Procedure Guideline for Assessing Wounds
Equipment for Assessing Wounds
The skill of wound assessment may not be delegated to nursing assistive personnel (NAP). It is your responsibility as the nurse to assess, and document wound characteristics. Before delegating related tasks, be sure to inform NAP of the following:
Sample Documentation for Assessing Wounds
1000 Abdominal dressing dry and intact. The skin around the dressing is pink with no swelling, bruising, discoloration, or excessive warmth. Resident denies pain on palpation and appears comfortable during the assessment. —T. Wulandari, RN 12/17/13
1630 Removed initial surgical dressing per order. 3-inch wound is red. Suture line is approximated. Steri-Strips intact. Small amount of serous drainage, no foul odor. Sterile dressing applied. —J. Doe, RN 12/17/13