Focus on documentation in wound care inservice
It always helps to know the basics
Nurses sometimes need help in assessing wounds, and this is where you can help with an inservice on the required documentation of all wounds.
Medical Innovations of Woodbridge, VA, has a simple inservice program that first reviews federal requirements for wound care and then covers documentation and assessment of wounds.
It doesn’t hurt to start with the basics, one wound care specialist says.
"Nurses need to recognize necrotic [dead] tissue as opposed to granulation tissue, which is the healthy red tissue that is going to heal," says Marilyn Fishel, RN, CETN, MS, wound care preceptor of Medical Innovations’ Richmond, VA, office.
Fishel often helps nurses with their assessments, and she has seen some common mistakes occur:
• Sometimes nurses use the wrong product to absorb drainage in a wound. They might use a product that absorbs a lot of drainage when one that absorbs less would be adequate.
• Nurses sometimes use the wrong size dressing, placing one over a wound when the dressing’s too small. The dressing always should leave an inch around the border of a wound, Fishel says.
• Nurses might leave a wound too dry; moisture will provide a better climate for healing.
How it works
Medical Innovation’s inservice on wound care covers the following documentation steps:
• Make accurate measurements of wounds on admission and weekly throughout care.
"We use a disposable acetate sheet that nurses can put over a wound and trace the wound, or they can use measurement tape," Fishel says. The sheet is disposable, and it provides measurements in centimeters.
At the top of the wound assessment sheet, the nurse is asked to write down the wound’s length, width, and depth. Also, the assessment asks about the wound’s closure or whether the wound has sutures or staples present.
• Document, on the plan of treatment, a predictable end to daily or twice-a-day wound care.
Nurses use a separate order sheet to write down the specific wound care for up to three wounds, Fishel says. One copy is left in the home, another copy is put in the patient’s chart, and the third copy is sent to the physician’s office.
"Medicare requires us to make a prediction as to how long we’re going to keep doing the wound care," she adds.
The order form also has a place for comments where the nurse can write down whether the patient needs special provisions or directions.
• Document the color, odor, consistency, and quality of drainage on each visit.
Each of these characteristics are carefully documented on the assessment sheet, according to a common criteria. For example the nurses are asked to describe the odor in these terms:
There’s no odor at all.
There’s a slight odor with odor evident when the dressing is removed and the nurse is in proximity to the patient.
There’s a moderate odor that is evident at six to 10 feet after the dressing is removed.
There’s a strong odor that is evident upon entering the room with the dressing intact.
• If different nurses are doing twice-a-day wound care, then a complete assessment must be done on each visit as ordered by the plan of treatment.
Each assessment also includes a category for wound pain, measured in terms of whether its mild, moderate, or severe. Moderate pain is defined as being uncomfortable, but it doesn’t interfere with daily activities; severe pain does prevent the patient from engaging in daily activities, including walking.
The assessment also asks nurses to classify the wound into one of five stages, with the first being the skin is intact, and the redness doesn’t go away after 30 minutes of pressure release; 2-4 are more severe pressure sores; and five is when the nurse doesn’t know how deep a wound is or how many layers of tissue are involved, Fishel says.
• Temperatures are to be taken at each visit, and nurses are assessing for infection.
"Generally, taking the vital signs is a part of any home visit, whether the nurse is doing wound care or not," Fishel says.
"Other signs are to look for the drainage and the color around the wound to tell us if the wound is infected," she adds.
For example, a yellow or greenish drainage might indicate an infection. Likewise, if there’s redness around the wound and the patient has a fever, then it’s probably badly infected, Fishel explains. "At that point, the patient probably is going to require antibiotics."
• On the initial visit and weekly thereafter, there must be documentation stating why the client/caregiver is unable or unwilling to do the dressing changes.
Usually, Fishel says, if the patient has a family member who can take care of the dressing changes, then the nurse will go into the home once or twice a week to make sure the wound is healing properly.
But with Medicare patients, she adds, "often the spouse is too elderly or has poor vision and can’t do the care." In those cases, the agency will see if there’s a daughter or another family member who can help.
• On day 62 of nursing care, the summary documentation must include measurements and progress noted throughout the care, including documentation of changes in treatment.
Medical Innovations gives a "Nursing 62" update summary to the physician to let him know what kind of progress the agency has made in the last 62 days. This summary can be updated earlier than the 62 days, as well, Fishel comments.
"Our agency policy is if the assessment is changing, or if there’s not an improvement in the wound in two weeks then we probably need to make a change in our treatment," she explains.
"The summary makes us go back and look at how we can improve, and we must do it at a minimum of 62 days."
Skin likes moist environment
• If branch managers approve the purchase of a Polaroid camera, then two snapshots will be taken on admission and every other week thereafter, while daily visits are being made.
Fishel reviews the nurses’ wound assessments and snapshots to make sure the wound care is progressing as well as it should be.
Medical Innovations also has encouraged nurses to find the right product in treating wounds because this can help the wound heal faster. "We’ve changed to using some of the newer products on the market that will keep the wound moist," Fishel says.
"We don’t want the wound bed to dry out because that makes it take longer to heal," she adds. "New skin will grow more quickly in a moist environment."
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