Wound Documentation

[br3ktw, LPN]

As this is my first post to this forum I hope first of all that I am not posting on a topic that has already been covered in a previous thread. If I am I apologize.

I am a first semester nursing student (RN) from TN. As we are about to complete our check off for wound care and documentation I am amazed at how far we have come in so short a time. At the same time I am amazed at how much I don't know, or better put, how much I still have to learn. My purpose of posting is to pose to you the question of wound documentation. I understand the vocabulary associated with the things I may encounter during said dressing change, what seems to be giving me the most difficulty is documentation, in a narrative form, of what I have seen and assessed during the change.

If there is anyone who has some helpful information and maybe even some examples to provide I would be most grateful.

Thanks

Student-RN

[shrimpchips, LPN]

For wounds, we were taught to include the following:

• length
• depth
• width
• color
• edema
• odor
• drainage
• location
• # of staples/suture (and if they are intact or not)
• stage (ulcers)

I had to do a test-out on a dressing change and we also had to document it. I passed with a perfect, but I'm sure my documentation isn't perfect since I'm still in my first year of my program. Here is what I put:

11/13/08 1410 serous drainage present on dressing. wound is linear, midline and inferior to the umbilicus. wound is 7cm x 2cm (note: we did these on models and it was physically impossible to measure the depth of this incision, but clinically you should include it if possible.) skin is well-approximated c no edema or odor. slight redness around wound edges. cleaned c normal sterile saline and dressed c sterile gauze. name, credentials

Again, it probably isn't perfect, but there is one example and I really hope that it gives you some idea.

[Daytonite, BSN, RN]

I have websites that have drawings or pictures of wound staging and also describe what is classified in each stage of the wound. This wound staging is pretty universal for pressure ulcers and the language used to describe their appearance is used for most open wounds including surgical incisions. Also be aware that any time there is interruption of skin surface or tissue injury, the inflammatory response of the body goes into work (Histamine effect) and its 4 cardinal signs are going to be, in order of appearance, redness, heat, swelling and pain. Depending on the location of the tissue interruption or injury these signs of inflammation may/may not be visible to the naked eye, but they will be present to some degree no matter how subtle, so look for them when assessing.

Diagnosis, Staging, and Treatment of Pressure Ulcers: An Expert Interview With Carol A. White MS, RN, ANPC, GNPC, DNP(c)