment and documentation of pressure ulcers. Check our Website at www.pathwayhealth.com for up-to-date information.