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Aug 26
12m 19s

Wound Assessment & Documentation

Kyle Rice
About this episode

Getsemani examines a patient with a Stage 4 pressure injury over the sacrum. The therapist inserts a sterile cotton-tipped applicator beneath the intact wound edge. The applicator advances 2.4 cm toward the patient’s head while remaining immediately beneath the skin. Which of the following is the MOST appropriate documentation of this finding?

A) Tunneling of 2.4 cm at 12 o’clock

B) Undermining of 2.4 cm at 12 o’clock

C) Maceration extending 2.4 cm at 12 o’clock

D) Induration extending 2.4 cm at 12 o’clock

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