When the nurse documents a client's wound, which is the best means of describing the wound?

Question

1. Measuring the wound and documenting size
2. Comparing the wound to a universally understood object, such as a quarter or cashew
3. Using terms such as small, medium, or large
4. Taking a picture and inserting it into the record

Answer 1

1
Rationale 1: The wound should be described in as objective a manner as possible to allow for continuity of care. An objective description allows successive care providers to evaluate changes. The most objective means of describing a wound is using measurements.
Rationale 2: If measurement is not possible, comparing the wound to a universally understood object would be the next best means of describing the wound.
Rationale 3: Terms such as small, medium, or large have no universal meaning, and are very subjective.
Rationale 4: Taking a picture would require the client's signed consent. This is not usually done.
Global Rationale: The wound should be described in as objective a manner as possible to allow for continuity of care. An objective description allows successive care providers to evaluate changes. The most objective means of describing a wound is using measurements. If measurement is not possible, comparing the wound to a universally understood object would be the next best means of describing the wound. Terms such as small, medium, or large have no universal meaning, and are very subjective. Taking a picture would require the client's signed consent. This is not usually done.