How should I document an axillary wound after removal of gauze or foam packing, including location (right or left), dimensions, depth, granulation tissue appearance, drainage volume and timing, dressing type, analgesia administered, and plan for follow‑up?

Documentation of Axillary Wound After Packing Removal

Document the axillary wound systematically by recording laterality, dimensions (length × width × depth in centimeters), wound bed characteristics (granulation tissue quality, exposed structures), drainage volume and character, surrounding skin condition, pain management provided, and the follow-up plan. 1

Essential Documentation Components

Location and Wound Measurements

• Specify right or left axilla explicitly in your charting 1
• Measure and record wound dimensions: length, width, and depth in centimeters using a sterile probe to establish baseline for healing assessment 2, 1
• Document the wound size after packing removal, noting that the wound will appear larger once its full extent is exposed 2

Wound Bed Assessment

• Describe granulation tissue quality and quantity—healthy granulation tissue should be red, moist, and beefy in appearance 2
• Note any exposed structures such as tendon, bone, or fascia, which require immediate specialist referral 1
• Document tissue disorganization, necrotic tissue, or slough that may require further debridement 2
• Record the presence or absence of undermining or tunneling 2

Drainage Characteristics

• Quantify drainage volume (e.g., scant, moderate, copious) and note timing of assessment 3
• Describe drainage color (serous, serosanguineous, purulent), consistency, and odor 2, 3
• For wounds previously treated with negative pressure therapy, small amounts of serous ooze are normal findings 3

Surrounding Tissue and Infection Signs

• Document the extent of any surrounding erythema, measuring distance from wound edge (e.g., erythema extending >5 cm suggests systemic involvement) 2
• Record surrounding skin integrity, noting maceration, induration, or warmth 2, 3
• Note signs of infection: increased pain, swelling, purulent drainage, or foul odor 2, 3

Pain Management Documentation

• Record analgesia administered before and during dressing change, including medication name, dose, route, and time given 1
• Document patient's pain level using a standardized scale before, during, and after the procedure 4
• Note that gauze-based packing causes significantly less pain at removal compared to foam (mean pain score 4.15 vs 6.5, p=0.046) 4

Dressing Applied

• Specify the type of dressing applied after packing removal (e.g., dry sterile gauze, OpSite, foam-based negative pressure dressing) 2, 3
• For surgical site infections in the axilla, consider that these wounds require agents active against both gram-positive organisms and anaerobes 2
• Document whether the wound was left to heal by secondary intention or if closure is planned 2

Follow-Up Plan

• State the frequency of dressing changes (typically every 24-48 hours for negative pressure therapy, or as clinically indicated) 5
• Note whether repeat debridement is needed if nonviable tissue continues to form 2
• Document instructions for monitoring infection signs: increasing pain, redness, swelling, warmth, or discharge 6
• For hidradenitis suppurativa-related axillary wounds, consider secondary intention healing or TDAP flap closure for extensive excisions 2

Critical Findings Requiring Immediate Action

• Pain disproportionate to injury severity suggests deeper complications and requires immediate medical evaluation 1
• Exposed tendon or bone mandates immediate hospital referral for specialized care 1
• Systemic signs (fever >38.5°C, tachycardia >110 bpm, WBC >12,000/µL) with erythema extending >5 cm from wound edge indicate need for systemic antibiotics 2