Case Study: Assessing and Documenting a Laceration (Nursing)

00:00 As a member of the healthcare team, you're going to likely have the opportunity to assess and document a laceration in your practice.

00:08 So let's walk through a case study so you know what you should be looking for and how you should document it. So we're going to give you a client.

00:15 So our patient is John Smith.

00:18 Now John Smith is a 45-year-old male farmer who presented to urgent care with a laceration to his right palm after handling hay bales with rusty wire approximately three hours ago.

00:30 Now, let me tell you, I gave you all the information you need to have.

00:35 Doesn't usually work this way with patients.

00:37 So remember, your ability to ask good questions will help you get the best assessment.

00:41 Because not everyone comes in and tells you all the information like this.

00:46 So first let's think about Mr.

00:47 Smith. Let's look at his wound characteristics.

00:50 Is it linear? Is it stellate? Kind of like a circle or is it irregular with wound edges? What do you see? How deep is it? Is it superficial? Partial thickness or full thickness? What's the width of the wound edges and the degree of gaping the opening in their skin? Can you see a foreign body or any debris? Is there evidence of tissue loss or devitalization? And are deeper structures involved? Can you see muscle, tendon or bone? And graphically you may actually have that experience.

01:22 So let's give you an example of the appropriate documentation of wound characteristics.

01:28 So here's an example. You would document something like patient presents with a four centimeter irregular laceration across the right palm.

01:37 So I've told you how long it is, what it looks like, the shape of it and where it's located.

01:42 Now this is extending from the thenar eminence to the mid-palm.

01:46 That's some pretty fancy anatomy which you may or may not use.

01:49 But remember, you want to get a specific as you can.

01:53 Now the wound depth appears to be partial thickness with minimal subcutaneous tissue exposure. So you're showing them exactly, telling them what you see.

02:03 Wound edges are moderately gaping with approximately three millimeter separation.

02:09 So that tells you how wide it is.

02:11 So this is an example of taking all the wound characteristics.

02:15 So six things we recommended you document and showed you how this could be written in a narrative form in your charting.

02:23 Now you're going on in the note.

02:24 You say small fragments of hay and dirt are noted within the wound bed.

02:29 So there's the debris that you're looking for.

02:32 There's no apparent tissue loss or necrosis observed.

02:36 There's no visible tendon or bone exposure.

02:39 But wound locations suggest potential involvement of superficial palmar fascia, the last tetanus vaccination reported greater than eight years ago.

02:48 Whoa. Where did that come from? Remember, as we're walking through that guide, we talked about looking for debris, looking if there's any damage to the tissue.

02:57 What other structures can you see? Can you see a tendon or bone? But we hit last tetanus. Because where did he get this wound? Well, with the hay bales.

03:07 And it was a rusty wire. So it's always important when you have a client who has a wound or a laceration that you ask when their last tetanus vaccination was.

03:16 Now, let's talk about bleeding.

03:18 What do you do regarding bleeding in your documentation.

03:21 You're going to be looking for: Is it active bleeding? What's the character of that bleeding? And is there a hematoma that's formed? So if there's active bleeding you also want to address if there is evidence of significant blood loss. If the character of the bleeding does it look arterial to you.

03:37 Is it pulsing or does it look like venous more like oozing or capillaries.

03:41 So the final thing is: is a bruise, or a better word for that is, has a hematoma formed? So when it comes to bleeding these are the type of examples you should see in your note.

03:54 For our client John there's minimal active venous oozing noted from the wound site upon presentation. Now, the patient reports initial moderate bleeding that subsided with direct pressure. So they were able to put pressure on it and that stopped the bleeding.

04:09 Now this is important. No pulsatile bleeding observed.

04:13 So that means, this suggests no major arterial involvement.

04:17 Now the estimated blood loss reported by the patient as, and you'll see the quotation marks, "soaking through two hand towels".

04:25 That lets you know that that is what exactly what the patient said when you include the quotation marks. So prior to arrival.

04:32 So we've got no pulsatile bleeding observed, suggesting no major arterial involvement.

04:37 Estimated blood loss reported by patient as "soaking through two hand towels" prior to arrival.

04:43 So before they came to you, there is a small hematoma, and small doesn't tell you as much as it is approximately one centimeter forming at the proximal wound edge. Hemostasis achieved with direct pressure after irrigation.

04:58 So we've got a lot of information there that tells you pull back and look at that note.

05:03 They're not having a lot of bleeding now.

05:05 They're able to before they came they were able to stop the blood loss with pressure.

05:10 They soak through two hand towels, which isn't exactly an exact measurement, but it does give you an indication.

05:17 And there is a hematoma present.

05:19 Next, you want to consider pain and sensation.

05:21 So you're going to want to make sure that you document the location, the intensity, and the character of the pain.

05:28 The intensity is always documented with an appropriate pain scale, level of pain scale. Ask them about changes in sensation around the wound.

05:37 Is there any change in what they feel in the tissue around the wound? And finally, does moving it make the pain worse or not? Is it exacerbated by movement? This may tell you that there's some other structures involved.

05:50 So your note could look something like this. Patient reports moderate sharp pain at laceration site, rating it a six out of ten at rest and an eight out of ten with movement or when the edges are manipulated, meaning if we try to move them.

06:05 Now this describes the patient describes intermittent shooting pain extending to index and middle fingers when attempting to flex digits.

06:13 So when the patient tries to move their fingers, they have a shooting pain that goes to their index and their middle finger. Okay.

06:21 We're going to continue. Now the patient reports pins and needles sensation.

06:25 Remember that's an example of paresthesia.

06:28 And the report that pins and needles in the distal thumb and index finger.

06:32 Now the pain increases significantly when attempting to oppose the thumb to the little finger trying to do this suggesting potential involvement of underlying structures.

06:41 Okay, now that's a pretty complete note.

06:44 If you go back and look at the note, you can pause this.

06:48 Think about the note and the guide that we gave you for this section.

06:51 This will give you really good ideas on what you can document to have clear documentation for the healthcare team. Now next we're going to talk about functional assessment.

07:02 Now depending on who you are on the healthcare team you're going to do some documentation of this. But if it needs to be a real complex document, it's going to be another healthcare team member whose specialty is functional assessment.

07:14 But you're going to address do they have any limited movement or function based on this injury.

07:19 Can they do normal range of motion? And is there any evidence that the tendon or ligament or nerves might be injured? So think about this in the form of a functional assessment.

07:30 Patient demonstrates limited ability to fully flex right index and middle fingers secondary to pain.

07:37 So they're having a hard time doing this. But remember the laceration is on their palm.

07:41 Range of motion in remaining digits is intact.

07:44 But it's guarded due to discomfort.

07:46 Right. They're not wanting to move that hand all around.

07:48 But in your note you're letting them know that it's the right index and middle fingers that are having most impacted, so they're unable to complete fist or fully oppose thumb to fingertips due to pain. So they can't do this and they can't make a fist.

08:04 So the grip strength visibly diminished compared to the left hand where it's not injured.

08:09 When asked to perform precise movements, patient reports increased pain and demonstrates hesitation. I would too if I just ripped open my palm on a hay bale.

08:19 You also want to look for signs of infection.

08:22 Always important with any type of wound.

08:25 So you're looking for. Is there any sign of increased erythema that goes beyond the wound edges? Is there increased pain or tenderness? Is it warm? Is it localized? Is it spreading? Is there any drainage? Is it purulent? Do you see any impact to the lymph nodes, or does patient having systemic symptoms like fever, chills or feeling malaise or really tired.

08:47 Now this wouldn't happen immediately, generally with a laceration, but it could be someone who's delayed getting treatment.

08:53 So those are the signs of infection.

08:55 You'll notice when we document in this section, we're going to continue to document the things that aren't there. These specific signs of infection that we don't assess.

09:04 That's you communicating to the whole team.

09:07 You're aware of what the signs of infection are and you assess the patient for those.

09:11 Let's take a look at the wording.

09:13 No significant redness extending beyond immediate wound edges at this time.

09:18 It's consistent with acute injury.

09:20 So you're telling them hey I know that erythema that's spreading beyond the wound that's a sign of infection in this patient doesn't have it.

09:29 Next, patient reports tenderness localized to the wound area without spreading pain because that's another sign of infection.

09:37 Patient doesn't have that.

09:38 There's no increased warmth noted on palpation compared to surrounding tissue.

09:43 Again, you're seeing a theme here.

09:45 There's no sign of warmth.

09:48 That's beyond the normal that you would expect with a laceration, which would indicate a sign of infection.

09:54 Now the next step. Get really gross, right? No purulent drainage observed. Serous exudate only.

10:01 Also, you're going to say patient denies fever, chills or systemic symptoms.

10:06 You would also obviously document their vital signs.

10:08 So you'd have an actual number to go along with that.

10:12 Now depending on how involved the laceration is, how complex it is or the patient's response to that, there are some associated symptoms you may also want to include in your charting.

10:23 So possibly think of things like dizziness or lightheadedness, particularly if the patient has had significant blood loss.

10:30 They may be nauseated or vomit.

10:32 This might indicate pain that's so severe, or they may have had a concussion or head injury.

10:37 And finally, think about the patient's level of anxiety or psychological distress.

10:42 Sometimes patients, just the sight of their own blood is enough to cause them severe anxiety.

10:49 So let's give you an example.

10:50 Patient denies dizziness, lightheadedness, or syncope, suggesting hemodynamic stability despite bleeding.

10:58 No nausea or vomiting reported. Patient exhibits mild anxiety regarding potential for lockjaw, which is why the tetanus, due to rusty wire exposure and inability to recall exact date of that last tetanus vaccination.

11:13 Okay. We've got more, but I want you to just go back to that.

11:16 Patients may call this lockjaw.

11:18 That's kind of the common term.

11:20 What we're trying to avoid with a tetanus vaccination.

11:24 Of course, this is going to be on your client's mind because they know that they've exposed themselves to the classic risk of something that's rusty breaking their skin.

11:33 So the patient expresses concern about impact on farm work responsibilities and ability to operate equipment during upcoming harvest season.

11:40 Given rusty wire exposure, patient counseled on signs of infection to monitor for. So there you've got your patient education.

11:48 You think, why would we document that the patient expresses concern about impact on their farm work? Because this is something we need to follow up on.

11:57 This is a valid concern that our client has.

12:00 And unless you're in a disaster setting, this would be something we should take the time to talk to them about. Also, we educated them about, hey, these are the signs you should look for that you need to come back and we need to take another look at that. So that wraps up some examples of very specific documentation.

12:18 Use those as a guideline.

12:19 Use this as a way for you to develop your own style in thorough, accurate and safe documentation.