Reporting Wound Changes

Observation without communication is incomplete care. When you observe a wound change and report it effectively, you initiate the chain of events that prevents infection from progressing to sepsis.

Section 01

What Always Requires Immediate Reporting

🚨 Report immediately — do not wait

New or suddenly increased purulent drainage (yellow, green, white cloudy)
Wound visibly larger than at previous visit
Red streaks extending from the wound (lymphangitis)
Significant increase in wound odor
Wound edges separating (dehiscence)
Client reports significantly increased pain at wound site
Fever or other systemic symptoms in a client with a wound
Exposed bone, tendon, or implant visible in wound
Any wound change that concerns you — even if you cannot specifically characterize it

When in doubt — report. The nurse can dismiss a non-urgent report. They cannot act on one never made.

Section 02

SBAR — Structured Reporting

💡 Use SBAR to organize your report to the nurse

S — Situation: "I am calling about [client]. The wound on their [location] has changed significantly since my last visit."

B — Background: "The wound has been healing with minimal drainage until today. The care plan specifies foam dressing changes every 3 days."

A — Assessment: "Today I found moderate purulent yellow drainage, increased redness extending 2cm beyond the wound, and client reports increased pain. Temperature is 99.8."

R — Recommendation: "I am concerned this wound may be infected and requesting nurse assessment today."

Section 03

Documentation After Reporting

Document wound findings in detail using specific descriptive language (REEDA framework)
Document that you reported: "Findings reported to supervising nurse [name] at [time]."
Document the nurse's response: "Nurse directed to continue current dressing and monitor" or "Nurse will visit for wound assessment."
Document any client education provided

Section 04

When Client or Family Asks You Not to Report

⚠ Your reporting obligation cannot be overridden

If a client or family member asks you not to report: your duty to report to the supervising nurse is a professional and legal obligation — not subject to client or family override. Explain kindly that you are required to report clinical changes to your supervisor. Document that they requested no report and that you reported anyway. If obstruction is consistent, notify your supervisor.

Section 05

Module 3 Complete

✓ Module 3: Wound Care and Infection Prevention complete

You now know how to recognize wound infection signs, apply clean and sterile technique, perform safe wound care in the home, select appropriate dressings, and report wound changes using SBAR. Module 4 covers preventing the spread of infection — environmental cleaning, isolation, and transmission prevention.