Documenting a New Pressure Injury

Scenario

During a shift assessment, you observe a 3 cm red, non-blanchable area on the sacrum of your patient.
The patient is immobile and incontinent of urine. There is no open skin, but redness persists after repositioning.

Question: How should you accurately document and respond to this finding?

Best Practice Answer

1. Accurate Identification and Staging:

   • The finding represents a Stage 1 pressure injury, defined as intact skin with non-blanchable erythema.
   • Avoid outdated or non-clinical terms like bedsore or decubitus ulcer — use the proper terminology consistent with NPIAP (National Pressure Injury Advisory Panel) standards.

2. Comprehensive Objective Documentation:
   Your charting should include precise, measurable descriptors:

   • Location: “Sacrum” — use anatomical references (not “lower back”).
   • Size: Length × width × depth (even if zero depth for Stage 1).
   • Appearance: “Intact skin, red, non-blanchable, no drainage, no odor.”
   • Periwound area: Note firmness, warmth, or bogginess.
   • Pain: Include patient’s pain level if present.
   • Example entry:

     “3 cm x 3 cm area of non-blanchable redness on mid-sacrum, skin intact, warm to touch, tender on palpation, no drainage.”

3. Immediate Interventions:

   • Reposition the patient at least every 2 hours using turning schedule.
   • Apply protective barrier cream if incontinence is a contributing factor.
   • Place foam dressing or pressure-relief cushion as appropriate.
   • Maintain skin dryness and inspect at every round.

4. Notify and Collaborate:

   • Notify provider to obtain formal wound consult.
   • Consult Wound, Ostomy, and Continence Nurse (WOCN) for staging validation and preventive plan.
   • Communicate to next shift and interdisciplinary team to ensure continuity of care.

5. Follow Hospital Policy for Photo Documentation:

   • Take a clinical wound photo if policy allows, ensuring consent, privacy, and proper labeling with patient ID and date.
   • Upload securely to the EMR — never to personal devices.

6. Ongoing Monitoring:

   • Reassess site each shift for changes (blistering, opening, or increased erythema).
   • Escalate if progression occurs (e.g., skin breakdown → Stage 2).
   • Continue preventive measures even if site improves.

Real-World Application

Accurate wound documentation is critical for:

• Legal protection (pressure injuries are reportable events).
• Reimbursement and quality tracking under CMS guidelines.
• Interdisciplinary communication — wound progression or improvement depends on accurate, consistent reporting.

Interviewers use this question to evaluate:

• Your knowledge of staging and terminology.
• Your attention to detail in documentation.
• Your ability to translate observation into prevention (turning, skin barriers, and early escalation).

Tip: State clearly in interviews —
“I would document objectively, stage accurately, notify the provider and wound nurse, and start preventive interventions immediately.”
That phrasing signals thoroughness, accountability, and regulatory awareness.