Infection Nursing Diagnosis: A Comprehensive Guide for Wound Care Management

Wound care is a critical aspect of nursing practice, and understanding the nuances of wound infection and its associated nursing diagnoses is paramount. A wound, defined as any damage to the skin, tissues, or organs, compromises the body’s protective barrier, creating a portal of entry for pathogens. This article delves into the complexities of wound infection, providing a comprehensive guide for healthcare professionals, particularly nurses, to effectively assess, diagnose, and manage wound infections.

Understanding Wound Infection and Healing

Wound infection occurs when pathogenic microorganisms breach the body’s defenses through damaged skin, overwhelming the immune system. This can be exacerbated by inadequate aseptic techniques or wound contamination. Certain chronic conditions such as diabetes mellitus and HIV weaken the immune system and impede healing, significantly increasing the risk of wound infections. Untreated wound infections can escalate into severe, life-threatening conditions.

The body’s natural response to injury is wound healing, a complex process that commences immediately after tissue damage to restore tissue integrity. Any disruption in this healing cascade can predispose the wound to infection. Wound healing progresses through four distinct phases:

• Hemostasis (Immediate Response): The body’s initial reaction to injury involves blood vessel constriction to minimize blood loss, followed by coagulation and platelet aggregation to form a clot, effectively sealing the wound and initiating the repair process.
• Inflammation (0-4 days): The immune system’s defense mechanisms are activated, with neutrophils and macrophages migrating to the wound site to combat potential infection. This phase is characterized by the classic signs of inflammation: swelling and redness.
• Proliferation (2-24 days): The wound repair phase begins as granulation tissue, a matrix of new connective tissue and blood vessels, fills the wound bed. Simultaneously, epithelial cells proliferate and migrate across the wound surface to cover and close the defect.
• Maturation (24+ days): The final phase involves collagen remodeling and strengthening, increasing the tensile strength of the newly formed tissue. A scar may form as the tissue matures and reorganizes.

Types of Wound Healing and Infection Risk

Wound healing can occur through different mechanisms, each carrying varying risks of infection:

• Primary Intention: This method involves closing the wound edges directly using sutures, staples, surgical glue, or steri-strips. Primary intention healing is typical for clean lacerations or surgical incisions with minimal tissue loss and carries the lowest risk of infection due to the immediate closure of the wound, minimizing pathogen entry.
• Secondary Intention: When wounds cannot be closed directly, often due to significant tissue loss, contamination, or infection, they heal by secondary intention. This process involves the formation of granulation tissue to gradually fill the wound cavity. Secondary intention healing is commonly observed in pressure ulcers and wounds left open to drain infection, and it carries a higher risk of infection compared to primary intention due to the prolonged exposure of the wound bed.
• Tertiary Intention (Delayed Primary Closure): Tertiary intention is employed when a wound is initially left open, often to manage infection or allow for drainage. Once the infection is controlled and the wound bed is clean and granulating, the wound edges may be surgically closed. This delayed closure approach is used to balance infection control with wound closure and is associated with a moderate risk of infection, depending on the initial wound condition and management.

Factors Influencing Wound Healing and Infection Susceptibility

Numerous factors can influence the body’s ability to heal and increase susceptibility to wound infection. Nurses must consider these factors when assessing and planning care for patients with wounds:

• Nutritional Status: Adequate nutrition, particularly protein, vitamins, and minerals, is essential for tissue repair and immune function. Malnutrition impairs wound healing and increases infection risk.
• Stress: Psychological and physiological stress can negatively impact the immune system and delay wound healing.
• Comorbidities: Underlying health conditions such as diabetes mellitus, peripheral vascular disease, and immunocompromising conditions significantly impair wound healing and increase infection susceptibility.
• Age: Advanced age is associated with physiological changes that slow down wound healing and weaken the immune response.
• Obesity: Obesity can compromise blood supply to tissues and increase the risk of wound complications, including infection.
• Medications: Certain medications, such as corticosteroids, chemotherapy drugs, and immunosuppressants, can impair wound healing and increase infection risk.
• Alcohol Use: Excessive alcohol consumption can impair immune function and wound healing.
• Smoking: Smoking constricts blood vessels, reducing oxygen delivery to tissues and significantly delaying wound healing while increasing infection risk.
• Friction and Shearing: These mechanical forces can damage skin and underlying tissues, creating entry points for pathogens.
• Poor Mobility: Immobility increases pressure on certain areas, predisposing individuals to pressure ulcers and impaired wound healing.
• Knowledge Deficits: Lack of understanding regarding proper wound care practices can lead to inadequate wound management and increased infection risk.

The Nursing Process in Wound Care

The nursing process is fundamental to providing effective wound care. It begins with a comprehensive nursing assessment to gather crucial data, followed by the formulation of nursing diagnoses, planning and implementing interventions, and evaluating outcomes. This systematic approach ensures patient-centered care and promotes optimal wound healing while minimizing infection risks.

Nursing Assessment: Gathering Subjective and Objective Data

A thorough nursing assessment is the cornerstone of effective wound care. It involves collecting both subjective data (patient’s perceptions and symptoms) and objective data (observable and measurable signs).

Review of Health History

1. General Symptoms of Wound Infection: Nurses should inquire about and document the patient’s general symptoms, which may indicate wound infection. Key symptoms include:

• Purulent discharge from the wound (thick, discolored drainage)
• Skin discoloration (erythema, increased redness)
• Swelling (edema)
• Foul-smelling odor emanating from the wound
• Warmth, tenderness, pain, or inflammation around the wound site

Systemic symptoms suggest a more severe, potentially life-threatening infection and warrant immediate attention. These include:

• Fever (elevated body temperature)
• Chills
• Lymphadenopathy (swollen lymph nodes) near the wound site

2. Underlying Cause of the Wound: Determining the etiology of the wound is crucial for understanding the risk of infection and guiding appropriate care. Wounds can result from various causes, including trauma, surgery, pressure, and underlying medical conditions. Wound infection occurs when bacteria colonize damaged skin and proliferate. Factors increasing infection risk related to wound cause include:

• Large, deep, or jagged wounds that are more susceptible to contamination and provide a larger surface area for bacterial colonization.
• Wounds contaminated with dirt, animal saliva (animal bites), or human saliva (human bites), which introduce a diverse range of pathogens.
• Penetrating wounds caused by rusty nails or other contaminated objects, which can introduce tetanus or deep-seated infections.

3. Patient’s Medical Risk Factors: Pre-existing medical conditions significantly influence a patient’s susceptibility to wound infection. Nurses must identify and document these risk factors:

• Diabetes mellitus: Impaired immune function and microvascular circulation increase infection risk and impede healing.
• Immunosuppression (e.g., HIV, autoimmune disorders, organ transplantation): Compromised immune system makes individuals highly vulnerable to infections.
• Renal failure: Uremia and impaired immune function increase infection risk.
• Obesity: Compromised circulation and increased tissue tension hinder wound healing and increase infection risk.
• Advancing age: Age-related decline in immune function and slower healing processes increase vulnerability.
• Neuropathy: Nerve damage, particularly in diabetic neuropathy, can lead to unnoticed injuries and delayed wound healing, increasing infection risk.
• Peripheral vascular disease: Reduced blood flow to extremities impairs oxygen and nutrient delivery, hindering healing and increasing infection risk.
• Treatments or medications (e.g., chemotherapy, radiation therapy, immunosuppressants): These therapies suppress the immune system, increasing infection susceptibility.

4. Surgical History: Surgical procedures inherently increase the risk of wound infection, particularly surgical site infections (SSIs). Key surgical characteristics to review include:

• Poor surgical technique: Inadequate aseptic technique during surgery increases contamination risk.
• Prolonged hospital stay: Longer hospitalizations increase exposure to nosocomial pathogens.
• Intraoperative contamination: Contamination during surgery introduces pathogens into the wound.
• Hypothermia: Perioperative hypothermia impairs immune function and wound healing.

5. Medication History: Certain medications can impair wound healing and increase infection risk. Nurses should review the patient’s medication list for:

• Immunosuppressants (e.g., steroids, DMARDs): Suppress immune response and increase infection vulnerability.
• Hydroxyurea: Can impair wound healing.
• Chemotherapeutic drugs: Suppress immune system and impair cell proliferation necessary for wound repair.
• NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Can interfere with the inflammatory phase of wound healing.

6. Nutritional Status: Adequate nutrition is vital for wound healing. Protein deficiency and insufficient intake of vitamins and minerals impair tissue repair and immune function. Dehydration also hinders circulation and tissue oxygenation. Nurses should inquire about the patient’s dietary intake, including protein, vitamins, and fluid intake.

Physical Assessment

1. Wound Type Determination: Identifying the type of wound is crucial as it dictates the appropriate wound care strategies. Common wound types encountered in nursing practice include:

• Skin tears: Traumatic injuries to fragile skin, often seen in older adults.
• Diabetic foot ulcers: Ulcerations on the feet of individuals with diabetes, often due to neuropathy and poor circulation.
• Arterial ulcers: Ulcers caused by insufficient arterial blood flow, typically on the lower extremities.
• Venous stasis ulcers: Ulcers resulting from venous insufficiency, commonly in the lower legs.
• Pressure ulcers (bedsores): Injuries to skin and underlying tissue caused by prolonged pressure.
• Surgical wounds: Incisions made during surgical procedures.
• Traumatic wounds: Wounds resulting from accidents or injuries.

2. Wound Characteristics Assessment and Documentation: Thorough assessment and meticulous documentation of wound characteristics are essential at each dressing change and according to facility protocols. Key parameters to assess and document include:

• Location: Precise anatomical location of the wound.
• Size: Length, width, and depth of the wound, measured in centimeters or millimeters.
• Drainage: Type, color, odor, and amount of wound drainage (exudate).
• Wound bed: Description of the tissue in the wound bed (e.g., granulation tissue, slough, eschar).
• Wound edges and surrounding skin (periwound): Condition of the wound edges (approximated, unapproximated) and periwound skin (erythema, edema, maceration).
• Presence of tunneling or undermining: Assessment for tissue destruction extending under intact skin at the wound edges.
• Signs of infection: Local and systemic signs and symptoms of infection.

3. T.I.M.E. Acronym for Wound Assessment: The T.I.M.E. acronym is a helpful tool for nurses to remember key aspects of wound assessment:

• T – Tissue: Evaluate tissue type in the wound bed. Epithelial tissue (pink and newly formed) and granulation tissue (red, beefy) indicate healing. Slough (yellow or gray, stringy) and necrotic tissue (black, dead) indicate non-viable tissue that impedes healing and must be removed.
• I – Infection/Inflammation: While inflammation is a normal part of wound healing, infection is not. Assess for signs of infection and differentiate between normal inflammation and signs of bacterial colonization or spreading infection.
• M – Moisture: Maintaining a moist wound environment is crucial for healing, but excessive moisture can cause maceration (skin breakdown due to prolonged moisture exposure), while insufficient moisture leads to wound desiccation. Assess the type and amount of wound exudate:
  • Purulent exudate: Thick, yellow, green, or creamy discharge, often indicative of infection.
  • Serous exudate: Thin, clear, or pale yellow fluid, normal in small amounts in healing wounds.
  • Sanguinous exudate: Bloody drainage, expected initially after injury but should decrease over time.
• E – Edges: Monitor wound edges for signs of poor healing, such as rolled edges (epibole), undermining, or tunneling. Assess the periwound skin for erythema, edema, and maceration, which can indicate complications or infection.

4. Pain Assessment: Wound pain is common and can significantly impact patient comfort and healing. Nurses should use pain assessment tools (e.g., numerical pain scale, visual analog scale) to evaluate pain severity and effectiveness of pain management strategies.

Diagnostic Procedures

Diagnostic procedures play a crucial role in confirming wound infection and identifying causative pathogens, guiding targeted treatment.

1. Wound Culture: Obtaining a wound swab for culture and sensitivity testing is a cost-effective and readily available method to identify bacterial pathogens causing infection.

2. Biopsy or Aspiration: For deeper or complex infections, a tissue biopsy (removal of a small tissue sample) is the most accurate method for pathogen detection but is more invasive and costly. Aspiration of fluid from the wound, particularly from suspected abscesses, is used to identify microorganisms below the skin surface.

3. Laboratory Values: Blood tests can provide valuable information about systemic infection and inflammation. Laboratory values assessed for infection include:

• White blood cell (WBC) count: Elevated WBC count indicates systemic infection.
• C-reactive protein (CRP): Elevated CRP is a marker of inflammation, often elevated in infection.
• Procalcitonin (PCT): PCT is a more specific marker for bacterial infection than CRP and rises earlier in sepsis.
• Presepsin: Another biomarker that increases rapidly in response to bacterial infection.
• Microbial DNA: PCR (polymerase chain reaction) testing can detect specific microbial DNA in wound samples.
• Bacterial protease activity (BPA): Elevated BPA levels in wound fluid can indicate bacterial infection.

4. Imaging Tests: Imaging studies may be necessary to assess the extent of infection, particularly in deeper tissues or to rule out complications:

• Plain X-rays: Useful for detecting soft-tissue gas (crepitus) in gas gangrene or foreign bodies.
• Computed tomography (CT): Provides detailed images of soft tissues and can identify deep tissue infections, abscesses, or osteomyelitis (bone infection).
• Magnetic resonance imaging (MRI): Offers superior soft tissue detail and is valuable for assessing the extent of infection in tissues and bone, particularly in complex infections like diabetic foot infections.
• Ultrasound: Useful for evaluating superficial soft tissue infections, abscesses, and fluid collections.

5. Peripheral Perfusion Assessment: Assessing peripheral perfusion is critical, especially in patients with diabetes or peripheral vascular disease, as impaired circulation compromises wound healing.

• Ankle-brachial index (ABI) and toe-brachial index (TBI): These non-invasive tests measure blood pressure in the ankles/toes compared to the arm to assess for peripheral artery disease.
• Monofilament testing: Used to assess protective sensation in the feet, particularly in patients with diabetes or peripheral neuropathy, to identify risk of unnoticed foot injuries.

Nursing Interventions for Wound Care and Infection Management

Nursing interventions are crucial for promoting wound healing, preventing infection, and managing existing wound infections.

Providing Appropriate Wound Care

1. Debridement of Nonviable Tissue: Debridement, the removal of necrotic or devitalized tissue, is essential for wound healing. Types of debridement include:

• Autolytic debridement: Using the body’s own enzymes to break down necrotic tissue under moist dressings (e.g., hydrogels, hydrocolloids).
• Enzymatic debridement: Applying topical enzymatic ointments to digest necrotic tissue.
• Sharp wound debridement: Surgical removal of necrotic tissue using sharp instruments, performed by trained professionals.

2. Moisture Management: Maintaining appropriate wound moisture balance is critical.

• For wounds with excessive exudate, absorbent dressings like hydrofiber or alginate dressings can be used to manage moisture levels and prevent maceration. Frequent dressing changes may be necessary.
• For dry wounds, moisture-retentive dressings (e.g., hydrogels, hydrocolloids) can maintain a moist wound environment conducive to healing.

3. Wound Packing: Wounds with tunneling or undermining require packing to prevent premature closure of the wound surface and ensure healing from the base up. Moistened sterile gauze or hydrogel-impregnated dressings are used for packing.

4. Periwound Skin Protection: Protecting the skin surrounding the wound (periwound skin) prevents skin breakdown and irritation. Barrier creams, powders, protective wipes, or barrier wafers can be applied to the periwound area.

5. Wound Vac Therapy: Vacuum-assisted closure (wound vac) is a specialized therapy for complex open wounds, skin grafts, flaps, or pressure ulcers. It uses a foam dressing and negative pressure to remove exudate, reduce edema, promote granulation tissue formation, and facilitate wound closure.

6. Pain Management: Wound care procedures can be painful. Premedication with prescribed analgesics prior to dressing changes is essential to manage pain and improve patient comfort.

Preventing and Managing Wound Infection

1. Aseptic or Clean Technique: Choosing the appropriate technique for wound care is crucial for infection control.

• Aseptic technique (sterile technique) using sterile gloves and equipment is necessary for high-risk wounds such as burns, surgical wounds, and when introducing materials into deep tissues.
• Clean technique using non-sterile gloves and clean equipment is appropriate for chronic wounds like pressure ulcers and simple wounds like skin tears in non-immunocompromised individuals.

2. Antibiotic Administration: Antibiotics are used to treat wound infections.

• Topical antibiotics or silver-containing dressings may be used for localized wound infections.
• Systemic antibiotics (oral or IV) are required for wounds with signs of systemic infection or spreading cellulitis.
• Targeted antimicrobial therapy is based on wound culture and sensitivity results to ensure effective treatment of the specific pathogens.

3. Emphasize Immediate Wound Cleaning: Educating patients on the importance of immediate wound cleaning is crucial for preventing infection. Wounds should be cleaned immediately with mild soap and water to remove contaminants. This is particularly important for “dirty” wounds like animal bites or wounds contaminated with foreign material. Medical assistance should be sought if the patient cannot clean the wound adequately themselves.

4. Avoid Harsh Cleansing Agents: Patients should be educated to avoid using hydrogen peroxide or rubbing alcohol to clean wounds. These agents are cytotoxic to healthy tissue and can impair wound healing.

5. Hand Hygiene: Strict hand hygiene is paramount. Healthcare providers and patients/caregivers should wash hands thoroughly with soap and water or use alcohol-based hand sanitizer before and after wound care procedures.

6. Wound Coverage: Dispelling the myth that wounds need to “breathe,” nurses should educate patients that wounds heal best when kept covered with a dressing. Dressings maintain a moist wound environment, protect the wound from contamination, and prevent bacterial entry.

Promoting Wound Healing

1. Nutritional Support and Hydration: Optimizing nutrition and hydration is vital for wound healing.

• A high-protein diet is recommended to provide building blocks for tissue repair. Protein supplements can be used if dietary intake is insufficient.
• Vitamin C is an important antioxidant and cofactor in collagen synthesis, promoting tissue regeneration.
• Adequate fluid intake is essential for maintaining blood volume, nutrient transport, and tissue oxygenation.

2. Education on Skin Breakdown Prevention: Nurses play a key role in educating patients and families on strategies to prevent further skin injury and promote wound healing:

• Pressure redistribution: Frequent turning and repositioning to minimize pressure on vulnerable areas.
• Foot protection: Wearing shoes or socks at all times to protect feet from injury, especially for individuals with diabetes or neuropathy.
• Edema management: Compression stockings to control swelling in lower extremities, particularly for venous insufficiency ulcers.
• Skin hygiene: Keeping skin clean and dry, especially for incontinent patients, to prevent moisture-associated skin damage.

3. Wound Documentation: Comprehensive and accurate wound documentation at every dressing change is essential for monitoring wound progress and adjusting treatment plans. Documentation should include wound size, exudate characteristics, wound bed appearance, periwound skin condition, and treatments applied. Wound photographs can also be used for objective documentation of wound progression.

4. Referral to Wound Care Specialist: Chronic, non-healing wounds or complex wounds often require specialized care. Referral to a wound care clinic or wound care certified nurse should be considered for assessment, advanced wound dressings, and specialized treatments such as hyperbaric oxygen therapy.

Nursing Care Plans for Wound Infection: Addressing Key Nursing Diagnoses

Nursing care plans provide a structured framework for organizing and delivering patient care based on identified nursing diagnoses. For wound care, common nursing diagnoses related to infection include Acute Pain, Impaired Skin Integrity, Ineffective Protection, Ineffective Tissue Perfusion, and Knowledge Deficit.

Acute Pain related to Wound Infection

Nursing Diagnosis: Acute Pain related to wound infection, potentially caused by tissue damage (nociceptive pain) or nerve involvement (neuropathic pain).

Related Factors:

• Loss of blood supply and ischemia in the affected site
• Necrotic tissue and inflammatory processes
• Damaged nerve endings due to tissue injury or inflammation

Evidenced by:

• Verbal reports of pain (using pain scales)
• Guarding or protective posture of the affected area
• Restlessness and agitation
• Tenderness or pain to palpation of the wound and surrounding tissues
• Changes in vital signs (increased heart rate, blood pressure, respiratory rate)

Expected Outcomes:

• Patient will verbalize a reduction in pain related to the wound.
• Patient will report a decrease in pain intensity on a 0-10 pain scale within a specified timeframe after pain management interventions.
• Patient will demonstrate improved comfort and ability to participate in daily activities without significant pain interference.

Nursing Assessments:

1. Pain Assessment using a Pain Scale: Utilize a validated pain scale (e.g., numerical rating scale, Wong-Baker FACES Pain Rating Scale) to quantify pain intensity and monitor pain levels over time. Pain is subjective, and patient self-report is the most reliable indicator of pain.
2. Pain Characterization: Assess the characteristics of the pain, including location, quality (e.g., sharp, burning, throbbing), onset, duration, aggravating and relieving factors. Differentiate between nociceptive pain (tissue injury) and neuropathic pain (nerve damage).
3. Palpation for Tenderness: Gently palpate the wound and surrounding skin to assess for tenderness, increased warmth, and pain upon touch. Persistent or worsening pain can be a sign of infection or inadequate pain control.

Nursing Interventions:

1. Premedication for Wound Care: Administer prescribed analgesics (e.g., oral pain medication, topical anesthetic) prior to painful wound care procedures such as dressing changes or debridement. Allow sufficient time for the medication to take effect before initiating the procedure.
2. Pain Management Education: Educate the patient about their prescribed pain medication regimen, including medication names, dosages, frequency, and potential side effects. Emphasize the importance of taking pain medication as prescribed and reporting any unrelieved pain. Explain different types of pain medications (NSAIDs for inflammation, neuropathic pain agents, opioids for severe pain).
3. Symptom Management: Address contributing factors to wound pain such as excessive wound dryness, drainage, edema, or skin maceration. Implement interventions to manage these symptoms, such as appropriate dressing selection, elevation of the affected extremity (for edema), and frequent dressing changes.
4. Wound Splinting/Support: If appropriate, consider splinting or supporting the wounded site to immobilize the area, reduce movement, and protect it from further injury and pain. This can be particularly helpful for extremity wounds.

Impaired Skin Integrity related to Wound Infection

Nursing Diagnosis: Impaired Skin Integrity related to factors compromising skin and tissue integrity, leading to wound development and potential infection.

Related Factors:

• Skin injury due to shearing forces, pressure, friction, or trauma
• Burns (thermal, chemical, electrical)
• Exposure to excessive moisture (incontinence, wound exudate)
• Surgical incisions disrupting skin layers
• Impaired circulation (arterial or venous insufficiency)
• Poor skin turgor (dehydration, aging)
• Edematous tissues increasing skin fragility
• Conditions that delay wound healing (e.g., diabetes mellitus, malnutrition)

Evidenced by:

• Observable disruption of skin integrity (wound, ulcer, lesion)
• Purulent discharge from the wound (signs of infection)
• Skin discoloration (erythema, pallor, cyanosis)
• Foul-smelling odor from the wound
• Tight skin sutures (in surgical wound infections)
• Warmth, tenderness, pain, and inflammation at the wound site
• Prolonged or delayed wound healing beyond expected timeframe

Expected Outcomes:

• Patient will demonstrate wound healing progression as evidenced by decreased wound size, presence of granulation tissue, and absence of purulent drainage.
• Patient will maintain clean and approximated wound edges (if applicable to wound type).
• Patient will verbalize understanding of wound care management principles and techniques.
• Patient will actively participate in performing wound care as able.

Nursing Assessments:

1. Comprehensive Wound Assessment: Conduct a thorough assessment of the wound with each dressing change, documenting wound size (length, width, depth), color of wound bed, presence and characteristics of drainage (color, odor, amount, type), presence of tunneling or undermining, condition of wound edges and periwound skin, and signs of infection.
2. Wound Classification: Categorize the type of wound (e.g., pressure ulcer, surgical wound, diabetic foot ulcer) and classify it according to depth of tissue involvement and other relevant classification systems (e.g., National Pressure Ulcer Advisory Panel staging for pressure ulcers). Wound classification guides appropriate treatment strategies.
3. Risk Assessment for Impaired Skin Integrity: Utilize a validated risk assessment tool (e.g., Braden Scale for pressure ulcer risk) to identify patients at high risk for skin breakdown and impaired skin integrity. Consider patient’s medical history, physical exam findings, and laboratory data. Risk factors include immobility, incontinence, malnutrition, and chronic diseases.
4. Wound Culture (as indicated): Obtain a wound culture if signs of infection are present (purulent drainage, increased pain, redness, swelling, fever) to identify causative pathogens and guide antibiotic therapy.

Nursing Interventions:

1. Wound Cleansing and Disinfection: Cleanse the wound with appropriate antiseptic wound cleansers (e.g., normal saline, prescribed antiseptic solutions) as ordered. Avoid harsh chemicals like alcohol or hydrogen peroxide that can damage healthy tissue.
2. Wound Decontamination: Decontaminate the wound by removing any foreign material, debris, or contaminants. Perform debridement to remove necrotic tissue, slough, or eschar to promote wound healing.
3. Appropriate Wound Dressing Application: Apply appropriate wound dressings based on wound type, wound bed characteristics, drainage amount, and presence of infection. Utilize non-adherent dressings, saline-soaked gauze, absorbent dressings, hydrogels, hydrocolloids, foams, alginates, silver dressings, or other advanced wound dressings as indicated. Secure dressings with appropriate tape or bandages.
4. Wound Healing Stage Management: Manage wound care based on the stage of wound healing. Adjust wound cleansing solutions, ointments, and dressings as the wound progresses through different healing phases (hemostasis, inflammation, proliferation, maturation).
5. Maintain Moist Wound Environment: Keep the wound bed moist but not overly wet to promote optimal wound healing. A moist environment supports cell migration, angiogenesis, and collagen synthesis. Choose dressings that maintain moisture balance.
6. Topical Antimicrobials (as prescribed): Apply topical antibiotics or antiseptics as prescribed by the physician or wound care specialist to manage or prevent wound infection. Use cautiously and according to prescribed directions.
7. Suture/Staple Removal (for surgical wounds): Remove sutures or staples from surgical wounds at the appropriate time frame (typically 10-14 days post-operatively, or earlier for wounds on the head and neck) once wound edges are approximated and healing is progressing. Adhesive strips or surgical glue may be used for wound closure.
8. Wound Care Specialist Referral: Refer the patient to a wound care specialist if the wound shows signs of delayed healing (no improvement within two weeks), chronic non-healing wounds (not healed within six weeks), or complex wounds requiring specialized management.

Ineffective Protection related to Potential Wound Infection

Nursing Diagnosis: Ineffective Protection related to compromised ability to guard against skin breakdown and infection.

Related Factors:

• Inadequate primary defenses (broken skin, tissue trauma)
• Circulatory compromise reducing blood flow to tissues
• Tissue trauma or injury disrupting skin integrity
• Older age associated with skin fragility and decreased immune function
• Malnutrition impairing immune function and tissue repair
• Immobility increasing pressure and friction on skin
• Incontinence exposing skin to moisture and irritants
• Compromised immunity (e.g., immunocompromising conditions, medications)
• Ineffective health self-management related to wound care practices

Evidenced by:

• Impaired tissue healing or delayed wound closure
• Maladaptive stress response (physiological response to infection or illness)
• Development of pressure ulcers or new wounds
• Weakness and fatigue
• Neurosensory impairment reducing awareness of skin injury
• Poor mobility limiting ability to reposition and relieve pressure

Expected Outcomes:

• Patient will remain free from developing a wound infection during hospitalization or episode of care.
• Patient will demonstrate understanding and implementation of interventions to improve protection against skin breakdown and wounds.

Nursing Assessments:

1. Vital Signs Monitoring: Assess and monitor vital signs (temperature, heart rate, blood pressure, respiratory rate) regularly. Changes in vital signs can indicate systemic infection (e.g., fever, tachycardia, hypotension).
2. Nutritional Status Assessment: Assess and monitor the patient’s nutritional status, including dietary intake of protein, vitamins, minerals, and fluids. Malnutrition and dehydration impair immune function and wound healing.
3. ADL Ability Assessment: Assess the patient’s ability to perform activities of daily living (ADLs), particularly mobility and self-care activities. Assess ability to ambulate, reposition, bathe, and maintain skin hygiene. Impaired mobility and self-care increase risk of skin breakdown and infection.

Nursing Interventions:

1. Antibiotic Therapy Administration: Administer prescribed antibiotic therapy (oral or IV) as indicated for confirmed wound infection or as prophylactic treatment to prevent infection in high-risk wounds. Monitor for therapeutic effects and adverse reactions to antibiotics.
2. Dietitian Referral: Refer the patient to a registered dietitian for nutritional assessment and development of an individualized meal plan to address nutritional deficiencies, promote immune function, and support wound healing.
3. Infection Control Education: Educate the patient, family, and caregivers about infection control measures, including proper hand hygiene techniques (hand washing with soap and water or alcohol-based hand sanitizer), wound care procedures, and signs and symptoms of wound infection to report to healthcare providers.
4. Proper Wound Care Implementation: Provide or ensure proper wound care is provided according to established protocols and best practices. Demonstrate wound cleansing, dressing application, and infection prevention techniques to patient and caregivers.

Ineffective Tissue Perfusion related to Delayed Wound Healing and Infection Risk

Nursing Diagnosis: Ineffective Tissue Perfusion (peripheral) related to compromised blood flow to tissues, impairing wound healing and increasing infection susceptibility.

Related Factors:

• Inadequate primary defenses (skin injury)
• Circulatory compromise (arterial or venous insufficiency)
• Tissue trauma or injury disrupting blood vessels
• Smoking causing vasoconstriction and impaired oxygen delivery
• Malnutrition affecting blood cell production and circulation
• Sedentary lifestyle/immobility reducing blood flow
• Chronic conditions (diabetes mellitus, peripheral vascular disease, hypertension) affecting blood vessels
• Insufficient knowledge of how comorbidities and lifestyle factors affect tissue perfusion and wound healing

Evidenced by:

• Edema (swelling) in affected extremities
• Skin discoloration (pallor, cyanosis, rubor)
• Paresthesia (numbness, tingling) in extremities
• Pain in extremities, particularly with activity (intermittent claudication) or at rest (ischemic pain)
• Altered skin characteristics (cool to touch, thin, shiny, hair loss on legs)
• Delayed peripheral wound healing (slow or non-healing wounds on extremities)
• Decreased or absent peripheral pulses (dorsalis pedis, posterior tibial)
• Abnormal ankle-brachial index (ABI) indicating peripheral artery disease

Expected Outcomes:

• Patient will demonstrate improved tissue perfusion as evidenced by effective wound healing, resolution of signs and symptoms of poor perfusion (edema, skin discoloration, pain), and palpable peripheral pulses.
• Patient will verbalize understanding of how comorbidities and lifestyle factors affect tissue perfusion and wound healing.

Nursing Assessments:

1. Diagnostic Test Review: Assess and monitor results of diagnostic tests related to tissue perfusion, such as skin perfusion pressure (SPP) testing, transcutaneous oximetry (TcPO2), and angiography. These tests provide objective measures of blood flow and oxygenation to tissues.
2. Signs of Ineffective Tissue Perfusion Assessment: Note and document signs and symptoms of ineffective peripheral tissue perfusion in the wound and surrounding area, including skin discoloration, temperature changes (coolness), hair loss on extremities, decreased or absent peripheral pulses, paresthesias, edema, and muscle weakness.
3. Comorbidity Consideration: Consider the patient’s comorbidities that affect perfusion, such as diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease, and peripheral vascular disease. These conditions significantly impact circulation and peripheral tissue perfusion, complicating wound healing.

Nursing Interventions:

1. Foot Care Education: Instruct patients on proper foot care practices, especially those with diabetes or peripheral vascular disease. Emphasize the importance of daily foot inspection for blisters, cuts, or skin irritation, wearing well-fitting shoes and socks, and avoiding going barefoot.
2. Exercise Encouragement: Encourage regular walking or other appropriate exercise as tolerated to improve peripheral blood flow, unless contraindicated by wound location (e.g., weight-bearing wounds on feet). If ambulation is limited, instruct on range-of-motion exercises, ankle circles, and seated calf raises to promote circulation.
3. Extremity Elevation and Compression (for venous disease): For patients with venous insufficiency ulcers, recommend leg elevation above heart level and application of compression therapy (compression stockings or bandages) to reduce edema and improve venous return, enhancing tissue perfusion. Note: Elevation and compression are contraindicated in arterial insufficiency.
4. Smoking Cessation Counseling: Strongly advise patients who smoke to quit smoking. Provide smoking cessation counseling and resources, as smoking significantly impairs tissue perfusion by causing vasoconstriction and damaging blood vessels.
5. Hyperbaric Oxygen Therapy Referral (as indicated): For wounds with delayed healing or in patients with compromised tissue perfusion, consider referral to a wound care specialist for evaluation for hyperbaric oxygen therapy (HBOT). HBOT increases oxygen delivery to tissues, promoting wound healing in hypoxic wounds.

Knowledge Deficit related to Wound Care Management and Infection Prevention

Nursing Diagnosis: Knowledge Deficit related to wound care management and infection prevention practices.

Related Factors:

• Lack of exposure to information about wound care processes
• Misinformation or misunderstanding regarding wound care techniques
• Limited access to wound care resources and educational materials
• Cognitive limitations or learning barriers affecting information processing
• Cultural or belief systems influencing wound care practices

Evidenced by:

• Verbalization of lack of knowledge about wound care
• Requests for further information about wound management
• Nonadherence to prescribed wound care regimen
• Development of wound infection or worsening wound condition due to improper care

Expected Outcomes:

• Patient will verbalize understanding of wound care management plan, including wound cleansing, dressing changes, infection prevention measures, and medication administration (if applicable).
• Patient will demonstrate adherence to the prescribed wound care treatment plan.
• Patient will verbalize strategies to prevent wound infection and promote wound healing.

Nursing Assessments:

1. Knowledge Assessment: Assess the patient’s current level of knowledge regarding wound care, wound healing processes, and infection prevention measures. Use open-ended questions to elicit patient’s understanding and identify knowledge gaps.
2. Demonstration Assessment: Ask the patient or caregiver to demonstrate wound care techniques (e.g., dressing change) to assess their skills and identify areas needing improvement. Observe for correct techniques and adherence to aseptic or clean principles.
3. Misunderstanding Identification: Identify any misunderstandings, misconceptions, or cultural beliefs that may influence the patient’s approach to wound care and adherence to recommended practices. Address misinformation and provide accurate information.
4. Resource Assessment: Assess the patient’s access to wound care resources, including financial resources for supplies, transportation to appointments, home health services, and availability of support systems. Identify potential barriers to adherence and access to care.

Nursing Interventions:

1. Wound Care Education: Provide comprehensive education to the patient, family, or caregivers about their specific wound care plan. Explain the rationale for each step in wound care, including wound cleansing techniques, dressing selection and application, frequency of dressing changes, medication administration (if applicable), and signs and symptoms of wound infection to monitor for.
2. Inquiry Time: Allow ample time for the patient and caregiver to ask questions, express concerns, and clarify any misunderstandings. Address their inquiries thoroughly and patiently.
3. Caregiver Involvement: Involve caregivers in wound care education and training, especially if the patient requires assistance with wound care at home. Ensure caregivers are confident and competent in providing wound care.
4. Infection Control Emphasis: Emphasize the importance of infection control measures in wound care, particularly hand hygiene before and after wound care procedures, proper disposal of soiled dressings, and maintaining a clean wound environment. Instruct on aseptic or clean techniques as appropriate for the wound type.
5. Social Worker/Case Manager Referral: Refer the patient to a social worker or case manager to assist with accessing resources such as home health care, durable medical equipment, transportation assistance, financial aid programs, and community support services.
6. Dietitian Referral (for nutritional counseling): Refer the patient to a registered dietitian for nutritional counseling to ensure adequate intake of protein, vitamins, minerals, and fluids to support wound healing. Provide education on dietary recommendations for wound healing.