Documentation of Wound Assessment (Nursing)

00:04 Hello, let's talk about documentation of a wound assessment.

00:09 So we're talking about wound assessment documentation.

00:12 Remember, there's three points that we need to look at when we're assessing a wound and make sure we document these.

00:18 So the wound bed, of course, is the piece that's actually the inside part of the wound.

00:23 And the edge, believe it or not, is important for us to monitor and document as well.

00:29 Now, if you remember this kind of a funny word, but it's called peri-wound skin.

00:33 This is the skin that surrounding the wound.

00:36 And it's important for us to document the integrity of that.

00:40 Now, don't forget, when you're documenting a wound, we're going to measure it.

00:44 Yes, I said, measure it.

00:46 So just like you would a lot of measurements, you're going to look at the width, the length and the depth.

00:51 So why we do this? This actually helps us really importantly track the progress of the healing of the wound.

00:59 Or if it's not getting any better, we can also determine how it's healing by these measurements as well.

01:06 So if we take a look at this image, let's look at the width first.

01:09 So when this graphic, you can see where it's highlighted that we'll look at the width, the length is just that, but I want you to pay close attention to the depth.

01:19 So we talk about the depth of the wound, how we measure that is we take a sterile.

01:25 Remember, make sure use a sterile cotton tip applicator.

01:28 We will take that applicator, put it in the deepest part of the wound, then we'll take our finger and where the edge of the wound comes in or comes up.

01:38 We'll take that and compare it against our measuring tape.

01:41 So if you look at this slide here, there's two different pieces of equipment you need with measurement, a sterile cotton tip applicator because that will be touching the wound.

01:50 And we typically have some sort of measuring device, many times it will be like a disposable measuring tape like you see here.

02:00 So don't forget about when we're talking about wounds, we've got to make sure we describe specifically where it's at.

02:07 So here's a couple examples.

02:09 So this first example is a really bad example.

02:12 This is just saying a client has a wound on their leg.

02:15 Well, when you're talking about documentation, this is not specific.

02:19 And it's really not very descriptive.

02:22 When you document just think, if someone else read my documentation, I should have a pretty good clinical picture of what that looks like.

02:30 So this poor example here just says, "A client has a wound on their leg." Well, that's not really telling us much is it.

02:36 So let's look at a much better example.

02:39 Let's look on the other side of the screen where it says a client has a wound on their right, distal medial upper leg.

02:47 That's much more specific than the previous example of it's just on their leg.

02:52 So again, just take away as be specific and accurate with your documentation on location.

02:59 Now, let's talk about the wound bed itself.

03:02 So we need to look at the tissue type.

03:03 And really, there's about three different things we want to make sure we document with the wound bed: the tissue type, the exudate, and if you remember, when we talk about exudate, that's the drainage of the wound.

03:16 And is there any signs and symptoms of infection that's important to document.

03:20 So let's start with the tissue type.

03:23 So we look at the tissue, three different pretty common types of tissue that you'll see is necrotic.

03:29 This is that tissue that is like black, it's typically over setting inside the wound.

03:36 Now product problem with necrotic tissue is a lot of times you can't see underneath, what's that top necrotic tissue.

03:44 This can be problematic when you're treating a wound.

03:47 Next, you've got granulating tissue.

03:50 This is actually a positive sign.

03:52 When you see granulating tissue in a wound bed, you should see a little bit of redness, maybe hopefully little bleeding.

03:59 This is new tissue growth and this is healthy tissue.

04:03 So that's a positive sign.

04:05 Now you may also see a sloughing tissue type.

04:09 So what that may look like is maybe some white, kind of dead cells, debris inside the tissue.

04:16 This a lot of times may need to be cleaned off so we can get good granulating healthy tissue to the surface.

04:24 Now let's talk about that exudate.

04:27 FYI, this is our drainage we're going to talk about.

04:30 This is going to be really important about the consistency of it.

04:33 Does it have an odor or not? Also what color? That's going to determine on the progression of the healing of the wound.

04:42 And lastly, on this piece, don't forget signs and symptoms of infection.

04:47 So when we're talking about assessing that wound bed, the inner part of that wound, we definitely want to make sure we assess and document any of these signs of infection that you see here.

04:57 So this is a long list, but let's talk about a few with these.

05:01 So when you have an initial injury or initial wound, there can be some associated pain, which makes sense.

05:08 However, the longer that wound has been present, if there is brand new pain, or maybe increasing pain, this isn't always a good sign.

05:18 The pain eventually over time should decrease.

05:21 So again, if there's an odd increase or new pain that the patient experiences, you definitely want to report this to the physician.

05:29 And next, there should be some redness initially, but again, remembering the redness that's pretty normal in the inflammatory phase of our wound healing.

05:38 But if there's excess redness, and edema or swelling, this could be signs of infection.

05:45 Sometimes when you start healing a wound, you'll have again that exudate, that drainage, that's normal.

05:51 But if there's an increase in this, this could be a potential sign of infection.

05:56 And of course, if there's any extra bleeding, that's abnormal, this could be a delay in healing.

06:02 Don't forget that odor makes a difference.

06:05 So typically, our wound should not have an odor.

06:08 But if we're talking about maybe those diabetic foot wounds that are not healing properly, they've a really bad infection.

06:15 A lot of the times there's a gangrenous smell or odor that you may notice as a nurse.

06:20 This is a serious issue and we want to report this to the physician.

06:25 And lastly, there's something called tunneling.

06:28 Sometimes there's maybe a little pocket underneath the wound edge that we can't hardly see.

06:33 It's almost digging underneath or there's a little tunnel under the surface.

06:37 This is a bad sign, this could be a sign of infection and delayed healing.

06:43 Now we talked about the wound bed, don't forget, the other piece of wound care assessment is the edge of the wound itself.

06:50 So here, we're just focusing on that border.

06:53 Some things that can happen if there's an excess amount of exudate or drainage, or the wound is super moist, we call this maceration.

07:02 And this is a problem because the tissues around it can get really soft, too much moisture, and it can break down.

07:10 This kind of makes me think of my skin if maybe I was sitting in water too long and my skin gets really soft.

07:16 Well, the integrity, the skin's not as strong right.

07:20 And next, we've touched about this briefly before, this is something we call undermining or tunneling.

07:27 Now, this is when the tissue under that wound edge becomes eroded, and there's a little pocket underneath what we can see around that wound edge.

07:36 That also could be a potential issue for our patient and also something we need to report.

07:43 And lastly, with that edge, don't forget, assess that, that should be healing nice and closing up.

07:50 Sometimes the edge can kind of roll over itself, if you will.

07:53 The problem with this is the body thinks that it's healed.

07:57 And then those wound edges don't want to come in and close because of this rolled edge.

08:01 This is also an issue in wound healing.

08:05 Now don't forget the other piece that last piece of wound bed assessment is or excuse me, wound assessment is the peri-wound skin.

08:14 This is the stuff that's around the border the skin that's around the wound edge.

08:19 So if you take a look at this list here, these are all issues that we need to address.

08:24 Remember that maceration, that softness, any redness or any kind of chafing, dry skin, this could all be an issue.

08:33 If you have hyperkeratosis or calluses, so there's a buildup of excess tissue, this could prevent this wound from healing appropriately or any excess of drying.