Puncture Wound, Bite, Sliver, Splinter

Also Consider:  Abrasion, Laceration, Rash, Skin tear 

1. Take Vital Signs

• Temperature:

• Blood Pressure:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Location, depth, and size of wound

• Retained material in wound

• Bruising, redness, tenderness, swelling around or near the wound

• Bleeding, exudate or drainage from wound

• If on an extremity, evaluate vascular and neurologic function distal to the wound, known as a Circulation - Motion - Sensation (CMS) check.

• Unrelieved pain

• Patient description of what caused the wound

3. Take Action using SBAR Report:

• Immediately notify the medical staff & resident representative

  • Deep (through subcutaneous tissue) wound, OR

  • Abnormal Circulation - Motion - Sensation (CMS) check, OR

  • Retained material in wound, 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

4. Implement Management Plan

• Allow wound to bleed if bleeding is not profuse

• Cleanse the wound and apply treatment per the facility protocol

  • Irrigate wound with saline solution

  • 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, assistance needed with ADLs, supervision for safety.

• Review status and plan of care with designated representative

• Monitor wound each shift until healed

2025-04-26