The nurse is caring for a patient with a deep wound that has tunneling
Following the dressing change, what factors are essential for the nurse to document? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Amount of irrigation poured into the tunnel
2. Type of drainage coming from the wound
3. Size and shape of the tunnel
4. Direction and number of tunnels
5. Length of dressing needed to pack wound
2,3,4,5
Rationale 1: Irrigation fluid would not be poured into the tunnel during dressing changes.
Rationale 2: It is essential to document the type of drainage in order to assess for the presence of infection.
Rationale 3: The size and shape of the tunnel must be documented so the next person changing the dressing has that information as a guide.
Rationale 4: The number of tunnels and their direction must be documented so that the next person changing the dressing has that information as a guide.
Rationale 5: It is essential to document the length of dressing to provide information about the depth of the tunnel.
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