Skin and Wound Care Management

1. 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

2. 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