Wound Care Nursing: Skin Assessment and Documentation

Introduction

• Presenter: Cathy, Certified Wound Care Nurse
• Purpose: To help nurses and nursing students feel comfortable and confident in providing wound care.
• Topics in Series:
  • Thorough skin assessment
  • Identifying and caring for wounds
  • Effective charting on wounds
  • Staging pressure injuries
  • Care for common wounds: skin tears, moisture-associated damage
  • Wound VAC: usage, troubleshooting, changing dressings

Importance of Skin Assessment

• Timing: Critical during patient admission.
• Objective: Identify and document any existing wounds to prevent classification as hospital-acquired.
• Consequences of Missed Documentation:
  • Hospital-acquired pressure injuries lead to no reimbursement and potential state audits.
  • Importance of documentation within the first 24 hours.

Conducting a Thorough Skin Assessment

• Target Patients: All patients regardless of age.
• Method: Head-to-toe assessment, ideally with a second person.
• Areas to Focus:
  • Pressure injuries over bony prominences: head, scapula, coccyx, sacrum, heels.
  • Moisture-associated skin damage due to incontinence.
  • Diabetic foot ulcers, especially in diabetic patients.
• Tools: Take pictures of wounds for documentation.

Identifying Wounds

• Types of Wounds:
  • Pressure Injuries: Occur over bony prominences, previously known as pressure ulcers.
  • Moisture Damage: Associated with incontinence; look for redness, erythema, rashes.
  • Diabetic Wounds: Common on feet.
• Assessment Strategy:
  • Utilize mentors or charge nurses to help identify.
  • Document based on best judgment when unsure.

Documentation and Follow-Up

• Documentation:
  • Essential for legal and reimbursement reasons.
  • Take a picture and chart to establish the wound was present on admission.
• Wound Consult:
  • Required if unsure about wound identification or care.
  • Wound care team can reclassify wounds after assessment.

Conclusion

• Critical Reminder: First 24-hour documentation is crucial.
• Next Steps: Upcoming videos will provide further wound care insights.

End of Notes