Case Scenarios: Accidentally Retained Dressings and Standardized Documentation Protection Status
Standardized Documentation

by Margaret Heale RN, MSc, CWOCN

Wound care can be so straightforward. The process starts with a comprehensive assessment, and then the wound care regimen can be planned and the frequency of dressing changes determined. A well-written order will include all of the relevant components of a wound care regimen listed below:

  • Clean
  • Debride
  • Address bioburden
  • Actively manage wound bed
  • Hydrate or maintain moisture balance or absorb drainage
  • Protect periwound skin
  • Secure and maintain a semi-occlusive environment
  • Support venous return
  • Optimize arterial supply
  • Address pain
  • Supplement nutrition
  • Prevent infection
  • Offload pressure
  • Address continence issues
  • Refer to therapies and social services

At the simplest, this can read as a one liner such as:

"Wound care to dehisced midline abdominal incision every other day and prn Irrig NS, clean and dry periwound, apply skin protectant tuck in Aquacel Ag ribbon secure with tape."

Exactly the same dressing could also read like this:

"Patient may remove dressing (keep to show to VN), shower, and then shower wound (avoid soap on wound). Skin protectant to skin edge and where tape will be. Tuck Aquacel Ag ribbon into base starting with the 4cm tunnel at 2 o'clock leave a long tail folded over gauze cover. Secure with tape."

Reading wordy instructions is difficult, and when in a rush to get the day started, it is difficult to trudge through detail. When most orders are written using the same format, some detail is missed because, at a glance, people see the bit they need (abdominal wound, tuck in Aquacel Ag). It is very easy to miss specific or important instructions.

Uncustomized formats are unnecessarily lengthy, with blank spaces and redundant detail. If the nurses reading the procedure are more experienced and familiar with how the agency or facility works, they don't look, or rather see, what is written.

Case Scenarios

A patient is admitted to rehab with a small, heavily draining wound. The order states ribbon gauze daily and prn. After several weeks, when it is clear there is little progress and possibly some deterioration, a nurse irrigates the wound copiously with saline for well over the time normally given. Eventually, she manages to get hold of something with forceps and extracts a full length of ribbon gauze.

A wound care nurse goes with a new employee to begin a competency session for performing negative pressure wound therapy (NPWT). The specialist thinks it odd that two tiny wounds are still having foam applied and demonstrates during the dressing change how to use Q-tips to probe the wound and discusses with the nurse how to ensure pieces of foam are not missed. The wound bed is clearly granulation tissue. The top two small wounds are no longer included in the dressing. Four weeks later, these two small wounds remain unhealed, the patient has a fever, and the top wound is draining excessively and starts to break down. The surgeon removes a piece of black foam left in long before admission to home care. We have all extracted "foreign bodies" from wounds, and it is easy to lay blame on others. Dressings can look like wound tissue, and granulation tissue can grow over and cover dressing material.

Strategies to Avoid Retained Dressing Products

There are a few avenues to follow that will reduce the likelihood of retained dressing products:

Lighting. This allows you to be able to discern an incongruent wound bed.

Probing. Pressing a Q-tip over the base of a wound and identifying undermined areas or tunnels (where a dressing can hide) is important.

Palpation. This is important for several reasons: it can indicate a collection of pus if fluctuance is felt or, if the wound is indurated, tissue damage from deep tissue injury, bruising, an infective process, or a hidden dressing.

Pressing. This is a little different from palpating as pressure is applied in a way that will express exudate, pus, and—yes, you got it—foreign bodies: a hidden dressing.

Pillars, not layers. When tucking a dressing into a wound, don't use layers from the base to the top; use a line of pillars, or envelop the dressing layers.

Tails. Dressings migrate, and now that we tend to tuck a dressing into the wound base instead of packing it tight, migration may be occurring more often. Leaving a 2cm piece outside of the wound is not sufficient. Taping a tail to the skin is not possible if the dressing gels when wet. Placing gauze over the wound and folding the tail on top of this works well.

Counting and documenting dressings. Counting and documenting the number of dressings used in the wound is a basic, long-standing standard. It is a must for NPWT. It is difficult (for some unknown reason) to remember to write the number of dressings used on the dressing, but this is a helpful and very efficient way of ensuring the next nurse knows what to expect.

Education Versus Detail

A patient with a leg wound who is not able to wash the leg should not need an order stating to wash the foot and leg. All nurses should know to do this and dry between and behind the toes; it should not need to be stated. Just as any detail relating to applying a wrap should be superfluous. Orders exist because of the need for prescriptive treatments, as it is this that drives reimbursement. Care is bundled and not reimbursable; sadly, this is interpreted as its being less important. The level of responsibility relating to wound care is high and cannot be assumed without the education of the bedside clinician. Clinicians performing wound care need to have better background education as the details matter, especially when it comes to caring for wounds. Just doing what is ordered is insufficient as without critical thinking skills the clinician at the bedside is an automaton, and that is not what patients need.

About the Author
Margaret Heale has a clinical consulting service, Heale Wound Care in Southeastern Vermont and draws on her extensive experience as a wound, ostomy and continence nurse in acute and long-term care settings to provide education and holistic care in her practice.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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