Wound Care 101

Diane Krasner's picture
wound care documentation

By Diane L. Krasner, PhD, RN, FAAN

Scope of Practice and Standards of Practice guide nurses and other members of the interprofessional wound care team in caring for patients with wounds. Documentation in the medical record is a key aspect of the standard of practice and serves to record the care delivered to the patient or resident. Your documentation should follow your facility guideline for documentation. Accurate documentation helps to improve patient safety, outcomes, and quality of care.

This WoundSource Trending Topic blog considers general wound documentation dos and don'ts and presents 10 tips for success. Good, better, and best documentation examples are included for each tip.

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Aseptic: Aseptic surgical procedures are those that aim at eliminating the risk of transmission of all harmful microorganisms. Aseptic practices can prevent the cross-contamination of pathogens.

Bioburden: The number of microorganisms within a wound is referred to as bioburden. Bioburden management is crucial in post-operative care to prevent infection.

Cellular/tissue-based products: These are products, commonly derived from cadavers or other human and other animal cells, that can aid in closing dehisced surgical wounds by providing a substitute for the skin to act as a barrier while healing.

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Maceration

By the WoundSource Editors

Maceration occurs when skin has been exposed to moisture for too long. A telltale sign of maceration is skin that looks soggy, feels soft, or appears whiter than usual. There may be a white ring around the wound in wounds that are too moist or have exposure to too much drainage.

Lauren Lazarevski's picture
Personal Protective Equipment

By Lauren Lazarevski RN, BSN, CWOCN

Calling the COVID-19 pandemic an "unprecedented time" is an understatement. In this time of uncertainty, predicting what to expect can provide some comfort via preparation for the future. We can presume several implications for wound care professionals, based on the clinical course and community response to our evolving situation. Wound care health professionals should be prepared for some unique circumstances on the other side of the curve.

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Burns

Burns occur when the skin comes into contact with a heat source or caustic substance, commonly fire or flames, boiling liquid, hot objects, electrical current, or chemical agents. Different mechanisms of injury that can cause a burn include scalding, fire, chemical exposure, electrical exposure, and radiation. The extent of injuries that can occur from a burn is highly variable, and morbidity and mortality tend to increase as the surface area of the burn increases. Proper classification of burns is essential in guiding the initial management of the burn wound and achieving optimal outcomes.

Kara Couch's picture
Frequently Asked Questions

By Kara S. Couch, MS, CRNP, CWCN-AP

Hospital-acquired pressure ulcers (HAPUs) pose a challenge for acute and post-acute care environments and are listed as hospital-acquired conditions (HACs) by the Centers for Medicare & Medicaid Services (CMS). Other HACs include central line–associated blood stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). Although CLABSIs and CAUTIs have seen a decrease in prevalence over the past decade, the HAPU is the only HAC that has not. In my recent WoundSource webinar, I discussed the topic of building a pressure ulcer prevention program within hospitals. The webinar is still available for viewing on WoundSource.com.

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Emily Greenstein's picture
Wound Care Resolutions

By Emily Greenstein, APRN, CNP, CWON, FACCWS

The New Year is finally here, the beginning of a new decade. And we all know that with the calendar change comes the urge to get rid of any and all bad habits. Time to start over, wipe the slate clean, and transform into something amazing. Except, in reality it never seems to happen that way. We may start out well and then fall off the wagon and back into old habits.

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Fistulas

By the WoundSource Editors

Fistulas are abnormal connections or passageways between two organs or vessels that do not usually connect. Although they typically develop as a result of an injury or surgery, they can also be caused by infection or inflammation. The World Health Organization estimates that there are between 50,000 and 100,000 new cases of obstetric fistula annually, and the number of all types of fistulas is substantially higher.

Holly Hovan's picture
Wound Documentation Mistakes

By Holly M. Hovan MSN, RN-BC, APRN.ACNS-BC, CWOCN-AP

Documentation is a huge part of our practice as wound care nurses. It is how we take credit for the care we provide to our patients and how we explain things so that other providers can understand what is going on with the patient, and it is used for legal and billing purposes as well.

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Complex Wounds

By the WoundSource Editors

Complex wounds pose a significant challenge for many health care providers. These wounds are often multifaceted, making treatment tremendously difficult. They represent a substantial burden on the health care industry, with annual costs in North America alone estimated at $10 billion annually. They often also result in patient discomfort and pain, caregiver frustration, individual economic losses, and diminished quality of life.