Wound infections are a significant concern in healthcare, potentially leading to serious complications if not properly managed. As a healthcare professional, understanding the nuances of wound care and accurately diagnosing infection is paramount. This guide delves into the critical aspects of wound infection, focusing on the application of NANDA nursing diagnoses to enhance patient care and outcomes.
Understanding Wound Infections and Healing
A wound is defined as any disruption to the skin’s integrity, tissues, or organs. This damage can range from minor abrasions to deep tissue injuries, and all wounds carry the risk of infection. Infections occur when pathogens breach the body’s defenses, overwhelming the immune system and leading to complications.
Wounds can be classified in several ways:
- Acute vs. Chronic: Acute wounds heal predictably and quickly, while chronic wounds are slow to heal or recurring.
- Open vs. Closed: Open wounds involve a break in the skin, exposing underlying tissues. Closed wounds occur beneath the skin surface, such as bruises or hematomas.
Understanding the wound healing process is crucial for effective nursing care. Wound healing progresses through four distinct phases:
- Hemostasis (Immediate): The body’s initial response to injury, involving blood vessel constriction, coagulation, and platelet aggregation to stop bleeding and initiate clot formation.
- Inflammation (0-4 days): The immune system’s response to injury and potential pathogens. Neutrophils and macrophages migrate to the wound site to control infection risk, leading to visible swelling and redness.
- Proliferation (2-24 days): New tissue formation. Granulation tissue fills the wound bed, and epithelial cells migrate to cover and close the wound surface.
- Maturation (24+ days): Long-term tissue remodeling. Collagen strengthens the wound site, and scar tissue may form, continuing for months or even years.
Types of Wound Healing
Wound healing can occur through different mechanisms, each with varying infection risks:
- Primary Intention: Wound edges are approximated and closed using sutures, staples, or adhesives. This method is common for surgical incisions and clean lacerations and carries the lowest risk of infection.
- Secondary Intention: Wounds are left open to heal from the base up, forming granulation tissue. This is typical for pressure ulcers and infected wounds. Secondary intention healing inherently carries a higher risk of infection due to the exposed wound bed.
- Tertiary Intention (Delayed Primary Closure): Wounds are initially left open to manage infection or contamination and are closed later once the infection is controlled.
Factors Affecting Wound Healing and Infection Risk
Numerous factors can influence the body’s ability to heal and increase susceptibility to wound infections:
- Nutritional Status: Adequate protein, vitamins, and minerals are essential for tissue repair and immune function.
- Stress: Psychological and physiological stress can impair the immune system and slow healing.
- Comorbidities: Conditions like diabetes mellitus, peripheral vascular disease, and immunosuppression significantly increase infection risk and hinder healing.
- Age: Older adults often have compromised immune systems and slower healing processes.
- Obesity: Obesity can impair blood supply and increase the risk of infection.
- Medications: Certain medications, such as corticosteroids and immunosuppressants, can delay wound healing and increase infection susceptibility.
- Lifestyle Factors: Alcohol use and smoking impair circulation and immune function, negatively impacting wound healing.
- Local Wound Factors: Friction, shearing forces, poor mobility, and knowledge deficits in wound care contribute to wound development and infection.
Nursing Assessment of Wound Infections: A Foundation for NANDA Diagnosis
A thorough nursing assessment is the cornerstone of effective wound care and accurate diagnosis of infection. This assessment involves gathering subjective and objective data to inform clinical decision-making and the selection of appropriate NANDA nursing diagnoses.
Review of Health History
The health history provides vital clues about the patient’s risk for wound infection and potential underlying causes. Key areas to explore include:
-
General Symptoms: Inquire about symptoms indicative of local or systemic infection:
- Purulent wound drainage (pus)
- Skin discoloration (erythema, increased redness)
- Localized swelling (edema)
- Foul odor emanating from the wound
- Increased warmth, tenderness, pain, or inflammation around the wound site
- Systemic symptoms such as fever, chills, and lymphadenopathy (swollen lymph nodes) near the wound, which may indicate a more serious, systemic infection.
-
Underlying Cause of the Wound: Determine the mechanism of injury or cause of the wound, as this can impact infection risk. Consider:
- Traumatic wounds (lacerations, abrasions, puncture wounds)
- Surgical wounds (incisions)
- Pressure ulcers (related to immobility and pressure)
- Vascular ulcers (arterial or venous insufficiency)
- Burns
- Specific circumstances of injury, such as wounds contaminated with dirt, animal bites, or penetrating injuries from rusty objects, which increase infection risk.
-
Medical Risk Factors: Identify pre-existing conditions that predispose the patient to infection or impaired healing:
- Diabetes mellitus
- Immunosuppression (HIV, autoimmune disorders, medications)
- Renal failure
- Obesity
- Advanced age
- Neuropathy (especially peripheral neuropathy)
- Peripheral vascular disease
- Cancer and cancer treatments (chemotherapy, radiation therapy)
-
Surgical History: For surgical wounds, gather details about the procedure and perioperative period:
- Type of surgery and surgical technique
- Length of hospital stay
- Potential for intraoperative contamination
- Presence of hypothermia during surgery
-
Medication Review: Identify medications that may impair wound healing or increase infection risk:
- Immunosuppressants (corticosteroids, DMARDs)
- Chemotherapeutic drugs
- Hydroxyurea
- NSAIDs (non-steroidal anti-inflammatory drugs)
-
Nutritional Assessment: Evaluate the patient’s nutritional status, as deficiencies can significantly impair wound healing:
- Assess dietary intake of protein, vitamins (especially Vitamin C), and minerals.
- Inquire about fluid intake and hydration status, crucial for circulation and tissue oxygenation.
Physical Assessment of the Wound
A detailed physical examination of the wound is essential to characterize the wound and identify signs of infection. Key components include:
-
Wound Type Determination: Classify the wound type, as this guides appropriate care:
- Skin tears
- Diabetic foot ulcers
- Arterial ulcers
- Venous stasis ulcers
- Pressure ulcers
- Surgical wounds
- Traumatic wounds
-
Wound Characteristics Assessment: Document detailed wound characteristics at each dressing change or according to facility protocol. This includes:
- Location: Anatomical site of the wound.
- Size: Measure length, width, and depth in centimeters.
- Drainage: Describe the type, color, odor, and amount of exudate (serous, sanguinous, serosanguinous, purulent).
- Wound Bed: Describe the tissue type present (granulation tissue, slough, eschar, epithelial tissue).
- Wound Edges and Periwound Skin: Assess the wound margins and surrounding skin for color, integrity, maceration, erythema, and induration.
- Tunneling or Undermining: Note the presence and extent of any tracts or tissue destruction extending under the wound edges.
- Signs of Infection: Carefully observe for local and systemic signs of infection as listed in the health history review.
-
T.I.M.E. Framework: Utilize the T.I.M.E. acronym as a structured approach to wound assessment:
- Tissue: Assess tissue type in the wound bed. Healthy healing tissue includes epithelial (pink, resurfacing) and granulation (red, beefy) tissue. Non-viable tissue includes slough (yellow or gray, stringy) and necrotic tissue (black, dead).
- Infection/Inflammation: Differentiate between normal inflammation (expected in healing) and signs of infection (not normal). Bacterial presence can impede healing and lead to systemic infection.
- Moisture: Evaluate wound moisture balance. A moist wound environment promotes healing, but excessive moisture can cause maceration, while insufficient moisture leads to dryness. Assess the type and amount of wound exudate.
- Edges: Monitor wound edges for signs of non-advancing edges (epibole), rolled edges, undermining, or tunneling, which can indicate impaired healing. Assess the periwound skin for erythema, edema, or maceration.
-
Pain Assessment: Evaluate wound-related pain using a validated pain scale. Assess pain intensity, quality, location, and factors that exacerbate or relieve pain.
Diagnostic Procedures for Wound Infection
Diagnostic procedures are crucial to confirm infection, identify causative pathogens, and guide treatment:
-
Wound Culture: Obtain a wound swab for culture and sensitivity testing to identify the infecting organism and determine antibiotic sensitivities. This is a cost-effective initial step.
-
Biopsy or Aspiration: In cases of deep or persistent infection, or when surface cultures are inconclusive, consider:
- Tissue Biopsy: Provides the most accurate method for pathogen detection but is more invasive, costly, and potentially painful.
- Aspiration: Fluid aspiration from the wound bed or suspected abscess is used to assess for subcutaneous or deep tissue infection.
-
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): An acute phase reactant, elevated CRP indicates inflammation and infection.
- Procalcitonin (PCT): A more specific marker for bacterial infection; elevated PCT levels are strongly suggestive of systemic bacterial infection.
- Presepsin: Another marker of bacterial sepsis, elevated levels indicate bacterial infection.
- Microbial DNA/PCR: Polymerase chain reaction (PCR) can detect specific pathogens’ DNA in wound samples for rapid identification.
- Bacterial Protease Activity (BPA): Elevated BPA levels can indicate bacterial burden in chronic wounds.
-
Imaging Studies: Imaging may be necessary to assess the extent of infection, particularly in deeper tissues:
- Plain X-rays: Useful for detecting soft tissue gas or foreign bodies in wounds.
- Computed Tomography (CT): Provides detailed images of soft tissue infections, abscesses, or osteomyelitis (bone infection).
- Magnetic Resonance Imaging (MRI): Offers superior soft tissue detail and is excellent for evaluating the extent of infection in tissues and bone.
- Ultrasound: Can be used to assess superficial soft tissue infections, fluid collections, or abscesses.
-
Peripheral Perfusion Assessment: Evaluate peripheral circulation, especially in patients with vascular disease or diabetes, as poor perfusion impairs healing:
- Ankle-Brachial Index (ABI) and Toe-Brachial Index (TBI): Assess for peripheral artery disease.
- Monofilament Testing: Evaluate protective sensation in patients with diabetes or neuropathy to identify risk for foot ulcers.
NANDA Nursing Diagnoses for Wound Infection
Based on the comprehensive assessment, several NANDA nursing diagnoses may be relevant to wound infection. These diagnoses provide a standardized framework for identifying patient problems and guiding nursing interventions. Key NANDA diagnoses related to wound infection include:
Risk for Infection
This diagnosis is applicable when a patient is at increased risk of infection due to compromised defenses or environmental factors. In the context of wounds, any break in skin integrity creates a risk for infection.
-
Related Factors (Risk Factors):
- Inadequate primary defenses (broken skin, tissue trauma)
- Chronic disease (diabetes mellitus, immunosuppression)
- Malnutrition
- Obesity
- Advanced age
- Invasive procedures (surgery, IV lines)
- Environmental exposure to pathogens
- Insufficient knowledge to avoid exposure to pathogens
-
Defining Characteristics (Not Applicable for Risk Diagnoses – Focus on Risk Factors):
-
Expected Outcomes:
- Patient will remain free from signs and symptoms of wound infection throughout care.
- Patient will demonstrate preventive measures to reduce the risk of wound infection.
-
Nursing Assessments:
- Identify patients at high risk for wound infection based on health history and risk factors.
- Monitor wounds regularly for early signs of infection (redness, warmth, drainage, pain).
- Assess patient’s understanding of infection prevention measures.
-
Nursing Interventions:
- Implement meticulous hand hygiene practices.
- Maintain aseptic technique during wound care procedures when indicated.
- Educate patient and caregivers on proper wound care and infection prevention measures.
- Promote optimal nutrition and hydration to support immune function.
- Ensure appropriate wound dressings and management to protect the wound from contamination.
Impaired Skin Integrity
This diagnosis applies when the patient’s skin is damaged, which is the case with any wound. When infection is present or likely, this diagnosis becomes even more critical.
-
Related Factors:
- Physical injury (trauma, pressure, shearing, burns, surgical incisions)
- Altered circulation
- Moisture (excessive or insufficient)
- Nutritional deficits
- Age-related skin changes
- Underlying medical conditions (diabetes, edema)
-
As evidenced by (Defining Characteristics):
- Disruption of skin surface (wound, break in skin)
- Drainage from wound
- Redness (erythema)
- Swelling
- Pain or tenderness at wound site
- Delayed wound healing
- Changes in skin color or texture around the wound
-
Expected Outcomes:
- Patient will demonstrate progressive wound healing with reduced wound size and improved tissue integrity.
- Patient will remain free from purulent drainage and other signs of wound infection.
- Patient will verbalize understanding of wound care management and preventive measures.
-
Nursing Assessments:
- Assess and document wound characteristics at each dressing change using a consistent framework (T.I.M.E., wound size, drainage, etc.).
- Monitor for signs and symptoms of wound infection.
- Evaluate factors contributing to impaired skin integrity (pressure, friction, moisture, nutrition).
-
Nursing Interventions:
- Implement appropriate wound care based on wound type and healing stage (cleansing, debridement, dressing selection).
- Maintain a moist wound environment to promote healing.
- Apply topical antibiotics or antiseptics as prescribed for infected wounds.
- Reposition patient frequently to relieve pressure and promote circulation.
- Educate patient and caregivers on wound care techniques, pressure relief measures, and signs of complications.
Acute Pain
Wound infections often cause or exacerbate pain due to inflammation and tissue damage.
-
Related Factors:
- Tissue destruction (wound, infection, inflammation)
- Nerve compression or irritation
- Muscle spasms
- Edema
-
As evidenced by (Defining Characteristics):
- Verbal report of pain (using pain scale)
- Guarding behavior
- Facial grimacing, restlessness
- Changes in vital signs (increased heart rate, blood pressure, respiratory rate)
- Tenderness to palpation
-
Expected Outcomes:
- Patient will report pain at a manageable level (using pain scale).
- Patient will demonstrate effective pain management strategies.
- Patient will participate in wound care activities with minimal discomfort.
-
Nursing Assessments:
- Assess pain intensity, quality, location, and aggravating/relieving factors using a pain scale.
- Evaluate the impact of pain on patient’s function and quality of life.
- Monitor for nonverbal cues of pain, especially in non-communicative patients.
-
Nursing Interventions:
- Administer analgesics as prescribed, preemptively before painful procedures like dressing changes.
- Utilize non-pharmacological pain relief measures (positioning, distraction, relaxation techniques).
- Educate patient on pain management options and strategies.
- Minimize wound manipulation during dressing changes to reduce pain.
- Splint or support the affected area to reduce movement and pain.
Ineffective Protection
This diagnosis may be relevant if a patient has decreased ability to protect themselves from infection or further injury, often due to underlying conditions or compromised immunity.
-
Related Factors:
- Compromised immune system
- Malnutrition
- Older age
- Immobility
- Incontinence
- Neurosensory impairment
- Disruption of skin integrity
-
As evidenced by (Defining Characteristics):
- Recurrent infections
- Delayed wound healing
- Pressure ulcer development
- Maladaptive stress response
- Weakness, fatigue
- Impaired tissue healing
-
Expected Outcomes:
- Patient will remain free from new infections.
- Patient will demonstrate behaviors to enhance protection against infection and injury.
- Patient will maintain intact skin without breakdown or further injury.
-
Nursing Assessments:
- Assess patient’s immune status and risk factors for infection.
- Monitor vital signs for indications of systemic infection.
- Evaluate nutritional status and ability to perform self-care activities.
- Assess skin integrity regularly, especially in pressure-prone areas.
-
Nursing Interventions:
- Implement infection control measures rigorously.
- Promote adequate nutrition and hydration.
- Provide assistance with hygiene and skin care as needed.
- Educate patient and caregivers on infection prevention and self-protection strategies.
- Administer prophylactic antibiotics as prescribed.
Ineffective Tissue Perfusion
Poor tissue perfusion can significantly impair wound healing and increase infection risk, particularly in patients with vascular disease or diabetes.
-
Related Factors:
- Disruption of arterial or venous blood flow
- Hypovolemia
- Hypervolemia
- Impaired gas exchange
- Smoking
- Sedentary lifestyle
- Chronic conditions (diabetes, vascular disease)
-
As evidenced by (Defining Characteristics):
- Skin discoloration (pallor, cyanosis, rubor)
- Cool extremities
- Diminished or absent peripheral pulses
- Edema
- Delayed wound healing
- Pain (intermittent claudication, rest pain)
- Paresthesia
- Altered skin characteristics (thin, shiny, hairless skin)
- Abnormal ABI/TBI measurements
-
Expected Outcomes:
- Patient will demonstrate improved tissue perfusion as evidenced by wound healing and resolution of perfusion-related signs and symptoms.
- Patient will verbalize understanding of factors affecting tissue perfusion and strategies to improve circulation.
-
Nursing Assessments:
- Assess peripheral pulses, skin color and temperature, and capillary refill.
- Monitor for signs and symptoms of inadequate tissue perfusion (pain, edema, skin changes).
- Evaluate ABI/TBI results and other perfusion studies.
- Identify and address factors contributing to impaired perfusion (smoking, sedentary lifestyle, uncontrolled comorbidities).
-
Nursing Interventions:
- Promote smoking cessation.
- Encourage regular exercise as tolerated to improve circulation.
- Position limbs to promote blood flow (elevation for venous insufficiency, dependent position for arterial insufficiency – as directed by physician).
- Apply compression therapy for venous insufficiency (if appropriate and ordered).
- Educate patient on foot care, skin protection, and signs of worsening perfusion.
Knowledge Deficit
Lack of knowledge about wound care and infection prevention can lead to poor self-management and increased risk of complications.
-
Related Factors:
- Lack of exposure to information
- Misinformation
- Cognitive limitations
- Lack of interest in learning
- Language barriers
-
As evidenced by (Defining Characteristics):
- Verbalization of lack of knowledge
- Requests for information
- Inaccurate follow-through of instructions
- Development of wound infection or complications
- Non-adherence to wound care regimen
-
Expected Outcomes:
- Patient will verbalize understanding of wound care management, infection prevention, and signs of complications.
- Patient will demonstrate proper wound care techniques.
- Patient will adhere to the prescribed wound care plan.
-
Nursing Assessments:
- Assess patient’s current knowledge level about wound care and infection prevention.
- Identify learning needs and preferred learning style.
- Evaluate factors that may hinder learning (language barriers, cognitive deficits).
- Assess patient’s access to resources and support for wound care at home.
-
Nursing Interventions:
- Provide clear, concise, and individualized education on wound care techniques, infection prevention, medication administration, and signs of complications.
- Use various teaching methods (demonstration, written materials, visual aids).
- Allow time for questions and address concerns.
- Involve caregivers in education and training as needed.
- Provide resources for wound care supplies, support groups, and home health services.
- Reinforce teaching at each encounter and evaluate understanding through teach-back methods.
Nursing Interventions for Wound Care and Infection Management
Effective nursing interventions are crucial for promoting wound healing, preventing infection, and managing existing wound infections. These interventions encompass a range of strategies:
Providing Appropriate Wound Care
-
Debridement: Remove nonviable tissue (eschar, slough) to promote healing. Methods include:
- Autolytic debridement: Using moisture-retentive dressings to allow the body’s enzymes to break down necrotic tissue.
- Enzymatic debridement: Applying topical enzymes to digest necrotic tissue.
- Sharp debridement: Surgical removal of necrotic tissue by a trained professional.
-
Moisture Balance: Maintain optimal wound moisture.
- Use appropriate dressings to absorb excess exudate (hydrofiber, alginate) or add moisture (hydrogels) as needed.
- Change dressings frequently to prevent maceration or wound drying.
-
Wound Packing: For deep wounds or those with tunneling, pack loosely with moistened sterile gauze or hydrogel-impregnated dressings to maintain wound bed moisture and prevent premature closure of the wound opening.
-
Periwound Skin Protection: Protect the skin surrounding the wound from maceration and irritation using barrier creams, powders, wipes, or wafers.
-
Wound Vac Therapy: Consider vacuum-assisted closure (VAC) for complex wounds, pressure ulcers, grafts, or flaps to promote healing by removing exudate, reducing edema, and increasing blood flow.
-
Pain Management: Premedicate with analgesics before dressing changes to minimize pain and discomfort.
Preventing and Managing Infection
-
Aseptic/Clean Technique: Use aseptic technique (sterile gloves and supplies) for high-risk wounds like surgical wounds or burns. Clean technique (non-sterile gloves) is appropriate for less critical wounds like pressure ulcers.
-
Antibiotic Administration: Administer topical antibiotics or silver dressings for localized wound infections. Systemic infections require oral or IV antibiotics based on culture and sensitivity results.
-
Immediate Wound Cleaning: Emphasize immediate cleaning of wounds with mild soap and water to reduce bacterial load, especially for contaminated wounds.
-
Avoid Harsh Cleansers: Educate patients to avoid using hydrogen peroxide or rubbing alcohol, as these can damage healthy tissue and delay healing.
-
Hand Hygiene: Reinforce the importance of thorough handwashing before and after wound care.
-
Wound Covering: Educate patients that wounds heal best when kept covered with a dressing to maintain moisture and prevent bacterial contamination.
Promoting Wound Healing
-
Nutritional Support: Promote a high-protein diet and adequate hydration to support tissue repair and immune function. Consider protein supplements if needed. Encourage Vitamin C intake.
-
Skin Breakdown Prevention Education: Educate patients and families on strategies to prevent further skin injury:
- Frequent turning and repositioning to relieve pressure.
- Wearing protective footwear.
- Using compression stockings to manage lower extremity edema (for venous insufficiency).
- Keeping skin clean and dry, especially for incontinent patients.
-
Wound Documentation: Document wound assessments and care provided at each dressing change, including wound characteristics, treatments, and patient response. Consider using wound photography for tracking progress.
-
Wound Care Specialist Referral: Refer patients with chronic or non-healing wounds to a wound care clinic for specialized assessment and advanced treatments like hyperbaric oxygen therapy.
Conclusion
Utilizing NANDA nursing diagnoses provides a structured and standardized approach to addressing the complex needs of patients with wound infections. By conducting thorough assessments, accurately identifying relevant nursing diagnoses such as Risk for Infection, Impaired Skin Integrity, and Acute Pain, and implementing evidence-based interventions, nurses play a vital role in promoting wound healing, preventing complications, and improving patient outcomes. A comprehensive understanding of wound care principles, coupled with the framework of NANDA diagnoses, empowers healthcare professionals to deliver optimal, patient-centered care for individuals with wound infections.
