Determine the cause of the tear. If unrelieved pressure (as opposed to the kind of pressure that results from slamming your hand against the wall, for example), such as friction from sliding down in bed (see page 3-162 of the RAI User's Manual) contributed to the tearing of the skin, then it is staged in M1. If you really are unable to determine the cause of the wound, then it is important to look at the location of the wound, the resident's mobility status, etc., and make a clinical judgment about whether it is likely that pressure was a contributing factor.
Rena
Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse Assessment Coordinators
[EMAIL PROTECTED]
Subj: skin tears
Date: 1/8/04 4:34:03 AM Pacific Standard Time
From: [EMAIL PROTECTED]
Reply-to: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the Internet
Please tell me if I am correct in my thinking. When you have a skin
tear that is not on a pressure point. I do not have to stage it in
section M1. I would only put it in M3.
Thanks,
Billie Stewart, RNAC
[EMAIL PROTECTED]
