How do you document a dressing?

Indicate how you cleaned the wound and what materials you used to dress the site. Document the patient’s response to wound care and the dressing change. Write the date, time, and your initials on the dressing itself so the next nurse knows when you changed it.

How do you describe a wound in writing?

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.

What is a wound assessment tool?

The Triangle of Wound Assessment is a new tool that extends the current concepts of wound bed preparation and TIME beyond the wound edge5. It divides assessment of the wound into three areas: the wound bed, the wound edge, and the periwound skin.

What does approximated mean in wound care?

Most wounds heal with primary intention, which means closing the wound right away. 1 Wounds that fit neatly together are referred to as “well approximated.” This is when the edges of a wound fit neatly together, such as a surgical incision, and can close easily.

How to document wound?

Method 2 of 2: Measuring with Tracing Obtain 2 wound tracing sheets and clean one of them. You’ll need 2 different types of sheets. Place the transparency over the wound and trace the wound. Make sure that the transparency covers the entire wound. Label the adhesive tracing with the patient’s information and wound size. Decide how frequently to measure the wound.

What is wound care assessment?

Wound assessment. Wound assessment is a component of wound management. As far as may be practical, the assessment is to be accomplished before prescribing any treatment plan. The objective is to collect information about the patient and about the wound, that may be relevant to planning and implementing the treatment.

What is a nursing documentation?

Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process.