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Nursing Knowledge
There are 3 overall areas of wound assessment and documentation:
Assess and document the following:
Check for:
Assess for:
The different types of wounds include:
Signs of abnormal wound healing include:
Date: June 28, 2023
Location: right lower leg, lateral
Size: length 4 cm, width 3 cm, depth 2 mm
Wound bed appearance: wound bed 70% covered in red granulation tissue, 30% yellow slough; no necrotic tissue present
Exudate: moderate amount of serosanguinous drainage noted, no odor detected
Pain: client reports pain level as 4 on a 0–10 scale, describes a 'burning' sensation
Peri-wound skin: skin pink, warm to touch, no signs of infection; mild edema present
Wound edges: well-defined, not rolled
Treatment: wound cleansed with normal saline; topical hydrogel applied then absorbent dressing applied and secured with paper tape
Client Response: tolerated procedure well, reports decreased pain following dressing application
Progress: compared to last assessment on June 26, 2023, wound length decreased by 1 cm, width remains the same, depth decreased by 1 cm; granulation tissue increased by 20%
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