WOUND CARE

Effective Date: 
Wed, 12/01/2004
Reviewed: 
Sat, 08/27/2011
Revised: 
Fri, 09/09/2016

SUBJECT: WOUND CARE: initial visit

PERSONNEL: RN, LVN who has demonstrated competency in the care of wounds.

EQUIPMENT: Various supplies for the cleaning and dressing of wounds.

PROCEDURE:
In an initial visit for a new minor wound, first aid may be provided by the nurse. The nurse may clean and bandage a small abrasion, first degree burn (pink with no blistering), or superficial laceration (split thickness with easily controlled bleeding)
More serious or complex injuries and those incurred while bike riding, skateboard or MVA, where internal injuries may have occurred, are always evaluated by clinician.
The nurse utilizes universal precautions when caring for open wounds.
Vital signs, Td status noted, allergies to iodine, sulfa or other medications are noted.
If Td more than 10 years or dirty wound and Td more than 5 years, immunization is given with patient consent.
Wound may be soaked, cleaned, irrigated or scrubbed with sterile normal saline to clean and remove foreign material.
Irrigation is done with an irrigation splash guard and a 35 cc syringe to achieve recommended 8.0 psi
A moist wound may be dressed dry or Polysporin or Silvadene applied if bacterial contamination likely.
Sterile dressing is applied.
Patient is advised on how to care for wound and given follow-up instructions.
Minor wounds should not require follow-up visit, but patient encouraged to return if signs of infection or other problems.

DOCUMENTATION AND FOLLOW-UP:
The nurse documents vital signs, tetanus immunization status and history of present injury.
Utilizing SOAP format, the injury is described, a diagram drawn, measurements noted in the Medical Record.
The nurse’s evaluation of the injury, the care given and follow-up plan are written in chart.