If a patient had a Stage 2 pressure ulcer on discharge papers but the assessment shows it is intact, how should it be classified?

When classifying pressure ulcers, it's essential to understand the definitions and criteria set forth by the National Pressure Injury Advisory Panel (NPIAP). A Stage 2 pressure ulcer involves partial-thickness skin loss with exposed dermis and may present as a shallow open ulcer.

In this case, the patient’s discharge papers indicate that the ulcer was Stage 2, but the current assessment shows it is intact, meaning there is no longer an open wound. It is important to adhere to the guidelines regarding the classification of pressure injuries. The correct approach is to continue to classify it as Stage 2 until it has completely healed. This is because once a pressure ulcer has been classified at a certain stage, it cannot be down-graded based solely on healing. An intact Stage 2 ulcer is recognized as still present in the context of assessment documentation, as the original ulcer's history is significant for clinical care and future monitoring.

Therefore, classifying it as Stage 2 reflects its previous status and the need for ongoing attention, while any full healing of the ulcer would eventually lead to it being documented as healed, but this must be confirmed through follow-up assessments.