How do you document a wound appearance?
Do describe what you see: type of wound, location, size, stage or depth, color, tissue type, exudate, erythema, condition of periwound. Don’t guess at the type or the stage of a pressure ulcer or injury (hereafter, pressure injury [PI]) or the depth of the wound.
How would you describe Stage 1 pressure ulcer?
Stage 1 pressure injuries are characterized by superficial reddening of the skin (or red, blue or purple hues in darkly pigmented skin) that when pressed does not turn white (non-blanchable erythema). If the cause of the injury is not relieved, these will progress and form proper ulcers.
In what order do you document wound measurements?
The wound is typically measured first by its length, then by width, and finally by depth. The length is always from the patient’s head to the toe. The width is always from the lateral positions on the patient. The depth is usually measured by inserting a q–tip in the deepest part of the wound with the tip of finger.
How do you document a surgical wound?
Include the date, time, and your signature (including your credentials) in all your notes. Document the anatomic location of the incision, including on which side of the body surgery was performed. Chart the length of the incision in centimeters and include the depth measurement whenever appropriate.
What is a Stage 1 wound?
Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose colour briefly when you press your finger on it and then remove your finger).
What do Stage 1 bedsores look like?
Stage 1 bedsores typically appear as red-colored patches of skin that do not blanch. This means that the red-colored patch of skin does not turn white when a finger is pressed upon the irritated area. On a dark-skinned patient, a stage 1 bedsore may simply appear to be a different color than the surrounding skin.
What is wound documentation?
Documentation in wound care A wound assessment must be made and accurately recorded at every dressing change: the size of the wound, its depth, colour and shape, as well as the condition of surrounding skin, should all be documented.
Is a Stage 1 Blanchable?
Stage 1: Intact skin with non- blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from surrounding area.
How do you describe a wound?
Use correct terminology to describe your findings, such as ecchymosed (bruised), erythematous (red), indurated (firm), edematous (swollen). Wound edges must also be carefully defined. Wound edges can be described as diffuse, well defined or rolled.
How would you describe an open wound?
Unlike closed wounds, such as bruises or closed fractures, open wounds are injuries that involve a break in the skin and leave the internal tissue exposed. The skin has an important role in protecting the organs, tissues, and other structures inside the body, so a breach of the skin can potentially invite infection.
Why do you need to document a wound assessment?
Holistic wound assessment is essential to prevent infection, promote healing and improve the patient’s quality of life (Ousey et al, 2011). Many people like to use mnemonics to organize key facts and jog the memory. “WOUND PICTURES” (adapted from Hess 2004) organizes key aspects of wound assessment that should be documented (Box 1).
How is the staging of a pressure ulcer determined?
be staged Pressure ulcer staging is based on the depth in cm . As the ulcer heals, “reverse or back” stage the ulcer. Staging of pressure ulcers requires clinical skills including minimally observation and palpation CMS definition of stage 2 pressure ulcer differs from NPUAP . 24 . 5/12/2014
When to record the measurement of a wound?
Wound measurement is an essential part of wound assessment. It should be recorded on initial presentation, and at regular defined intervals as part of the reassessment process. There are various methods available to measure wounds and it is important to use the same method each time, with the patient in the same position.
What is the definition of an unstageable wound?
Unstageable Definition • Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Description •Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be