Clinical Procedure Page 1 of 2

Clinical Manual – Nursing Practice Manual

John Dempsey Hospital – Department of Nursing

The University of Connecticut Health Center

PROCEDURE FOR: Skin Care: Wound Management: Care of the Adult Inpatient

POLICY: 1. Complete a head-to-toe integumentary assessment within the time frame for adult physical assessment identified per unit in Protocol

for: Documentation: Admission (Inpatients).

2. Practitioner will be notified of the presence of or development of

any wound.

3. Documentation of wound appearance/assessment will occur on admission, on change of condition, upon development or

identification of a wound, with any dressing change and at

discharge.

4. Wound measurements will occur a minimum of weekly (every Wednesday), upon admission, identification of new wound, and at discharge.

5. On the day of discharge, the staff nurse responsible for the patient must document the wound, location, and treatment plan on the

discharge instructions/ W-10.

6. Treatment will be dependent upon Wound Care Specialist and practitioner recommendations. See Pressure Ulcers Prevention and

Management-Adults protocol for treatment of pressure ulcers.

7. All patients who have or develop a wound will have a dietary consult.

DESIRED PATIENT

OUTCOMES:

1. Patients will maintain optimal skin integrity. Wounds will heal

without complication.

CLINICAL

ASSESSMENT AND

CARE:

1. On admission, a full head-to-toe physical assessment of skin

integrity is to be performed. Dressings are to be removed unless

contraindicated i.e. negative pressure wound therapy (NPWT), unna

boot(s).

2. Documentation of all wounds will occur on the appropriate Skin and Wound Assessment Flowsheet.

a. Electronic documentation: for >4 pressure ulcers, >4 wounds or >1 wound vac, must select the box on the prevention screen stating

such.

b. Paper documentation: for >4 pressure ulcers, >4 wounds or >1 wound vac, additional pages can be used.

3. Documentation of wound appearance will occur with dressing change(s) a minimum of daily, (may not be visualized if dressing not

scheduled to be changed), and upon the development or identification

of a new wound and will include:

a. Location

b. Wound bed – color and type of tissue/character

c. Description of surrounding skin (periwound)

d. Exudate, if present – type, color, amount

Clinical Procedure Page 2 of 2

Clinical Manual – Nursing Practice Manual

John Dempsey Hospital – Department of Nursing

The University of Connecticut Health Center

PROCEDURE FOR: Skin Care: Wound Management: Care of the Adult Inpatient

PATIENT/CAREGIVER

EDUCATION:

e. Odor – presence or absence

f. Pain – presence of absence

4. Documentation of wound measurements will occur on admission, with the discovery of a new wound, at discharge, and a least weekly on

Wednesday. Wound measurement (in centimeters) will include:

a. Length – the longest measurement from 12 to 6 o’clock: use the patient’s head and feet as guides.

b. Width – the widest measurement from 3 – 9 o’clock, from side to side.

c. Depth – the distance from the visible surface to the deepest part of the wound. For intact skin document the depth as zero “0”.

If minimal measurable depth, document as less that <0.1 cm. If

depth cannot be determined because base of wound not visible

(covered with sough/eschar), document depth as indeterminable.

d. Location and depth of undermining and tunneling are to be documented using the clock face method (12 o’clock is the

patient’s head).

1. Educate patient/caregiver about risk factors, possible causes, preventative measures, and treatment regimens regarding patient’s

wounds.

2. Document on the Patient and Family Teaching Record and/or progress notes that education was provided.

APPROVAL: Nursing Standards Committee

EFFECTIVE DATE: 8/09

REVISION DATES: 11/09, 9/10, 9/10, 4/12, 12/12, 6/13