Wound Assessment/Documentation

  1. Ok I know when you document wounds you document location, size, draingae, odor, tunneling, etc...but what about when wound is black..this is called eschar! And when there is yellow/green drainage the term used is slough! Im interested in improving my description of wounds in my documentation. What other terms can be used to describe wound characteristics...anyone know a good book for wound care assessment. Also I was wondering what is the most COMMON ointments for pressure ulcers, what is the most COMMON for stasis ulcers, and most COMMON for tunneling wounds. I have used Xenederm for stage 1 and 2 decubs. Accuzyme for larger stasis wounds and larger decubs, Datkins solution wet to dry drsg for cleaning wounds. I know there is many more products. Anyone..please post/list wound products used at your facility and any key terms used for description of wounds! I would love to hear from a Wound Care Nusre! Any tips, hint, or warnings for a New Wound Care Nurse?? Thank You

    Preserving the Future and Dignifying the Past!
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    Joined: Mar '07; Posts: 1


  3. by   GoldenFire5
    Here are some sites for you:

    (this one has a page called "assessment of chronic wounds" with descriptive terms)

  4. by   sharlynn
    Normal Saline is approved for cleaning wounds. Dakins, Peroxide and Betadine are no longer used because they harm good tissue. For Stage II, I prefer a hydrocolloid dressing. The less you disturb the wound bed,the faster it will heal.
  5. by   rehabhereIcome
    is NS from an IV bag the same as the NS used to clean wounds from the bottle? I have seen nurses withdraw from the bag and use it to clean with..is it the same properties?
  6. by   spongebob6286
    NSS that we used to clean wounds is 0.9%. the one in iv bags come in different component they can have dextrose, different % of NSS, etc. so look at the bag itself
  7. by   BridgetLPN
    Helllo. I am new to this website and to being a Wound care nurse. I am looking for some guidance and information in order to help me documnet correctly. Here is an example of my first issue. I have a wound that is very superficial it may measure 0.2 cm by 0.2 cm and I donot feellike I can measure the depth because I am unable to see the wound bed clearly and I am unable to put a measuring device in there ( strerile tips are too big). I also can not document the wound bed beacause I cannot clearly see it. I know its a small pinpoint area due to pressure. How can I doucumnt accurately for MDS and for State review?
  8. by   christiandersen
    hi there,

    just to inform you that we have a free klonk image measurement software tool for download at our site.

    you can visit our site and register to download the tool. click on this link.

    this is how it's done:

    tests have demonstrated that a percent wound surface area reduction, were powerful early predictors of complete wound healing at 12 weeks. read a paper about the subject by clicking on this: