charting advice

[cjkekoa]

I am an LVN, and still learning how to chart well. My resident just has a small scratch on the right side of his neck close to his tracheostomy or near his adam's apple. How could I chart this ? there is no drainage, looks superficial. the shift before me did not endorse this and I noted it during trach care.

[TammyG]

I would document it as a shallow excoriation exactly ___ cm long starting at _____ (anatomical landmark) and ending at ______ (anatomical landmark). Note whether there is drainage, if there is surrounding redness, if there is a scab over it or if it has started to heal, how it occurred, and how you dressed it/treated it.

[CWONgal]

If you add the adjective "linear" (if it is) with excoriation it helps paint a better picture of what you are trying to share with other staff. Excoriation is often used incorrectly and using it when describing a scratch is appropriate, as Tammy stated. You can document this using a clock...."Linear excoriation extending horizontally at 0300 measured 2.5cm in length".

Any idea of the etiology? I know you said it was to the side...I would be careful with trachs in general because they often cause device related pressure ulcers that can deepen quickly.

[Davidaugustyn]

Whatever you do, don't chart without knowing the origin. Figure out where it came from, document it, and then what you're going to do about it. Easier said than done, but you don't want to be stuck with a wound of unknown origin. Get someone else to take a look at it. They may have seen something like it before. If it looks like a scratch from the Nebulizer attachment on the trach, document as so and move forward.

[CWONgal]

I don't know that I'd agree with that David. We can't always determine the etiology but we are still expected to document it's presence because it is an abnormality. Describing what you see (erythema, exudate type, exudate amount, odor, location, etc.) helps to paint a better picture of what is going on (unfortunately nurses often don't know the terminology). Following it up with a plan of care is key. If you found something, what is your plan to fix the situation?

[Davidaugustyn]

That may be true, and I may be speaking from my LTC experience. Of course we would not skip documenting on it; it is there. But if the origin is unknown, there becomes the opportunity to defend allegations of abuse, depending on the wound.

That's all I meant. Not that we wouldn't chart, but that we need to find the origin first or at least have a realistic idea of the cause when oversight comes around.

[CWONgal]

I can see your point from the LTC perspective. Inpatient assessment and documentation, especially upon admission, is important.