Question

write a nurses note documenting what you will found on this wound: the patient is a 47 years old female she is diabetic 25 years ago, she is a stroke survivor and has congestive heart faillure , she develop 4 cmx 4 cm stage 4 pressure ulcer on her coccyx after knee ampulation 6 month ago, she acquired this stage 4 ulcer during her hospital stay.

Answer 1

In the given scenario Nurse found that the patient had pressure ulcer and that ulcer was in the stage IV. The nurse can determine that the ulcer in this stage from the following signs present in the wound and that should be recorded on her note. The noted things would be as follows,

• The tissue loss seen in this wound is like full thickness
• Surrounding skin looks dark and black, even in the inside of some wound area
• Some part of tendons are vissible.
• Even bone surface are seen.
• Depth of this wound is very deep.