Wound Assessment and Documentation

Laurie Swezey's picture
identifying infected wounds

By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS

As health care providers, we are all familiar with the signs of wound inflammation. However, it can sometimes be difficult to determine whether a wound is inflamed, undergoing the normal and expected inflammatory response to tissue injury, or infected. In this article we’ll review the definition of infection and assessment of the potentially infected wound.

Cheryl Carver's picture
Keywords: 
Lab culture

By Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

I see it all of the time. Wound care clinicians performing wound cultures incorrectly, or obtaining cultures just because there is an open wound. With this being said, there are certain health care settings where per protocol, swab cultures are taken on every wound, even without signs and symptoms of infection. But I want you to always ask yourself a few questions when determining if a culture is warranted: Are there signs and symptoms of infection? Is there an odor after the wound has been cleansed? Has wound healing stalled? Maybe there is a biofilm present?

Cheryl Carver's picture
Staphylococcus aureus biofilm

By Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

One of my favorite topics to discuss in wound care is biofilms. When I conduct wound care in-services or trainings, I always ask the audience, "Who wants to tell me what a biofilm is?" There is silence. From that point, I proceed to tell my little story about biofilms. It sounds a little like this...You know when we go to bed at night, get up in the morning and feel that sticky film on our teeth? We brush our teeth with a minty-fresh toothpaste. Now our teeth feel clean. By the next morning, that sticky, fuzzy feeling returns, right? Or, when your pet's water dish develops that slimy swamp layer and then you change it? Well that, my folks, is a biofilm!

Margaret Heale's picture
Accountability

By Margaret Heale, RN, MSc, CWOCN

Most of the residents here are elderly, though some of the more acute rehab patients are quite a bit younger than me. We actually have five women over a 100 out of 116 people, quite impressive with the eldest being 105 years old. As for me, I am a retired British matron just doing a little volunteer work near where my granddaughter works.

Cheryl Carver's picture
safety net

By Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

Substandard documentation tops the list of mistakes for long-term care facilities. It involves "all hands in the chart" so to speak. This encompasses all disciplines, from the nursing assistant to the physician. Discrepancies and gaps in documentation put your facility at risk of litigation. Impeccable documentation is essential in defending any case. Your facility must have a "safety net" in place. This "safety net" consists of educating staff about the importance of timely and detailed documentation not only for the facility, but for their license. Often times, clinicians are not aware of the legal repercussions of their actions. Surveyors will also consider other related Federal Tags (F-Tags) during investigations for compliance.

Aletha Tippett MD's picture
periphereal vascular disease

By Aletha Tippett MD

I was recently talking to a young nursing student who told me she had had a terrible week and cried when she had to do wound care for a patient. When asked what the problem was she reported that her patient was an elderly man near death who had severe peripheral vascular disease with gangrene on both feet. He had severe pain whenever touched and she was instructed to wrap his legs with gauze and ace wraps.

Cheryl Carver's picture

By Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

Being an independent wound care education consultant in long-term care, I get a lot of questions regarding moisture-associated skin damage (MASD). Is it MASD or a pressure ulcer? When do I change it from MASD to pressure ulcer in my documentation?

Lydia Corum's picture
black widow spider

By Lydia A. Meyers RN, MSN, CWCN

In the times that I have worked with amazing hospitals and doctors, I have learned and gathered information on the differences between two types of necrotizing infections that happen in the world of wound care. Necrotizing fasciitis (NF) and spider bites can present as similar in nature and need immediate intervention.

Samantha Kuplicki's picture
Pain

By Samantha Kuplicki, MSN, APRN-CNS, ACNS-BC, CWS, CWCN, CFCN

The Patient Assessment
You've been asked to evaluate a patient for negative pressure wound therapy (NPWT). It turns out they're a perfect candidate, so you start the process to have the unit placed immediately! The order is entered into the EHR for the recommended settings, and the initial dressing application is scheduled.

Aletha Tippett MD's picture
Braden Scale

By Aletha Tippett MD

I was recently asked to speak on best practices for prevention of pressure ulcers for a group of state surveyors. This is an excellent subject and here is how I would address it: