Wound Care Documentation in the SNF
Wound assessment requires an assessment of the patient with the wound, not just the wound itself. When completing dressing changes or treatments the nursing documentation should include the current assessment of the wound. If the dressing is not being changed an assessment of the dressing and the skin around the dressing should be documented.
It is important to monitor and track, or reassess, wound status to identify signs and symptoms of complications of failure to heal as early in the process as possible. Early intervention improves the likelihood of resolving complications successfully and getting the healing process back on track.
Every 8 hours comprehensive nursing wound care documentation should indicate answers to at least the following questions:
What is the location of the wound?
Is the dressing intact?
Is there drainage on the outside of the dressing material?
Is there any odor from the wound?
A non-infected wound usually produces little to no odor.(exception hydrocolloid dressings )
Is the wound/ area surrounding the wound or dressing, red, hot or swollen?
The color of skin around the wound can alert you to problems.
White skin indicates maceration, too much moisture, may need a protective barrier around the wound or a more absorbent dressing. Red skin can indicate inflammation, infection / excessive pressure. Purple skin can indicate bruising /trauma.
Is there soreness out of proportion to what should be present given the patient's medical history and the progression and etiology of the wound?
When changing dressings or completing ordered wound treatment, assess and document the current wound status. Assess the wound bed and the surrounding skin only after they have been cleaned (according to facilities policy).