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This guide provides tips for wound assessment and documentation, including wound measurements, types of wounds, signs of abnormal wound healing, and assessment of the wound bed, wound edge, and periwound skin.
Wound assessment requires a multifaceted approach; this guide includes topics ranging from patient interview questions to wound bed preparation, and assessment of wounds for signs of infection. Documentation tips are also provided to help health care providers correctly translate their patient wound assessments into complete
McKesson offers comprehensive wound care products including: • Antifungals • Wound cleansers • Wound measuring guides • No sting liquid film skin protectors • Adhesive removers • Collagens • Xeroform • Hydrogels • Hydrophilic wound dressings • Transparent films • Hydrocolloids • Adhesive and non-adhesive foams
Steps of Assessment. Identify the location of the wound. Determine Cause (etiology) of wound. Determine stage (if applicable) of the wound. Pressure injury staging. Evaluate and measure depth, length, width of wound. Measure amount of undermining and tunneling. Evaluate wound bed.
Find a variety of wound care documents including charts, worksheets, and questionnaires for various treatments. Simplify your wound care process with our customizable templates.
DOCUMENTATION GUIDE. Wound Type/ Etiology. Document the Wound Type/Etiology, if known. If you cannot determine the cause of the wound: Consider your choices below. Consult with Wound Care Clinician as per agency policy for guidance, or. Chose the Unknown option if etiology is unknown Pressure Injury.
Skin/Wound Site Dietary Intervention Added to CP Date Healed Culture Results Culture Onset Date Notify MD Date Notify Family Intervention 1. Air Fluidized Mattress 4. Water Mattress 7. Positioning Pillows 10. Nutrition/Hydration Interventions 13. Other_____ Codes: 2. Air Mattress 5.Therapeutic Bed 8.
Wound Measurement & Documentation Guide. Pressure Ulcer Documentation. Wound Location: Designate left, right, top, bottom, side, front, middle, etc., as appropriate (for example, inner left knee)
WOUND DOCUMENTATION. Wound bed. Three areas of wound assessment and documentation =. Wound edge. Peri-wound skin. Supplies needed: Measuring tape. Sterile cotton tip applicator.
Easily track and manage wound injuries with our free Wound of Injury Care Tracker Chart Template. Download in PDF or Word format, or fill it online and save as a ready-to-print PDF.