WXY

WXY

WALKER USE

A walker consists of a metal frame with handgrips and four legs buttressing the patient on three sides. One side remains open. Because this device provides greater stability and security than do other ambulatory aids, it’s recommended that the patient with insufficient strength and balance use a walker instead of crutches or a cane.

ESSENTIAL DOCUMENTATION

Record the date and time of your entry. Record the type of walker used, such as a standard, stair, or reciprocal walker. Note whether any attachments are used, including platform attachments or wheels. Describe the degree of guarding that the patient requires. Chart the distance walked and the patient’s tolerance. Document all teaching related to the use of the walker.

WOUND ASSESSMENT

When caring for a patient with a wound, complete a thorough assessment so that you’ll have a clear baseline from which to evaluate healing and the appropriateness of therapy. Care may need to be altered if the wound doesn’t respond to therapy. Many facilities have a specific wound care protocol that specifies different treatment plans based on wound assessment. A wound should be assessed with each dressing change.

ESSENTIAL DOCUMENTATION

Record the date and time of your entry. Be sure to include the following points when documenting wound assessment:

wound size, including length, width, and depth in centimeters
wound shape
wound site, drawn on a body plan to document exact location
wound stage
characteristics of drainage, if any, including amount, color, and presence of odor
characteristics of the wound bed, including description of tissue type, such as granulation tissue, slough, or epithelial tissue, and percentage of each tissue type
character of the surrounding tissue
presence or absence of eschar
presence or absence of pain
presence or absence of undermining or tunneling (in centimeters).