Open Wound Assessment documentation

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Hello:

Can anyone give me an example of how to begin a open wound wet to damp charting? This is NOT wet to dry. Thanks!

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Specializes in Rehab, Med Surg, Home Care.

-Size of wound

-Drainage on old dressing: amount/ color (ie;bloody, sero-sang, purulent)/ odor

-appearance of wound bed

-tunneling (may need to "sound" it with a sterile swab)

-appearance of surrounding tissue, also is it warm/ hot to touch?

-pain

-what treatment/ dressing was done

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Specializes in Med/Surg, Tele, IM, OB/GYN, neuro, GI.
-Size of wound

-Drainage on old dressing: amount/ color (ie;bloody, sero-sang, purulent)/ odor

-appearance of wound bed

-tunneling (may need to "sound" it with a sterile swab)

-appearance of surrounding tissue, also is it warm/ hot to touch?

-pain

-what treatment/ dressing was done

I agree with this plus what your using as a wetting agent NS and how the patient tolerated the procedure. I usually put what size gauze I used to fill the wound and what I used to coaver it so when the next nurse reads the notes she'll know what supplies she may need.

Basically the documentation would be the same as a wet to dry.

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