Wound care is a vital component of both home health and hospice care, although wound care in the hospice setting might have a slightly different goal than in home health. The latter focuses more on comfort care, especially if healing is no longer possible, while the former focuses on recovery. Wound care, as a process, encompasses the assessment, treatment, and monitoring of wounds. Its proper administration by licensed professionals results in infection prevention and fast recovery among patients. On top of making sure that appropriate guidelines are observed in administering wound care, proper wound documentation and charting should also be adopted by your agency. This helps you not only care for your patients by closely monitoring their wounds’ progress but also protects your agency from possible lawsuits resulting from negligence. To ensure this does not happen, we give you some tips to properly administer and document wound care.
Tip 1. Perform a thorough assessment of the wound and be specific in your documentation.
It is a must that you perform a risk assessment including a full body check of the patient upon admission. Use available tools to predict the probability of pressure injuries, e.g., the Braden Scale. Identify risk factors and establish measures to avoid wounds from occurring, reoccurring, or developing complications. If a wound develops, conduct a thorough assessment by identifying and taking note of the wound’s location, type of tissue damage (e.g., partial thickness, full thickness, etc.), tissue class (i.e., viable or nonviable), wound size, color, odor, appearance of sinus tracts, undermining, and wound edges, signs of local infection, and the patient’s pain level. It is important to visually describe the wound as specific as possible. Take photos to get a better visual of the wound’s status. All these can provide critical information to develop the wound treatment plan well as determine how long the healing will take.
Tip 2. Administer treatment and regularly monitor the wound’s status.
Administer wound cultures and topical antiseptic products if the wound is infected. Just make sure that the products are prescribed by the overseeing physician. Regularly clean the wound, remove damaged tissues (i.e., necrotic tissue), pack wounds especially the ones with depth, manage the wound’s odor and the patient’s pain level, and protect the periwound skin which can be damaged by the improper use of moist dressings. Monitor the wound’s length, width, and depth with the same clinician or discipline taking the measurements for consistency.
Tip 3. Take note of the patient’s response to the care plan and look out for factors that can affect healing.
It is crucial that you take note of the patient’s physical and behavioral responses to the treatment such as the patient’s pain levels, adverse reactions, and even refusals or non-adherence to the plan of care. Make sure you document the who, where, why, and when of the refusal to the treatment as well as the actions taken by the clinician to educate the patient on why it is needed. In addition, you should also take note that wounds do not usually occur in isolation and there might be contributing factors to their development. As such, it is important to understand whether healing is impaired because of these factors. For example, if the patient is diabetic, the wound nurse should consider glycemic control. Finally, the wound treatment plan should always take into account the patient’s nutrition and hydration as they are critical to wound healing.
Poor administration, documentation, and monitoring of wound care can be detrimental to your patients and their loved ones. Data Soft Logic, as the software that is always on your side, acknowledges this struggle and is here to help you. As such, we would like to invite you to the Wound Prevention and Management Course on November 8-12, 2021, at the Excell College 14025 Paramount Blvd., Paramount, CA. Learn how to properly prevent, manage, and care for wounds and earn your wound care certification through this live onsite course. Register now at www.excellcollege.com.
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