Wound Care

348 Nurse to Nurse
Nursing Alert
All wounds other than neuropathic or diabetic are documented
as partial or full thickness.
Remember that pressure ulcers may heal but are
always documented by the deepest amount of tissue
involved.Therefore, a stage III pressure ulcer is always a
stage III pressure ulcer and is documented as a healing
stage III unless the wound worsens to a stage IV. There
is currently no back or down-staging of pressure ulcers
during healing.
• Document the current treatment, the patient’s ability to
adhere to the treatment plan, and any changes in the treatment
plan with rationale for these changes.
• Document patient and caregiver education provided including
their ability to state the education in their own words and
their intention of doing as the education suggests. For example:
elevate your left leg above heart level every 2 hours throughout
the day for at least 15 minutes each time. Patient states, “I
will elevate my leg on a pillow every 2 hours for 15 minutes
during the day at work.”
• Document the patient’s pain level at dressing change or treatment
and during the time between dressing changes or treatments.
It is recommended to use a scale that begins with no
or zero pain and goes up in increments to the worst pain ever
experienced. There are a variety of pain scales that have been
validated with differing patient populations.
— Documentation must include what the health-care provider
has done about the patient’s pain. This must include
whether the action has produced the desired effect or not.
— Document what actions the patient has taken to alleviate
the pain and whether these have achieved any difference
in pain level. For example: “I lowered my leg over the bed
and after about 15 minutes it was tolerable.”
• When removing the dressing, note the condition of the dressing
and document this in the medical record. For example: