While cleaning a wound, the nurse determines that undermining is at the top of the wound. Which documentation of the wound by the nurse is best?
a. Dark pink wound with undermining at 2 o'clock
b. Wound clean and without odor with slight undermining toward patient's head
c. See photograph of wound taken today
d. Pale pink wound 2 cm x 3 cm x 2 cm deep with undermining at 12 o'clock
D
The best documentation is "Pale pink wound 2 cm x 3 cm x 2 cm deep with undermining at 12 o'clock.". This entry contains the size, color, and location of the undermining of the wound. The other entries omit key information. Although a photo may be useful, the documentation contains no description of the wound itself.
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