20.6 Sample Documentation
Open Resources for Nursing (Open RN)
Sample Documentation of Expected Findings
3 cm x 2 cm Stage 3 pressure injury on the patient’s sacrum. Dark pink wound base with no signs of infection. Cleansed with normal saline spray and hydrocolloid dressing applied.
Sample Documentation of Unexpected Findings
3 cm x 2 cm Stage 3 pressure injury on the patient’s sacrum. Wound base is dark red with yellowish-green drainage present. Periwound skin is red, warm, and tender to palpation. Patient temperature is 36.8C. Cleansed with normal saline spray and wound culture specimen collected. Hydrocolloid dressing applied and Dr. Smith notified. Order received for wound culture.