Infection Nursing Diagnosis Care Plan: A Comprehensive Guide for Wound Care

Wound infections are a significant concern in healthcare, potentially leading to serious complications and prolonged recovery. Effective nursing care is crucial in preventing, identifying, and managing wound infections. This article provides a comprehensive guide to developing an Infection Nursing Diagnosis Care Plan, essential for nurses and healthcare professionals involved in wound management.

Understanding Wound Infections

A wound, defined as any disruption in the skin’s integrity, can range from minor cuts to severe injuries. When pathogens breach the body’s natural defenses through a wound, infection can occur. This is particularly prevalent when the host’s immune system is compromised or when proper aseptic techniques are not followed.

Wounds can be categorized as:

• Acute wounds: These wounds heal predictably and quickly, such as surgical incisions or traumatic injuries.
• Chronic wounds: These wounds fail to heal in a timely and orderly manner, often due to underlying conditions like diabetes, vascular insufficiency, or pressure ulcers.
• Open wounds: The skin barrier is broken, exposing underlying tissues. Examples include lacerations, abrasions, and surgical wounds.
• Closed wounds: Damage occurs without a break in the skin, such as bruises or hematomas.

The Process of Wound Healing

Wound healing is a complex physiological process that involves four overlapping phases:

1. Hemostasis: This immediate response to injury aims to stop bleeding. Blood vessels constrict, and platelets aggregate to form a clot, sealing the wound.
2. Inflammation: Beginning within hours and lasting up to four days, this phase is characterized by the body’s immune response to injury. Neutrophils and macrophages migrate to the wound site to clear debris and prevent infection. Cardinal signs of inflammation, such as redness, swelling, heat, and pain, are evident.
3. Proliferation: From day 2 to 24, the wound is rebuilt with new tissue. Granulation tissue, a network of collagen and capillaries, fills the wound bed. Epithelial cells migrate to cover and close the wound surface.
4. Maturation (Remodeling): This long-term phase, starting around day 24 and lasting for months to years, involves collagen remodeling, increasing tensile strength of the wound, and scar formation.

Image: Four phases of wound healing: hemostasis, inflammation, proliferation, and maturation.

Types of Wound Healing

Wound healing can occur through different intentions:

• Primary Intention: Ideal for clean wounds with well-approximated edges, such as surgical incisions. Closure is facilitated by sutures, staples, or adhesive strips, resulting in minimal scarring and lower infection risk.
• Secondary Intention: Used for wounds with extensive tissue loss, irregular edges, or infection. The wound is left open to heal from the base upwards through granulation tissue formation and epithelialization. This method results in larger scars and a higher risk of infection. Pressure ulcers and some infected wounds heal by secondary intention.
• Tertiary Intention (Delayed Primary Closure): Combines aspects of both primary and secondary intention. The wound is initially left open for observation or to allow drainage of infection. Once the infection is controlled and the wound is clean, it is surgically closed.

Factors Impeding Wound Healing and Increasing Infection Risk

Several factors can compromise wound healing and elevate the risk of infection:

• Compromised Nutritional Status: Inadequate protein, vitamins (especially Vitamin C), and minerals are essential for tissue repair and immune function. Malnutrition impairs collagen synthesis and immune cell activity.
• Elevated Stress Levels: Chronic stress can suppress the immune system and delay wound healing by affecting inflammatory responses and hormone levels.
• Co-existing Medical Conditions (Comorbidities): Conditions like diabetes mellitus, peripheral vascular disease, and immunocompromising conditions (HIV, autoimmune diseases) significantly impair wound healing and increase infection susceptibility. Diabetes, in particular, can cause neuropathy and poor circulation, hindering wound healing in the lower extremities.
• Advanced Age: Older adults experience age-related physiological changes, including decreased immune function, reduced skin elasticity, and slower cell regeneration, making them more vulnerable to wound infections and delayed healing.
• Obesity: Adipose tissue has poor vascularity and can contribute to chronic inflammation, both of which hinder wound healing. Obesity is also associated with conditions like diabetes and poor circulation.
• Medications: Certain medications, such as corticosteroids, chemotherapy agents, and immunosuppressants, can impair the immune system and wound healing processes.
• Lifestyle Factors: Alcohol consumption and smoking negatively impact wound healing. Alcohol impairs immune function and nutrient absorption, while smoking constricts blood vessels, reducing oxygen and nutrient delivery to the wound site.
• Mechanical Factors: Friction and shear forces can damage tissues and disrupt wound healing. Poor mobility increases the risk of pressure ulcers and impedes circulation.
• Knowledge Deficits: Lack of understanding regarding proper wound care techniques can lead to inadequate wound management and increased infection risk.

Nursing Process for Wound Infection: Developing a Care Plan

The nursing process provides a structured framework for delivering patient-centered care. In wound management, it involves assessment, diagnosis, planning, implementation, and evaluation. For wound infections, a comprehensive nursing care plan is essential to guide interventions and achieve optimal patient outcomes.

Nursing Assessment for Wound Infection

A thorough assessment is the first step in developing an effective infection nursing diagnosis care plan. It involves collecting subjective and objective data to identify the patient’s needs and potential problems.

Review of Health History (Subjective Data)

1. General Symptoms: Elicit information about symptoms indicative of wound infection:

   • Local Infection Signs: Purulent wound drainage (thick, colored, malodorous), increased pain, localized swelling, redness (erythema), warmth, and foul odor.
   • Systemic Infection Signs: Fever, chills, malaise, and lymphadenopathy (swollen lymph nodes) near the wound site, suggesting a more severe or spreading infection.

2. Underlying Cause of the Wound: Determine the etiology of the wound to understand potential contamination risks and healing trajectories:

   • Trauma: Accidents, burns, bites (animal or human), punctures from contaminated objects (rusty nails).
   • Surgical Incisions: Post-operative wound infections.
   • Pressure Ulcers: Immobility, pressure, and friction.
   • Vascular Ulcers: Arterial or venous insufficiency.

3. Medical Risk Factors: Identify pre-existing conditions that increase infection susceptibility and impair healing:

   • Immunocompromised States: HIV/AIDS, autoimmune disorders, organ transplant recipients.
   • Diabetes Mellitus: Impaired immune function, neuropathy, and poor circulation.
   • Renal Failure: Uremia impairs immune function.
   • Obesity: Poor vascularity and chronic inflammation.
   • Peripheral Vascular Disease (PVD): Reduced blood flow and oxygen delivery to extremities.
   • Neuropathy: Reduced sensation, increasing risk of unnoticed injuries and infections.
   • Cancer and Cancer Treatments: Chemotherapy and radiation therapy suppress the immune system.

4. Surgical History: For post-surgical wounds, consider factors that increase infection risk:

   • Surgical Technique: Poor aseptic technique during surgery.
   • Prolonged Hospital Stay: Increased exposure to nosocomial pathogens.
   • Intraoperative Contamination: Contamination of the surgical site during the procedure.
   • Hypothermia: Impaired immune function and wound healing.

5. Medication History: Review medications that may impair wound healing or increase infection risk:

   • Immunosuppressants: Corticosteroids, cyclosporine, azathioprine.
   • Chemotherapy Drugs: Cytotoxic effects on immune cells and tissues.
   • NSAIDs (Nonsteroidal Anti-inflammatory Drugs): Can interfere with the inflammatory phase of wound healing.
   • DMARDs (Disease-Modifying Antirheumatic Drugs): Immunosuppressive effects.
   • Hydroxyurea: Immunosuppressive effects.

6. Nutritional Assessment: Evaluate the patient’s nutritional status, focusing on factors critical for wound healing:

   • Protein Intake: Essential for tissue repair and collagen synthesis.
   • Vitamin and Mineral Intake: Vitamin C, zinc, and vitamin A are crucial for wound healing.
   • Hydration Status: Adequate fluid intake is necessary for tissue perfusion and nutrient transport.

Physical Assessment (Objective Data)

1. Wound Type Identification: Classify the wound type to guide appropriate care and predict healing trajectory:

   • Surgical Wounds: Incisions, excisions.
   • Traumatic Wounds: Lacerations, abrasions, punctures, avulsions, burns, skin tears.
   • Ulcers: Pressure ulcers (decubitus ulcers), diabetic foot ulcers, arterial ulcers, venous stasis ulcers.

2. Comprehensive Wound Assessment: Document detailed wound characteristics at each dressing change or as per protocol:

   • Location: Anatomical site of the wound.
   • Size: Length, width, and depth (in centimeters or millimeters).
   • Wound Bed: Describe tissue type: granulation tissue (red, beefy, healthy), slough (yellow or tan, stringy, nonviable), eschar (black or brown, hard, necrotic).
   • Drainage (Exudate): Amount (scant, moderate, copious), color (serous – clear, serosanguineous – pale pink, sanguineous – bloody, purulent – yellow, green, or white), odor (foul, pungent, or odorless), and consistency.
   • Wound Edges: Well-approximated, irregular, rolled, undermined, or epibole (rolled edges).
   • Periwound Skin: Skin surrounding the wound; assess for erythema, edema, maceration (softening due to excessive moisture), induration (firmness), and temperature changes.
   • Tunneling or Undermining: Presence and extent of tissue destruction extending under intact skin at the wound edges.
   • Signs of Infection: Local and systemic signs as described in subjective data.

3. T.I.M.E. Assessment Framework: Utilize the T.I.M.E. acronym as a structured approach to wound assessment:

   • Tissue (T): Type of tissue in the wound bed – viable (granulation, epithelial) or nonviable (slough, necrotic).
   • Infection/Inflammation (I): Assess for signs of local or systemic infection; differentiate between normal inflammatory response and infection.
   • Moisture Balance (M): Evaluate wound moisture level – too dry, too moist (macerated). Assess exudate type and amount.
   • Edge Advancement (E): Monitor wound edge progression – are edges closing, stalled, or deteriorating? Assess for undermining or tunneling.

4. Pain Assessment: Quantify and characterize wound-related pain:

   • Pain Scale: Use a validated pain scale (numerical rating scale, visual analog scale) to assess pain intensity.
   • Pain Characteristics: Location, quality (sharp, dull, burning), radiation, aggravating/relieving factors, and timing.

Image: TIME acronym for wound assessment: Tissue, Infection/Inflammation, Moisture, Edge.

Diagnostic Procedures

1. Wound Culture: Obtain wound swabs to identify causative pathogens and guide antibiotic therapy.

   • Swab Culture: Easy, cost-effective method to identify superficial wound pathogens.
   • Tissue Biopsy: More invasive but considered the gold standard for identifying deep tissue infections and specific pathogens.
   • Aspiration: Needle aspiration of wound fluid is used to assess for deeper infections, such as abscesses.

2. Laboratory Tests: Blood tests to assess for systemic infection and inflammation:

   • White Blood Cell (WBC) Count: Elevated WBC count indicates infection.
   • C-Reactive Protein (CRP): Elevated CRP is a marker of inflammation.
   • Procalcitonin (PCT): More specific marker for bacterial infections, especially sepsis.
   • Presepsin: Another marker for sepsis, indicating bacterial infection severity.
   • Microbial DNA/PCR: Detects specific pathogens and antibiotic resistance genes.
   • Bacterial Protease Activity (BPA): Indicates bacterial burden in the wound.

3. Imaging Studies: Used to evaluate the extent and depth of infection, especially in deeper tissues or when complications are suspected:

   • Plain X-rays: Detect foreign bodies or gas in soft tissues suggestive of infection.
   • Computed Tomography (CT Scan): Detailed images of soft tissues and organs; useful for identifying abscesses or deeper infections.
   • Magnetic Resonance Imaging (MRI): Superior soft tissue detail; assesses extent of infection in tissues and bone (osteomyelitis).
   • Ultrasound: Evaluates soft tissue infections and fluid collections.

4. Peripheral Perfusion Assessment: Evaluate blood flow to the extremities, especially in patients with vascular risk factors:

   • Ankle-Brachial Index (ABI) and Toe-Brachial Index (TBI): Assess for peripheral artery disease by comparing blood pressure in ankles/toes to arms.
   • Monofilament Testing: Evaluates protective sensation in feet, particularly important for diabetic neuropathy and risk of foot ulcers.
   • Skin Perfusion Pressure (SPP): Measures blood flow in small vessels of the skin.
   • Transcutaneous Oxygen Pressure (TcPO2): Measures oxygen levels in the skin tissue, indicating tissue oxygenation and healing potential.

Nursing Diagnoses for Wound Infection

Based on the assessment data, relevant nursing diagnoses can be identified. For wound infections, common nursing diagnoses include:

• Risk for Infection: (While infection may already be present, this can still be used to address risk of secondary or worsening infection).
• Acute Pain: Related to wound infection and tissue damage.
• Impaired Skin Integrity: Related to wound and infection.
• Ineffective Protection: Related to compromised skin integrity and infection.
• Ineffective Tissue Perfusion: Related to underlying conditions and infection.
• Knowledge Deficit: Related to wound care and infection prevention.

Infection Nursing Diagnosis Care Plan: Goals and Outcomes

The overall goals for an infection nursing diagnosis care plan are to:

• Prevent further infection or complications.
• Promote wound healing.
• Manage pain effectively.
• Restore skin integrity.
• Improve tissue perfusion.
• Increase patient knowledge and self-care abilities.

Expected outcomes are specific, measurable, achievable, relevant, and time-bound (SMART). Examples include:

• Patient will demonstrate a decrease in wound size and signs of infection within [specific timeframe].
• Patient will report pain level of [specific number] or less on a 0-10 scale.
• Patient will verbalize understanding of wound care procedures and infection prevention measures.
• Patient will demonstrate proper wound care techniques.
• Patient will maintain adequate tissue perfusion to the affected area as evidenced by [specific indicators].

Nursing Interventions for Wound Infection

Nursing interventions are the actions nurses take to achieve the desired outcomes. For wound infections, interventions focus on wound care, infection management, pain control, and patient education.

Wound Care Interventions

1. Debridement of Nonviable Tissue: Remove necrotic tissue to promote healing.

   • Autolytic Debridement: Utilizing the body’s own enzymes to break down necrotic tissue using moisture-retentive dressings.
   • Enzymatic Debridement: Applying topical enzymatic agents to digest necrotic tissue.
   • Sharp Debridement: Surgical removal of necrotic tissue using sharp instruments, performed by trained professionals.
   • Mechanical Debridement: Wet-to-dry dressings (less selective and can damage healthy tissue, use with caution), wound irrigation.

2. Moisture Management: Maintain optimal wound moisture balance.

   • Moist Wound Healing: Select dressings that maintain a moist wound environment, promoting cell migration and healing.
   • Exudate Management: Choose absorbent dressings (alginates, hydrofibers) for wounds with excessive drainage. Frequent dressing changes may be necessary.

3. Wound Packing: For deep wounds with tunneling or undermining, pack loosely with sterile materials to prevent premature closure of the wound surface and ensure healing from the base up. Use moistened sterile gauze or hydrogel-impregnated dressings.

4. Periwound Skin Protection: Protect the skin surrounding the wound from maceration and breakdown. Apply barrier creams, powders, protective wipes, or skin sealant wafers.

5. Wound Vac (Vacuum-Assisted Closure): Consider for complex, open wounds, pressure ulcers, skin grafts, or flaps to remove exudate, reduce edema, promote granulation tissue formation, and wound closure.

6. Pain Management during Wound Care: Pre-medicate with prescribed analgesics (oral or topical) prior to dressing changes or debridement procedures.

Infection Management Interventions

1. Aseptic or Clean Technique: Adhere to appropriate aseptic or clean techniques during dressing changes. Aseptic technique (sterile gloves and equipment) is crucial for surgical wounds, burns, and immunocompromised patients. Clean technique (non-sterile gloves, clean equipment) is often suitable for chronic wounds like pressure ulcers.

2. Antibiotic Administration: Administer antibiotics as prescribed.

   • Topical Antibiotics or Silver Dressings: May be used for localized wound infections.
   • Systemic Antibiotics (Oral or IV): Necessary for wounds with systemic infection signs or deep tissue infections. Administer based on culture and sensitivity results for targeted therapy.

3. Wound Cleansing: Cleanse wounds appropriately.

   • Initial Wound Cleaning: Cleanse new wounds immediately with mild soap and water to remove contaminants.
   • Avoid Harsh Cleansers: Educate patients to avoid hydrogen peroxide and rubbing alcohol, which can damage healthy tissue and delay healing. Use normal saline or prescribed wound cleansers.

4. Hand Hygiene: Emphasize and practice meticulous hand hygiene before and after wound care.

5. Wound Dressings: Keep wounds covered with appropriate dressings to maintain moisture and prevent bacterial contamination. Educate patients that wounds heal best when kept covered, dispelling myths about needing air exposure.

Promoting Wound Healing Interventions

1. Nutritional Support: Promote adequate nutrition and hydration.

   • High-Protein Diet: Encourage a diet rich in protein to support tissue repair. Supplement with protein drinks if needed.
   • Vitamin and Mineral Supplementation: Ensure adequate intake of Vitamin C, zinc, and other essential nutrients.
   • Hydration: Encourage sufficient fluid intake to maintain tissue perfusion and nutrient delivery.

2. Education on Skin Breakdown Prevention: Educate patients and families on strategies to prevent further skin injury:

   • Pressure Relief: Frequent turning and repositioning, pressure-redistributing support surfaces.
   • Foot Care: Wear appropriate footwear to protect feet, especially for diabetics.
   • Edema Management: Compression stockings for lower extremity edema (venous insufficiency).
   • Skin Hygiene: Keep skin clean and dry, especially for incontinent patients.

3. Wound Documentation: Document wound assessments and care provided at each dressing change, including wound characteristics (size, drainage, tissue type), treatments, and patient response. Consider using wound photography to track progress.

4. Referral to Wound Care Specialist: Refer patients with chronic or non-healing wounds to a wound care clinic or specialist for advanced wound management, specialized dressings, or therapies like hyperbaric oxygen therapy.

Pain Management Interventions

1. Pain Assessment: Regularly assess pain using a pain scale and document pain characteristics.
2. Pharmacological Pain Management: Administer prescribed analgesics – preemptive analgesia before painful procedures. Educate patients about pain medication regimen.
3. Non-pharmacological Pain Management: Positioning, elevation of extremity, splinting to immobilize and protect the wound, distraction techniques, relaxation exercises.
4. Address Contributing Factors: Manage edema, prevent skin maceration and excessive dryness, and ensure appropriate dressing changes to minimize pain.

Ineffective Tissue Perfusion Interventions

1. Foot Care Education: Educate patients with diabetes or PVD on meticulous foot care, including daily inspection, proper footwear, and avoiding injury.
2. Promote Exercise: Encourage walking or appropriate exercises to improve circulation, unless contraindicated by wound location (e.g., plantar foot ulcers).
3. Positioning and Elevation: Elevate lower extremities for venous insufficiency (contraindicated in arterial insufficiency). Avoid leg elevation in arterial disease.
4. Smoking Cessation: Strongly advise smoking cessation due to its detrimental effects on blood vessels and tissue perfusion.
5. Hyperbaric Oxygen Therapy (HBOT) Referral: Consider referral to a wound care specialist for HBOT in cases of chronic, non-healing wounds with poor tissue perfusion.

Knowledge Deficit Interventions

1. Wound Care Education: Provide comprehensive education on wound care procedures, infection prevention, medication regimen, and warning signs of complications. Tailor education to the patient’s and caregiver’s level of understanding.
2. Demonstration and Return Demonstration: Demonstrate wound care techniques and have the patient or caregiver perform return demonstrations to ensure competency.
3. Address Misconceptions: Clarify any misconceptions about wound care practices and address cultural beliefs that may interfere with treatment adherence.
4. Resource Identification: Assess for and address barriers to wound care, such as financial constraints, transportation, or access to supplies. Refer to social workers or case managers for assistance with resources, home healthcare, or equipment.
5. Dietary Counseling: Refer to a dietitian for nutritional counseling to optimize wound healing through proper diet.

Evaluation of the Care Plan

Regularly evaluate the effectiveness of the infection nursing diagnosis care plan. Monitor patient progress towards achieving expected outcomes. Reassess wound status, pain levels, and patient understanding at each encounter. Modify interventions as needed based on the evaluation data.

Conclusion

Developing a comprehensive infection nursing diagnosis care plan is paramount for managing wound infections effectively. By conducting thorough assessments, formulating accurate nursing diagnoses, implementing evidence-based interventions, and continuously evaluating patient progress, nurses can significantly improve patient outcomes, promote wound healing, and prevent complications associated with wound infections. This detailed guide provides a framework for creating individualized care plans that address the multifaceted needs of patients with wound infections, ensuring optimal recovery and well-being.

References

(Note: For a real-world article, specific references would be listed here. For this exercise, we acknowledge the original article as the source and can indicate that standard nursing and wound care textbooks and reputable online resources were consulted in the expanded content.)