you want to document not only that you've changed the dressing, but what, if any, cleansing or treatment you've done to the wound. you want to note what drainage, if any, was on the old dressing and what it appeared like. wounds should be described in as objective a way a possible. this is why you should carry some type of measuring device with you. you need to review the terminology connected with the description of skin and open wounds so you get the terms correct. use the same terms consistently in your own charting.
"dressing to ulcer on heel changed. old dressing had a one inch area of light green drainage on it without any odor noted. wound edges slightly reddened. wound bed pink. wound cleaned with half-strength h2o2 and water, air dried and then a thin film of xxx applied. sterile 2 by 2 gauze dressing applied. feet and legs elevated on pillow so heels are off surface of bed."
when i changed surgical incisions: "dressing to abdominal incision changed. no drainage noted on old dressing. 15cm midline incision with wound edges well-approximated and no open areas or wet drainage noted. areas of dried eschar remain intact along incision line. all staples intact with redness around each. patient states the wound itches. incision painted with betadine solution which was allowed to air dry for 2 minutes. sterile 4 x 4's applied."
i always took time to chart this stuff. if things go wrong, i don't want my (non)charting to be included in the list of nurses getting called on the carpet for only writing things like "dressing changed" or for not charting anything at all! i can tell you that as a manager when something came up from time to time and we had to go through nursing notes to see when things, like a dressing change, were documented as being done for a patient, it was amazing how there would be huge gaps in the charting where these things weren't charted. so, if the patient came up with a big wound infection, what are you supposed to think about the kind of care the patient got? was the dressing being changed or not? if it was changed, what the heck did the wound look like? we assess so many things with patients that take only a few fleeting seconds. reducing those assessments to writing takes up far longer time and effort--remember that, but don't ignore it. murphy's law is always around the corner waiting to bite you in the butt in case you forget.
Depends on what type of wound. For surgical wound I try to remember REEDA-Redness, Edema, Ecchymosis, Drainage, Approximation. I also try to chart if there is any odor from the site. Are sutures or staples intact? If it is an open wound, I chart the inside wound appearance. Is the tissue beefy red? Is there any drainage et odor coming from it? What type of drainage? Sanguanous? Serosanguanous? (sp) Are the edges healing well? Any granulation tissue? Is there any necrotic tissue? How about how the patient tolerates the cleaning? Is it painful? Is it painful without doing anything with it? Any signs et symptoms of infection? I also like to measure it weekly to show the progress of healing or lack theirof and you can get wound consult.