Savoring Success by Empowering Our Nurses in Wound Care and Documentation

Wound care can be challenging for bedside nurses. If they are unfamiliar with the latest practices and products, they will lack confidence in staging, documentation and bedside management of wounds.  Frequent and inappropriate requests for Wound, Ostomy and Continence Nurse (WOCN) consultation often result as does the nurses’ resistance toward performing dressing changes. The implementation of a comprehensive wound care and documentation program can empower the bedside nurse to improve the patient’s wound care outcomes and appropriately utilize WOCN consultation as noted below.

Objectives:

• To empower the nurse with knowledge and tools for the staging, documentation, and bedside care of wounds
• To ensure WOCN consultations are necessary and appropriate.

Methods: All bedside nurses received online wound education that allowed the education department to track utilization and knowledge metrics. A documentation “sticker” and protocols were developed based on best practices to provide for staging, documentation and management of wounds by the bedside nurse. The study took place on two units where bedside nurses were required to complete wound care modules. The nurses were assisted by Education staff and WOCN consultation so they could develop confidence with the new protocols.Feedback from the nurses allowed changes in the new documentaion forms to be made prior to hospital wide  initiation.

Results: After three months, the WOCNs performed chart audits on all patients admitted with wounds. Chart audits demonstrated marked improvement by the bedside nurses, i.e.:

• Removing dressings on admission and weekly plus documentation in the progress notes with wound measurements, descriptions, and redressings
• Consistently staging and charting wound care in the narrative notes
• Appropriate WOCN consultation