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.

[doglvr]

Thanks for resonding! You all are the best!

Without a doubt there was an open wound, which is which I thought it was a stage 2. I did document the shearing it in the skin/wound assessment and there was a picture of a body and I circled the sacral area on the picture. I guess when I think of shearing I do think of a break in skin, but not really an open wound which is what my patient had. And to be honest, it's not like this patient is going to get better any time soon as I work in the ICU and it seems like everyday when I go into work she gets worse and worse.

I don't know what to do now. I just wanted to cover my butt, but I guess it's too late for that.

[doglvr]

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!

My preceptor saw the wound the first day I had the patient, at which time I asked my preceptor about it and she just said it was shearing. The very next day I had the same patient and I asked my preceptor to help me wash the patient up and asked the same question again and once again she said it was from shearing. I'm just worried that in a few days it's going to be a stage 4 and when they look back at all the documentation they're going to see my "shearing" and then the next day see that the wound care nurse called it at stage 4. Then I'll be the one in trouble.

[leslie :-D]

"shearing" is not the least bit descriptive.

it doesn't tell the reader anything.

the only times that staging is subjective, is when it's overlapping from one stage to the next.

for instance, if there's an ulcer that goes through the fascia and into the adipose, it would be stage III...

but some nurses may not see it extending to the adipose, staging it only as a II.

when there is no break in skin and it's nonblanchable, it's safe to stage it as I.

when it's a superficial break or when no adipose is seen, it's safe to stage as II (in the absence of tunneling).

that's why noting measurements, color, drainage and other identifying characteristics are all important.

you'll be just fine, i'm sure.:)

leslie

[Daytonite, BSN, RN]

i'm just worried that in a few days it's going to be a stage 4 and when they look back at all the documentation they're going to see my "shearing" and then the next day see that the wound care nurse called it at stage 4. then i'll be the one in trouble.

from my experience, worry if nothing was done. the fact that this is being documented and attended to is good. the final test of any case that ends up in a lawsuit is how it boils down to money damages because of negligence (failure to do nothing, indifference) and that's not what you have indicated. wrong wording in a chart isn't the same as being negligent.

sometimes because of the procedures that are required to be done in the units and the physical condition of the patient healing just isn't going to take place at this time in the acute phase of a patient's illness. i think it is admirable that you are attentive to the situation. there are priorities, however, that have to be attended to. i'm not saying that the decubitus is ok, but other problems may take precedence at the moment.

this also tells me that you are learning a great deal from the experience. remember the nursing process which is a problem solving method. when you discover a problem, develop a plan of action and set it into motion. impaired skin integrity should be added to this patient's plan of care and dated asap, interventions documented and instituted asap as well. the care plan is your documentation of the date that the problem was detected and addressed. your charting will document if you are following your own plan of action. while healing is the goal of your treatment that is not always going to happen. goals and outcomes take 3 levels:

• improvement of the patient's condition/cure
  
• stabilization of the patient's condition
  
• support for the deterioration of the patient's condition

that care plan becomes part of the patient's permanent chart and is proof that you were aware of the problem and were doing something about it. if it doesn't get better, and in fact gets worse, you are off the hook if your interventions were appropriate and followed. if you weren't the one following your own interventions then you are also off the hook. if the patient's body is just not able to respond and heal then the nursing staff is not at fault either.

[finchfamily4]

If you are SURE it's a pressure derived ulcer then stage it. I would on the other hand just DESCRIBE what you see. I'm not a Doctor

Is it open? then......

Note Anatomical Location (i.e., sacrum, tibia, L iliac crest , T3 area)

being vaque is ok just get the general area

Measure it from length to width x (head to toe) to y (left to right) axis Note depth i.e., 0.3 cm and undermining (under lip of wound) in clock referance i.e. 0.3 cm at 1 oclock

Fibrin - dead tissue in % to overall wound bed (i.e., 10% - 30% -80%) - it's yellow & stringy

ANY Readness generalized, Swelling generalized, drainage (*color) Odor, Echar?

Pain on pain scale. If no to any then say so!!! Means you assessed!!

Granulation tissue % or lack there of - red beefy cells in wound bed

See any bone or tendon? State yes or no

What about the periwound? Macerated, Red - inflammed, calloused or

intact?

Example: L tibia 20cm x 10cm. 50% fibrin 50% granulation. Edema noted at pitting 3+ Redness to periwound. Odor noted, Slight eschar noted at 2 oclock 0.4cm x 0.2 cm 0.1 depth No undermining No tendon or bone observed. Denies pain. Moderate serous drainage. Periwound intact.

[natrgrrl]

Thanks finch. That is the kind of charting I need to figure out how to do. Hopefully, I will get better with practice.