Laceration, Incised wound, Cut
Also Consider: Abrasion, Bite Wound, Puncture Wound, Rash, Skin Tear
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Definition
Laceration: a tearing of the skin usually caused by blunt trauma
Incised wound, cut: a cut through the skin usually caused by a sharp object such as a knife or razor
Wounds that are deeper than 5mm, longer than 20mm, over joints, or gaping may require closure with sutures or staples. Smaller wounds on the face may be closed with sutures for cosmetic reasons. Wounds involving the eyelids, lip, or ear may also require special closure techniques.
1. Take Vital Signs
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Location, depth, and size of wound
If on an extremity, evaluate vascular and neurologic function distal to the wound, known as a Circulation - Motion - Sensation (CMS) check.
Unrelieved pain
Skin: any new skin condition, i.e., bruising, rash, infection/cellulitis (redness, exudate), swelling, tenderness
Bleeding
Patient description of what caused the wound
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately notify the medical staff & resident representative
Requiring closure with sutures or staples, or 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
Wound without complication treated using the facility protocol
SBAR Report
Situation: (laceration length/size) "Laceration of" (laceration location) “association with” (pain) (bleeding) (infection)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
When the wound occurred, what treatments have been used.
Wound caused by a dirty or rusted object
Abnormal vital signs
Unrelieved pain
Abnormal findings on skin observations
Patient receiving anticoagulant or antiplatelet medication
Date of last tetanus vaccination if greater than 5 years in the past
Assessment: I am concerned about: __________
Recommendations/Requests:
Dressing
Tetanus vaccination (Tdap) for dirty wound or if last vaccination more than 10 years in the past
Pain medication
Systemic antibiotic
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Cleanse the wound and apply treatment per the facility protocol
Irrigate wound with saline solution
Apply adhesive-strip closures
Apply non-stick dressing
Place on 24-hour report for 2-3 days
Investigate the cause of the wound
Determine if abuse or neglect occurred
Update care plan regarding fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety.
Review status and plan of care with designated representative
Monitor wound each shift until healed
2025-04-27
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