Infection Nursing Diagnosis NANDA: A Comprehensive Guide for Wound Care

Wound infections are a significant concern in healthcare, complicating patient recovery and increasing morbidity. For nurses, accurate assessment and diagnosis are crucial first steps in effective wound management. Utilizing the NANDA International (NANDA-I) framework for nursing diagnoses provides a standardized language and approach to identify, address, and monitor patient problems related to wound infections. This article delves into the critical role of Infection Nursing Diagnosis Nanda in wound care, offering a comprehensive guide for nurses and healthcare professionals.

Understanding Wound Infection and Its Nursing Implications

A wound, defined as any disruption in the skin, tissues, or organ integrity, becomes susceptible to infection when pathogens breach the body’s natural defenses. This breach can overwhelm the immune system, leading to localized or systemic infection. Wound infections are a major obstacle to healing and can arise from various sources, including poor aseptic techniques, contamination, and patient-specific risk factors.

The Wound Healing Process and Infection Risk

Wound healing is a complex physiological process occurring in four overlapping phases:

• Hemostasis: Immediate response to injury involving blood vessel constriction and clot formation to stop bleeding.
• Inflammation (0-4 days): Immune cells, such as neutrophils and macrophages, migrate to the wound site to combat potential infection and clear debris, marked by swelling and redness.
• Proliferation (2-24 days): New tissue, known as granulation tissue, fills the wound bed, and epithelial cells regenerate to cover the wound surface.
• Maturation (24+ days): Collagen remodeling strengthens the wound, and scar tissue may form.

Any disruption in these healing phases increases the risk of infection. Delays in inflammation resolution, impaired immune response, or poor wound care practices can create an environment conducive to pathogen proliferation.

Types of Wound Healing and Infection Susceptibility

The method of wound closure significantly impacts infection risk:

• Primary Intention: Wounds with clean, approximated edges, closed with sutures, staples, or adhesives (e.g., surgical incisions, lacerations). These wounds generally have a lower infection risk due to the close approximation of tissue.
• Secondary Intention: Wounds left open to heal from the base up, forming granulation tissue (e.g., pressure ulcers). This method carries a higher risk of infection because the wound is exposed for a longer period.
• Tertiary Intention (Delayed Primary Closure): Wounds initially left open to address infection or contamination and are closed later once these issues are resolved. This approach is used when infection risk is high and requires careful monitoring.

Factors Elevating Risk for Wound Infection: A Nursing Diagnosis Perspective

Several factors can compromise the body’s defense mechanisms and elevate the risk of wound infection. Identifying these risk factors is crucial for formulating appropriate infection nursing diagnoses NANDA. These factors include:

• Compromised Immune System: Conditions like diabetes mellitus, HIV, autoimmune diseases, and immunosuppressive therapies weaken the immune response, making individuals more vulnerable to infections.
• Chronic Conditions: Diseases that impair circulation (e.g., peripheral vascular disease, renal failure) or delay healing (e.g., diabetes) increase infection susceptibility.
• Advanced Age: Older adults often have reduced immune function and slower healing processes.
• Obesity: Adipose tissue has poorer blood supply and can impair immune function and wound healing.
• Nutritional Deficiencies: Inadequate protein, vitamins, and minerals compromise the body’s ability to repair tissues and fight infection.
• Medications: Certain medications, such as corticosteroids, chemotherapy drugs, and NSAIDs, can suppress the immune system or delay wound healing.
• Lifestyle Factors: Smoking and excessive alcohol consumption impair circulation and immune function, increasing infection risk.
• Wound Characteristics: Large, deep, contaminated, or improperly managed wounds are at higher risk of infection.
• Poor Mobility: Reduced mobility increases the risk of pressure ulcers and impairs circulation, hindering wound healing.
• Knowledge Deficit: Lack of understanding regarding proper wound care practices can lead to infection.

Alt text: A nurse carefully assesses a patient’s wound, focusing on visual indicators of healing and potential infection during a routine dressing change.

Nursing Assessment for Wound Infection: Guiding the NANDA Diagnosis

A thorough nursing assessment is the cornerstone of identifying and managing wound infections. This assessment involves gathering both subjective and objective data to inform the infection nursing diagnosis NANDA.

Review of Health History: Uncovering Risk Factors and Symptoms

The health history provides valuable insights into the patient’s overall health status and risk factors for wound infection. Key aspects to review include:

1. General Symptoms of Infection:

• Local Signs: Purulent wound drainage, unusual skin discoloration (increased redness or abnormal color), swelling, foul odor, localized warmth, tenderness, and pain at the wound site are indicative of infection.
• Systemic Signs: Fever, chills, and lymphadenopathy (swollen lymph nodes, particularly near the wound) may signal a more serious, systemic infection requiring immediate attention.

2. Underlying Cause of the Wound: Understanding the wound etiology is essential for targeted interventions. Consider:

• Trauma (accidents, burns)
• Immobility (pressure ulcers)
• Surgical incisions
• Vascular insufficiency (arterial or venous ulcers)
• Specific injury types (animal bites, puncture wounds, lacerations).
• Circumstances of injury: Was the wound contaminated with dirt, saliva, or foreign material? Was it caused by a rusty object or in an unsanitary environment?

3. Medical Risk Factors: Identify pre-existing conditions that increase infection risk:

• Diabetes Mellitus
• Immunosuppression (HIV, autoimmune disorders)
• Renal Failure
• Obesity
• Advanced Age
• Neuropathy
• Peripheral Vascular Disease

4. Surgical History: Surgical procedures inherently increase infection risk, especially considering:

• Surgical Technique: Poor technique can increase the likelihood of infection.
• Length of Hospital Stay: Prolonged stays can increase exposure to nosocomial pathogens.
• Intraoperative Contamination: Contamination during surgery is a significant risk factor.
• Hypothermia: Hypothermia during surgery can impair immune function.

5. Medication Review: Certain medications can impede wound healing and increase infection risk:

• Immunosuppressants (e.g., steroids, DMARDs)
• Chemotherapy drugs
• Hydroxyurea
• NSAIDs

6. Nutritional Status: Inquire about dietary intake and hydration status.

• Protein deficiency, vitamin and mineral deficiencies, and dehydration impair wound healing and immune function.

Physical Assessment: Objective Signs of Wound Infection

A detailed physical assessment of the wound is crucial for identifying objective signs of infection and guiding the infection nursing diagnosis NANDA.

1. Wound Type Determination: Classify the wound type to guide appropriate care:

• Skin tears
• Diabetic foot ulcers
• Arterial ulcers
• Venous stasis ulcers
• Pressure ulcers
• Surgical wounds
• Traumatic wounds

2. Detailed Wound Assessment and Documentation: Assess and document wound characteristics at each dressing change, including:

• Location: Anatomical site of the wound.
• Size: Length, width, and depth in centimeters.
• Drainage: Type (purulent, serous, serosanguineous, sanguinous), amount, color, and odor.
• Wound Bed: Describe tissue type (granulation, slough, eschar).
• Wound Edges and Periwound Skin: Assess for erythema, edema, maceration, induration, and epibole.
• Tunneling or Undermining: Presence and extent of tissue destruction beneath the wound edges.
• Signs of Infection: Redness, warmth, swelling, pain, purulent drainage, odor.

3. Utilize the T.I.M.E. Acronym: This framework provides a structured approach to wound assessment:

• Tissue: Assess tissue type in the wound bed.
  • Epithelial (pink): Indicates healing.
  • Granulation (red): Healthy, new tissue formation.
  • Slough (yellow/gray): Nonviable, stringy tissue.
  • Necrotic (black): Dead tissue (eschar).
• Infection/Inflammation: Differentiate between normal inflammation and infection.
  • While inflammation is part of healing, infection is not and delays healing.
  • Look for signs of infection (increased pain, heat, redness, swelling, purulent drainage, odor).
• Moisture: Assess wound moisture balance.
  • Too Moist: Can cause maceration (skin breakdown from excessive moisture).
  • Too Dry: Impedes cell migration and healing.
  • Exudate: Characterize drainage (purulent, serous, sanguinous).
• Edges: Evaluate wound edges and surrounding skin (periwound).
  • Assess for rolled edges (epibole), undermining, tunneling, discoloration, erythema, swelling, maceration.

4. Pain Assessment: Evaluate wound-related pain using a pain scale.

• Pain is a subjective experience; utilize pain scales (numeric, visual analog) to quantify pain intensity and effectiveness of pain management.

Diagnostic Procedures: Confirming Wound Infection

Diagnostic procedures help confirm the presence of infection and identify causative pathogens, further refining the infection nursing diagnosis NANDA and guiding treatment.

1. Wound Culture: Obtain a wound swab for culture and sensitivity testing.

• Swabbing is a cost-effective method to identify bacterial pathogens and determine antibiotic sensitivities.

2. Biopsy or Aspiration: Consider more invasive procedures for deeper infections or when surface cultures are inconclusive.

• Tissue Biopsy: Most accurate method for bacterial identification in deep tissue infections, but more invasive and costly.
• Aspiration: Fluid aspiration (e.g., from abscesses) is used to assess for pathogens beneath the skin surface.

3. Laboratory Values: Blood tests can support the diagnosis of systemic infection.

• White Blood Cell (WBC) Count: Elevated WBC count suggests infection.
• C-Reactive Protein (CRP) and Procalcitonin (PCT): Inflammatory markers elevated in infection.
• Presepsin, Microbial DNA, Bacterial Protease Activity (BPA): Emerging biomarkers that can aid in early infection detection.

4. Imaging Studies: Imaging may be necessary to assess the extent and depth of infection, particularly in deeper tissues.

• Plain X-rays: Detect soft tissue infections or gas gangrene.
• Computed Tomography (CT): Visualize soft tissue infections and intra-abdominal abscesses.
• Magnetic Resonance Imaging (MRI): Detailed imaging to assess infection extent in soft tissues and bone (osteomyelitis).
• Ultrasound: Useful for evaluating skin and soft tissue infections, abscesses, and fluid collections.

5. Peripheral Perfusion Assessment: Evaluate peripheral circulation, especially in patients with risk factors like diabetes or peripheral vascular disease.

• Ankle-Brachial Index (ABI) and Toe-Brachial Index (TBI): Assess for peripheral artery disease.
• Monofilament Testing: Assess for peripheral neuropathy and loss of protective sensation, particularly in diabetic patients.

NANDA Nursing Diagnoses for Infection Related to Wounds

Based on the comprehensive assessment, nurses can formulate relevant NANDA nursing diagnoses to guide care planning. Key diagnoses related to wound infection include:

1. Risk for Infection: This diagnosis is applicable when the patient is at increased vulnerability to pathogenic organisms.

• Related to:

  • Inadequate primary defenses (broken skin, traumatized tissue)
  • Compromised immune system
  • Chronic disease
  • Invasive procedures
  • Environmental contamination
  • Insufficient knowledge to avoid exposure to pathogens

• Defining Characteristics: (Absence of signs and symptoms of actual infection; identification of risk factors as listed above).

2. Impaired Skin Integrity: This diagnosis describes altered or damaged epidermis and/or dermis. While not directly infection, it is a major precursor and often co-exists with infection or risk for infection.

• Related to:

  • External factors (pressure, shear, friction, moisture, trauma, surgical incision)
  • Internal factors (altered nutritional state, impaired circulation, fluid deficit/excess, immunocompetence)

• As Evidenced By: (When infection is present, evidenced by infection signs and symptoms, in addition to descriptors of skin damage such as disruption of skin surface, destruction of skin layers, invasion of body structures).

3. Acute Pain: Pain is a common symptom associated with wound infection and tissue damage.

• Related to:

  • Tissue destruction
  • Inflammatory process
  • Infection

• As Evidenced By:

  • Reported pain
  • Protective behavior (guarding)
  • Facial grimacing, restlessness
  • Changes in vital signs (increased heart rate, blood pressure)

While “Risk for Infection,” “Impaired Skin Integrity,” and “Acute Pain” are primary NANDA nursing diagnoses in wound infection, other diagnoses may be relevant depending on the individual patient’s situation, such as “Ineffective Tissue Perfusion” or “Knowledge Deficit” related to wound care. The key is to select diagnoses that accurately reflect the patient’s needs and guide nursing interventions.

Nursing Interventions: Addressing Infection Based on NANDA Diagnoses

Nursing interventions are directed at preventing, managing, and resolving wound infections, directly addressing the identified NANDA nursing diagnoses.

Wound Care Interventions: Promoting Healing and Preventing Infection

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

• Autolytic Debridement: Using moisture-retentive dressings to allow the body’s own enzymes to break down necrotic tissue.
• Enzymatic Debridement: Applying topical enzymatic agents to digest necrotic tissue.
• Sharp Debridement: Surgical removal of necrotic tissue by a trained professional.

2. Moisture Management: Maintain optimal wound moisture balance.

• Select dressings based on exudate levels (hydrofiber, alginate for high exudate; hydrogels for dry wounds).
• Frequent dressing changes may be necessary to manage excessive drainage.

3. Wound Packing: Pack wounds with tunneling or undermining to prevent premature closure and maintain moisture.

• Use moistened sterile gauze or hydrogel-impregnated dressings.

4. Periwound Skin Protection: Protect the skin surrounding the wound.

• Apply barrier creams, powders, wipes, or wafers to prevent maceration and skin breakdown.

5. Wound Vac Therapy: Consider vacuum-assisted closure (VAC) for complex wounds.

• VAC therapy promotes wound healing by removing exudate, reducing edema, and increasing blood flow.

6. Pain Management: Address wound-related pain.

• Premedicate with analgesics prior to dressing changes.
• Utilize pain assessment tools to monitor pain levels and treatment effectiveness.

Alt text: A healthcare professional meticulously performs wound care, demonstrating aseptic technique while changing a dressing on a patient’s leg wound.

Infection Prevention and Management Interventions: Targeting “Risk for Infection” NANDA Diagnosis

1. Aseptic or Clean Technique: Employ appropriate technique during wound care.

• Aseptic Technique: Sterile gloves and equipment for high-risk wounds (surgical wounds, burns).
• Clean Technique: Non-sterile gloves and clean equipment for chronic wounds (pressure ulcers, skin tears).

2. Antibiotic Administration: Administer antibiotics as prescribed.

• Topical antibiotics or silver dressings for localized wound infections.
• Oral or IV antibiotics for systemic infections, guided by culture and sensitivity results.

3. Immediate Wound Cleaning: Emphasize the importance of prompt wound cleaning.

• Clean wounds immediately with mild soap and water, especially contaminated wounds.
• Seek medical attention for deep, dirty, or animal bite wounds.

4. Avoid Harsh Cleansing Agents: Educate patients to avoid hydrogen peroxide and rubbing alcohol.

• These agents can damage healthy tissue and delay healing.

5. Hand Hygiene: Reinforce the importance of handwashing.

• Wash hands thoroughly before and after wound care.

6. Wound Coverage: Keep wounds covered with appropriate dressings.

• Dressings maintain a moist wound environment and prevent bacterial contamination.

Promoting Wound Healing: Addressing “Impaired Skin Integrity” and Related NANDA Diagnoses

1. Nutritional Support: Optimize nutritional status.

• High-protein diet to support tissue repair.
• Vitamin C supplementation to promote collagen synthesis and tissue regeneration.
• Adequate hydration for tissue oxygenation and nutrient delivery.

2. Education on Skin Breakdown Prevention: Teach strategies to prevent further skin injury.

• Frequent repositioning and pressure relief for immobile patients.
• Protective footwear.
• Compression stockings for lower extremity edema.
• Maintain skin cleanliness and dryness, especially for incontinent patients.

3. Wound Documentation: Thoroughly document wound assessment and care provided.

• Record wound size, exudate, tissue type, periwound skin, and interventions at each dressing change.
• Consider wound photography for visual documentation of healing progress.

4. Referral to Wound Care Specialist: Refer patients with chronic or non-healing wounds.

• Specialized wound care clinics offer advanced treatments and expertise in managing complex wounds.

Nursing Care Plan Examples Using NANDA Diagnoses for Wound Infection

Developing nursing care plans based on NANDA nursing diagnoses ensures individualized and goal-directed care. Here are examples for the diagnoses discussed:

Nursing Care Plan: Risk for Infection

NANDA Diagnosis: Risk for Infection related to impaired skin integrity and compromised immune defenses.

Expected Outcomes:

• Patient will remain free from signs and symptoms of wound infection throughout hospitalization/care period.
• Patient/caregiver will demonstrate proper wound care techniques and infection prevention measures.

Nursing Interventions:

• Assess: Monitor vital signs, WBC count, wound appearance, and patient risk factors for infection at least daily.
• Implement:
  • Adhere to strict aseptic/clean technique during wound care.
  • Administer prophylactic antibiotics as ordered.
  • Educate patient/caregiver on hand hygiene, wound cleaning, dressing changes, and signs of infection to report.
  • Ensure adequate nutrition and hydration to support immune function.
• Evaluate: Regularly assess for signs of infection (redness, warmth, swelling, purulent drainage, fever). Monitor lab results (WBC, CRP). Evaluate patient/caregiver understanding of infection prevention.

Nursing Care Plan: Impaired Skin Integrity (with Infection)

NANDA Diagnosis: Impaired Skin Integrity related to surgical incision, evidenced by wound drainage, erythema, and patient report of pain.

Expected Outcomes:

• Patient will demonstrate progressive wound healing as evidenced by decreased drainage, granulation tissue formation, and wound closure.
• Patient will verbalize understanding of wound care regimen and participate in wound care.

Nursing Interventions:

• Assess: Assess wound characteristics (size, depth, drainage, tissue type, periwound skin) at each dressing change. Utilize TIME framework. Monitor for signs of worsening infection.
• Implement:
  • Cleanse wound with prescribed antiseptic solution.
  • Debride nonviable tissue as ordered.
  • Apply appropriate wound dressing to maintain moist wound environment and manage exudate.
  • Administer topical or systemic antibiotics as prescribed.
  • Educate patient on wound care procedures, dressing changes, and signs of complications.
• Evaluate: Monitor wound healing progress at each dressing change, document changes in wound characteristics. Evaluate patient adherence to wound care regimen and understanding of instructions.

Nursing Care Plan: Acute Pain related to Wound Infection

NANDA Diagnosis: Acute Pain related to wound infection and tissue inflammation, evidenced by patient report of pain (8/10), guarding behavior, and restlessness.

Expected Outcomes:

• Patient will report pain reduced to a tolerable level (e.g., ≤ 3/10) within 1 hour after pain medication administration.
• Patient will demonstrate relaxed body posture and engage in activities of daily living without significant pain interference.

Nursing Interventions:

• Assess: Assess pain characteristics (location, intensity, quality, aggravating/relieving factors) using a pain scale before and after interventions.
• Implement:
  • Administer prescribed analgesics (oral, IV, topical) as ordered and PRN.
  • Premedicate prior to painful procedures (dressing changes).
  • Position patient for comfort and pressure relief.
  • Provide non-pharmacological pain relief measures (e.g., relaxation techniques, distraction).
• Evaluate: Evaluate pain level and relief after interventions. Monitor for side effects of pain medications. Assess patient’s ability to participate in activities with reduced pain.

Conclusion: Utilizing Infection Nursing Diagnosis NANDA for Enhanced Wound Care

Accurate identification of infection nursing diagnoses NANDA is paramount in providing effective, patient-centered wound care. By utilizing the NANDA-I framework, nurses can systematically assess patients, identify specific problems related to wound infection, and develop targeted interventions. This structured approach not only improves patient outcomes in wound healing and infection management but also promotes a standardized and evidence-based practice in nursing care. Embracing infection nursing diagnosis NANDA empowers nurses to deliver comprehensive and impactful care for patients with wounds, ultimately leading to better health and recovery.