1
DOCUMENTATION
Nurses Notes
Directions: After you irrigate your wound and dress the wound, document
information about the wound you cleansed, what solution you used to irrigate your
wound and the type of dressing you applied.
Date:
4/3/2023
Time:
4:30 pm
5:00 pm
Nurses Notes- Be sure to sign each entry
Patient wounds were irrigated, a wound culture was collected. Patient has a wound with granulation
tissue present. Narrow wound with redness present. Wound was packed with 1 4x4 gauze soaked
with Sterile saline. Covered with dry gauze. A large dry dressing was placed over the wound and
taped closed. SL-------------------------------------------------------------------------------------------------------------Examined eviscerated wound. Intestines were pouring out of upper abdomen. Put Saline-soaked
Gauze on abdomen, informed patient to flex their knees and informed HCP that patient will need
emergency surgery. ---------------------------------------------------------------------------------------------------------
___________________________
Nurse/Student Nurse signature
__Samuel Lankford_
Printed Name and Licensure