Charting Wounds

[natrgrrl]

Can anyone help me find descriptive words for narrative charting? Yesterday I had to chart a wound that looked like it had been there for several days but had gone unnoticed. When I sat down to chart, I drew a blank. Couldn't put down on paper what it looked like.

Any advice? I saw a book called Chart Smart but I don't know if it is what I am looking for. I bought one of those pocket guides for wound care but it didn't help for charting.

[XB9S, BSN, MSN, EdD, RN, APN]

We use a wound classification chart written by one of the NHS trusts in the UK. I love it because it gives a protocol for for treatment as well.

Wound Classification Chart

[XB9S, BSN, MSN, EdD, RN, APN]

Here is another useful link.

For really difficult wounds I just wanted to add that we measure the wound edge to edge and then use graph paper and draw and map the wound, it is photgraphed by medical illustrations weekly to monitor progress, these photographs are kept in the notes.

[grammyr]

Go to www.npuap.org

There is lots of helpful information on staging wounds on this site. We used it to revamp our wound care policy and protocols..

[Daytonite, BSN, RN]

try the information from this article:

• http://www.worldwidewounds.com/2002/may/lawton/skin-assessment-dermatology-patient.html - assessing the patient with a skin condition

[nightmare, RN]

We use a wound classification chart written by one of the NHS trusts in the UK. I love it because it gives a protocol for for treatment as well.

Wound Classification Chart

Thanks for that one,Sharrie.I've printed that one off.Looks really useful.

[doglvr]

Speaking of documenting wounds, I have a question. I'm a new nurse and have been on orientation for a few weeks. My preceptor was helping me get my patient washed up and we both noticed what I thought was a small early stage 2 on the patient's sacral area. My preceptor however called it shearing. I questioned her twice about it, and then figured okay, well she's been a nurse for over 20 years and I've only been a nurse for a month so she obviously knows what she's talking about and called it shearing in my documentation. Now I'm starting to worry because I realized what I did was wrong. Maybe I'm freaking out, but if the patient's family takes anyone to court it will be me, because I documented and signed all the paper work, not my preceptor. God I feel so bad for the patient. And I'm so scared. How would you define "shearing"? Please help! Thank you!!!!!!!!!!

[XB9S, BSN, MSN, EdD, RN, APN]

Speaking of documenting wounds, I have a question. I'm a new nurse and have been on orientation for a few weeks. My preceptor was helping me get my patient washed up and we both noticed what I thought was a small early stage 2 on the patient's sacral area. My preceptor however called it shearing. I questioned her twice about it, and then figured okay, well she's been a nurse for over 20 years and I've only been a nurse for a month so she obviously knows what she's talking about and called it shearing in my documentation. Now I'm starting to worry because I realized what I did was wrong. Maybe I'm freaking out, but if the patient's family takes anyone to court it will be me, because I documented and signed all the paper work, not my preceptor. God I feel so bad for the patient. And I'm so scared. How would you define "shearing"? Please help! Thank you!!!!!!!!!!

Did you document there was a wound / tissue breakdown at all. I would have documented what I had seen with measurements and description of the wound, this is one reason I like the charts for wound assessment, it just describes the wound and not the factors that have contributed to it.

From what I understand shearing is when the skin tears, which it can do in the elderly or unwell. It is difficult to know without being able to see the wound but on the sacral area I would have been tempted to classify this as a pressure injury

[Daytonite, BSN, RN]

chart what you observe, not what you think happened. "shearing" is a verb that describes an action which i am sure you did not witness.

here are more websites with information on describing wounds and the staging of ulcers:

• http://www.recovercare.com/pdf/clinical_woundstages.pdf - guidelines for staging of pressure ulcers (includes drawings)
  
• http://www.virginiageriatrics.org/consult/press_ulcer/staging.html
  
• http://www.nursing.uiowa.edu/sites/chronicwound/definitions.htm - there are more links at the bottom of the page to click on
  
• http://www.medicaledu.com/staging.htm - staging pressure ulcers
  
• http://www.wocn.org/pdfs/wocn_library/position_statements/staging.pdf - staging pressure ulcers (2006)
  
• http://www.wocn.org/pdfs/wocn_library/position_statements/pressureulcerstaging.pdf - wocns position statement: pressure ulcer staging

[leslie :-D]

Speaking of documenting wounds, I have a question. I'm a new nurse and have been on orientation for a few weeks. My preceptor was helping me get my patient washed up and we both noticed what I thought was a small early stage 2 on the patient's sacral area. My preceptor however called it shearing. I questioned her twice about it, and then figured okay, well she's been a nurse for over 20 years and I've only been a nurse for a month so she obviously knows what she's talking about and called it shearing in my documentation. Now I'm starting to worry because I realized what I did was wrong. Maybe I'm freaking out, but if the patient's family takes anyone to court it will be me, because I documented and signed all the paper work, not my preceptor. God I feel so bad for the patient. And I'm so scared. How would you define "shearing"? Please help! Thank you!!!!!!!!!!

what your preceptor referred to, was 'how' the lesion occured...

shearing forces is when the skin lifts up as the sheets/surface area goes down.

whenever you see a break in tissue integrity, you note its characteristics.

etiology (which preceptor is stating is shearing) isn't known unless it's directly observed.

we can hypothesize that it's r/t pressure, shearing, malnutrition, bony prominences, and intervene accordingly, but what is important, is what you see.

if there was a break in the skin, it's a stage II and warrants treatment.

leslie

[APBT mom, LPN, RN]

We aren't allowed to document the size of a wound or stage ulcers. When we find something that we are concerned about we can put in a consult with the wound nurse and she does all of those things. She also starts a treatment plan, does the dressing changes, and takes pictures during the initial assessment and during treatment.

We are only able to say where it is and what it looks like (red, black, drainage, smell, etc.). I was told it is done this way because everyone classifies the wounds or stages the ulcers differently and one person may say it's a stage 2 while someone else stages it a 3.

[iwanna]

I am an inactive nurse, however, I wanted to ask what is your line of report? You did report it to the preceptor. I would think that you would just chart what you observed and noted. Also, say that preceptor was notified. Always chart who you report to. As an LPN, I would chart that I reported to unit RN. Also, I would put them down on list for dr. consult for whatever reason. We learned in nursing school not to chart stages, however, in the facility that I worked at, we did stage them. However, I do agree that staging is quite subjective.

And, don't beat yourself up over this. We all learn through our mistakes, and we all make them. Especially being new, you will have a lot of learning. What we learn along the way makes us better nurses. And, someday you may be able to pass all of your knowledge on to a newbie.:wink2:

Just remember to CYA by documenting everything!