Abrasion

Also Consider:  Bite Wound,  Laceration, Puncture Wound, Rash, Skin tear 

1. Take Vital Signs

• Temperature:

• Blood Pressure:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Location and size of abrasion

• Unrelieved pain

• Itching

• Skin: any new skin condition, i.e., bruising, rash, infection/cellulitis (redness, exudate), swelling, tenderness

• Bleeding

• Patient description of what caused the abrasion

3. Take Action using SBAR Report:

• Immediately notify the medical staff & resident representative

  • Accompanied by significant pain or uncontrolled bleeding 

• Notify medical staff & resident representative within the next 16 hours. 

  • Symptoms or signs of infection

• Notify medical staff at the next regular rounds 

  • Abrasion without complication treated using the facility protocol

4. Implement Management Plan

• Cleanse the wound and apply treatment per the facility protocol

  • Irrigate wound with saline solution

  • Consider applying a topical antibiotic

  • Apply non-stick dressing

• Place on 24-hour report for 2-3 days

• Investigate the cause of the abrasion

• Determine if abuse or neglect occurred

• If self-inflicted, consider trimming and filing the patient’s fingernails

• Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs

• Review status and plan of care with designated representative

2025-04-20