Wound Assessment & Documentation Posts

Archive for the ‘Wound Assessment & Documentation’ Category

Exudate: What the Types and Quantities Tell You

Thursday, January 26th, 2023

For successful wound treatment and healing, it’s vital to understand the different types of exudate and how much is present.

Ooze. Pus. Secretion. The drainage that seeps out of wounds can go by many names, but as wound care clinicians, you know the technical term is exudate. This liquid is produced by the body in response to tissue damage and tells you all you need to know about the wound.

Dianna Dashner, DNP, FNP-C, WCC, CLNC, LLE, Senior Nurse Practitioner at ProMedica Skilled Nursing and Rehabilitation said it’s important to know the type and amount of exudate because this will direct the type of treatment.

“For example, the use of a calcium alginate necessitates moderate to heavy exudate,” she said. “If the wound has purulent drainage, you will want to thoroughly cleanse the wound to remove all the exudate and then culture the wound.” She added that if an infection is suspected and there is moderate to heavy drainage, a calcium alginate with silver may be a good choice for treatment. Her example highlights the significance that the amount and type of exudate makes in wound treatment.

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What Happened to Practicing Wound Care Basics?

Friday, September 23rd, 2022

Having been involved in wound care for about 25 years, I have seen many changes in our understanding of wound healing, research evidence, and technology, often straying from wound care basics.

As I hear my students describe common practices today and the many myths of wound care, I’m led to wonder, “What happened to starting with wound care basics for healing?”

A colleague of mine once stated there are basically two fundamentals to healing wounds: a healthy patient and a healthy wound environment. Once those are accomplished, topical treatments will not make that big of a difference.

However, clinicians often cling to some “holy grail” treatment in the form of a dressing or adjunctive modality that will somehow overcome the need to practice solid, evidence-based wound care.

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Posted in Nutrition & Wound Management, Skin & Wound Management, Wound Assessment & Documentation, Wound Healing | Comments Off on What Happened to Practicing Wound Care Basics?

Spotting Signs of Wound Infection is the First Step in Proper Treatment

Tuesday, May 31st, 2022

Understanding the most current literature describing stages and signs of wound infection helps clinicians to accurately assess wounds.

“If we allow wounds to become infected then it certainly impedes the healing process,” said Patricia A. Slachta, PhD, RN, APRN, ACNS-BC, CWOCN, co-director of the Wound Care Nurse Education Program at Relias.

With an accurate assessment, wound care clinicians can prevent infection or identify signs of wound infection early and allow the body to heal the wound as quickly as possible, without using antibiotics, according to Slachta, who shared her expertise on how to determine if a wound is infected and needs antibiotic treatment.

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Pediatric Patients Require Special Wound Care

Tuesday, September 21st, 2021

Pediatric patients with chronic and acute wounds need caregivers who are well-versed in wounds and in young patients’ unique needs. We spoke with three pediatric wound care experts to learn more about the most common wounds seen in kids, their etiologies, treatments, and recommendations for making dressing changes less traumatic.

Acute Wounds Seen in Pediatric Patients

Pediatric patients can need treatment for a wide range of wounds. In fact, the list is quite extensive, according to experts.

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Unpacking the Fundamentals of Burn Wounds

Wednesday, August 25th, 2021

As a wound care clinician, you may be called to work in a burn unit or be consulted on burn wounds. If that is not your normal work setting, it can be overwhelming.

Our purpose in this article is to address the fundamentals and provide a solid working knowledge of how to manage burn wounds.

Let’s start with terminology. The American Burn Association changed the classification of burns from the traditional first-, second-, third-, and fourth-degree burns to the following:

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A Look at the UT and Wagner Scale Diabetic Foot Ulcer Classification Systems

Thursday, August 19th, 2021

Given the fact that DFUs occur in approximately 15% of patients with diabetes and there are more than 34 million people in the U.S. with diabetes, using a relevant diabetic foot ulcer classification system for patients is essential.

There are several diabetic wound classification systems. But how do you choose which one to use?

This decision generally involves clinician preference along with the organization’s policy.

Two wound care specialists provide an overview of two systems for DFU classification: The Wagner Scale and the University of Texas (UT) Diabetic Wound Classification System.

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Legal Case Highlights Importance of Wound Care Documentation

Wednesday, November 4th, 2020

We have discussed the importance of nurse expert testimony in cases alleging professional negligence against you.

One blog addressed a breach of your standard of care when providing wound care.

A second reviewed the importance of your wound care documentation in the patient’s medical record.

This article takes a look at the 2016 case, Henson v. Grenada Lake Medical Center, to underscore both of these important points.

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Wound Treatment: 3 Questions to Help You Determine Appropriate Care

Thursday, September 24th, 2020

How many times have you wondered, or questioned, whether an ordered wound treatment was appropriate?

I would not be not surprised if you said, “More often than I would like.” Unfortunately, that is the reality for wound care specialists today.

According to a 2018 BMJ Open article, nurse researchers found an overuse of wound treatments with limited evidence and low value. They also found an underuse of evidence-based treatments.

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Nursing Documentation in Wound Care Is a Key Factor in Determining Liability

Thursday, August 13th, 2020

The medical record is an essential piece of evidence in any legal case alleging professional negligence against wound care nurses and others.

As you know, one of the purposes of the medical record is to reflect what nursing care was given to the patient. The entries speak to the quality of the care given.

The entries are supplemented by oral testimony at trial of those whose notations are in the medical record. A jury then decides if care was given that meets the standard of care in the situation or if the caregiver failed to meet his or her legal obligation.

The following 2020 legal court decision (Nixon v. The Brookdale Hospital Medical Center, Parkshore Health Care, LLC, Four Seasons Nursing and Rehabilitation Center, and the New York Community Hospital of Brooklyn, Inc.), illustrates the importance of nursing documentation and potential liability for patient injuries and death.

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Learn How to Determine What Wound Exudate Is Telling You

Wednesday, July 1st, 2020

An integral part of a wound assessment includes analyzing the type and amount of wound exudate coming from the wound.

Knowing how to correctly make those observations and documenting accordingly is critical to a comprehensive assessment. Ultimately, we want a wound with an optimal level of moisture to support healing and not an overly moist or dry environment.

However, as wound care specialists or experts, we need to take it one step further and ask a few more questions.

Is this the type and amount of drainage I expect to see based on the wound’s current healing path?
If it is not, why is the exudate presenting this way?
How do we correct that?

A good wound care clinician does more than just make observations and note them. They are continually critically thinking and asking “why” and seeking solutions.

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