Nursing Diagnosis for Wound Care: A Comprehensive Guide

What is Tissue Integrity?

The body’s primary defense against the external environment is the integumentary system. This system, encompassing the skin, cornea, subcutaneous tissues, and mucous membranes, acts as the initial barrier against external threats. In optimal conditions, these defenses effectively protect the body. However, various factors can compromise this protective barrier, leading to impaired tissue integrity, which is a crucial area for Nursing Diagnosis For Wound Care.

Common causes of tissue integrity impairment include physical trauma from incidents like car accidents, sports injuries, cuts, and blunt force. Thermal factors, such as burns and frostbite, chemical injuries from adverse drug reactions, infections, nutritional and fluid imbalances, and circulatory issues like pressure injuries, also contribute significantly.

While the body often repairs minor tissue damage effectively, more severe or neglected cases may result in replacement with connective tissue, incomplete healing, or even local or systemic infections, potentially leading to necrosis if left unaddressed. Effective nursing diagnosis for wound care is crucial to prevent these complications.

Additional risk factors for impaired tissue integrity include age-related skin changes, weight loss, inadequate nutrition and hydration, excessive skin moisture or dryness, smoking, and conditions affecting blood circulation. Personal hygiene practices, such as overly frequent bathing, prolonged UV exposure from leisure activities, and unfavorable occupational environments (e.g., wet work), can also compromise skin health (Kottner et al., 2020).

Signs and symptoms of impaired skin integrity range from unpleasant sensory experiences and inflammation to visible cutaneous lesions and loss of cutaneous substance, manifesting as wounds. These conditions can significantly diminish quality of life, causing itching, pain, disfigurement, and disability, and increase the risk of allergies and secondary infections. The global burden of skin diseases is on the rise, particularly with increasing age, highlighting the importance of timely and accurate nursing diagnosis for wound care (Kottner et al., 2020).

Close-up of a wound on a person's arm, showing redness and broken skin.

What is Wound Care?

A wound represents a disruption in the normal structure and function of the skin and underlying soft tissues. Acute wounds typically follow a predictable healing process, progressing through expected stages. Conversely, chronic wounds are characterized by physiological impairment that hinders normal healing (Armstrong & Meyr, 2023). Accurate nursing diagnosis for wound care is the first step to differentiate between acute and chronic wounds and tailor appropriate interventions.

Wound healing is a complex physiological process aimed at restoring the integrity of injured skin and tissue. This process is influenced by a multitude of factors, both internal and external, that can either promote or impede healing. In wound care management, nurses, in collaboration with the healthcare team, play a pivotal role in assessing and addressing these factors to create an optimal healing environment (Ernstmeyer & Christman, 2021). This holistic approach, guided by a sound nursing diagnosis for wound care, is essential for effective patient outcomes.

Phases of Wound Healing

The wound healing process is generally divided into four distinct phases: hemostasis, inflammation, proliferation, and maturation. Each phase is characterized by specific cellular and molecular events that contribute to tissue repair and regeneration. Understanding these phases is fundamental for nurses in formulating accurate nursing diagnosis for wound care and implementing phase-specific interventions.

Types of Wound Healing

Wound healing is categorized into three types based on the method of wound closure and the complexity of the healing process: primary intention, secondary intention, and tertiary intention. Recognizing these types is vital for appropriate nursing diagnosis for wound care and predicting healing trajectory.

Primary intention. This type of healing occurs when wound edges are brought together and closed using sutures, staples, glue, or adhesive strips. This method is typical for clean lacerations or surgical incisions where the wound edges are approximated, meaning they are closely aligned. Primary intention healing generally results in minimal scarring and a quicker recovery.
Secondary intention. Secondary intention healing is employed when wound edges cannot be approximated, often due to tissue loss, infection, or extensive damage. In these cases, the wound heals from the bottom up, filling with granulation tissue. Pressure injuries and chainsaw injuries are typical examples. Wounds healing by secondary intention are at a higher risk of infection and typically result in more significant scarring.
Tertiary intention. Also known as delayed primary closure, tertiary intention is used when a wound is initially left open, often to manage infection or contamination. Once the infection is resolved and the wound is deemed clean, it is surgically closed. These wounds have prolonged healing times and increased scar tissue formation (Ernstmeyer & Christman, 2021). Careful nursing diagnosis for wound care is crucial to manage the complexity of tertiary intention wounds and prevent complications.

Causes

Numerous factors can compromise skin integrity, leading to wounds. Identifying these causes is crucial for accurate nursing diagnosis for wound care and targeted interventions. Common causes and etiological factors include:

Physical Trauma: Injuries from car accidents, sports, cuts, and blunt trauma directly disrupt skin structure.
Thermal Factors: Exposure to extreme heat or cold, resulting in burns or frostbite, damages skin tissue.
Chemical Injury: Adverse reactions to drugs or contact with corrosive substances can chemically injure the skin.
Infection: Pathogenic invasion and proliferation in skin tissues lead to breakdown and delayed healing.
Nutritional Imbalances: Deficiencies in essential nutrients impair skin health and the repair process.
Fluid Imbalances: Dehydration or fluid overload can compromise skin elasticity and moisture balance.
Altered Circulation: Conditions like pressure injuries reduce blood flow, leading to tissue ischemia and damage.
Age: Older adults often have thinner, less elastic skin, making them more susceptible to injury.
Weight Loss: Loss of subcutaneous fat reduces cushioning and support, increasing skin vulnerability.
Poor Nutrition and Hydration: Inadequate intake of essential nutrients and fluids impairs skin health and repair mechanisms.
Excessive Moisture and Dryness: Imbalances in skin hydration can lead to maceration or cracking, compromising integrity.
Personal Hygiene Behaviors: Over-frequent bathing or harsh cleansing agents can strip the skin of natural oils, leading to dryness and irritation.

Understanding these diverse causes is fundamental for nurses to develop accurate nursing diagnosis for wound care and implement preventive and therapeutic strategies effectively.

Image alt text: Visual representation of various wound types – puncture, laceration, abrasion, incision, and avulsion – highlighting the diversity of skin injuries relevant to nursing diagnosis.

Signs and Symptoms

Recognizing the signs and symptoms of impaired skin integrity is crucial for timely intervention and accurate nursing diagnosis for wound care. Common signs and symptoms include:

Pain: Discomfort or abnormal sensations at the affected site, indicating tissue damage or nerve involvement.
Inflammation: Redness (erythema), swelling (edema), heat, and pain, which are classic signs of the body’s inflammatory response to injury.
Cutaneous Lesions: Visible abnormalities such as abrasions, lacerations, ulcers, or rashes, indicating a break in skin continuity.
Loss of Cutaneous Substance (Wounds): Openings in the skin that may expose underlying tissues, signifying significant damage to the protective barrier.
Skin and Tissue Color Changes: Alterations in skin color, including redness, purple hues, or black discoloration, suggesting compromised blood flow or tissue necrosis.
Swelling Around the Initial Injury: Edema surrounding the wound site, indicating fluid accumulation and inflammation.
Pruritic/Itchy Skin: Persistent itching that can lead to scratching and further skin damage, possibly indicating underlying skin conditions or allergic reactions.
Dry, Scaly Skin: Lack of moisture resulting in rough, flaky skin surfaces, indicating dehydration or impaired skin barrier function.
Thin, Fragile Skin: Increased vulnerability to tears and abrasions due to reduced skin strength, often seen in older adults or individuals with certain medical conditions.
Exudate or Drainage: Fluid leakage from wounds, which may be clear (serous), bloody (sanguineous), or purulent (containing pus), indicating the stage of healing or presence of infection.
Delayed Wound Healing: Wounds that do not progress through the normal healing stages within an expected timeframe, suggesting underlying complications or impaired healing capacity.
Presence of Necrosis: Dead tissue within or around the wound site, indicating severe tissue damage and compromised blood supply.
Erythema: Persistent redness around the wound area, a key indicator of ongoing inflammation or infection.
Edema: Swelling due to excess fluid trapped in tissues around the wound, suggesting inflammatory response or circulatory issues.

These signs and symptoms provide essential data for nurses to formulate effective nursing diagnosis for wound care and initiate appropriate management strategies.

Nursing Care Plans and Management

Effective wound care and skin integrity maintenance are fundamental to nursing practice. Nurses are central to ensuring prompt and appropriate wound management to facilitate healing and prevent complications. A comprehensive nursing care plan, guided by a precise nursing diagnosis for wound care, is essential for addressing each patient’s unique needs. This plan should consider wound characteristics, overall health status, and individual preferences.

Nurses, with their focus on thorough wound assessment, interdisciplinary collaboration, patient education, and evidence-based practices, are instrumental in optimizing patient outcomes and improving the quality of life for individuals with compromised skin integrity. The cornerstone of this approach is a well-defined nursing diagnosis for wound care, which directs all subsequent interventions and evaluations.

Nursing Problem Priorities

For patients with wounds or compromised skin integrity, nursing priorities are focused on promoting healing, preventing complications, and enhancing patient comfort. These priorities, informed by accurate nursing diagnosis for wound care, include:

Wound Assessment: Frequent and detailed wound assessment is critical. This includes evaluating wound type, cause, and characteristics to determine the most effective treatment approach and promote optimal healing.
Effective Wound Care: Providing high-quality wound care is essential for rapid and uncomplicated healing. This reduces complications, readmissions, hospital stays, and healthcare costs, while improving patient quality of life.
Proper Suture and Staple Removal: Timely and correct suture or staple removal techniques are vital to prevent complications associated with non-healed wounds or premature removal.
Drain Management: Ensuring drains are functioning correctly and monitoring for leaks are crucial aspects of postoperative wound care. Regular checks throughout each shift are necessary to maintain effective drainage.
Burn Wound Care: Specialized management for burn injuries is required to prevent wound deterioration and promote healing. This includes pain management, infection control, and appropriate dressing techniques.
Pressure Injury Management: Pressure injuries cause significant pain, suffering, and increased morbidity, mortality, and healthcare costs. Prevention and effective treatment, guided by nursing diagnosis for wound care, are imperative to avoid development or worsening of pressure injuries.
Patient and Caregiver Education: Educating patients and their caregivers empowers them to actively participate in the healing process. It promotes adherence to treatment plans and fosters a proactive approach to preventing complications, contributing to better outcomes in nursing diagnosis for wound care.

These priorities underscore the nurse’s role in providing holistic and effective care for patients with impaired skin integrity, with nursing diagnosis for wound care serving as the foundation for all interventions.

Nursing Assessment

A thorough skin and wound assessment is essential for effective nursing diagnosis for wound care. This assessment should include detailed measurements of wound dimensions, evaluation of the wound bed’s appearance, identification of infection signs, and assessment of surrounding skin integrity. This comprehensive evaluation guides the selection of appropriate wound dressings, cleansing agents, and adjunctive therapies.

Impaired tissue integrity is characterized by both subjective and objective data:

Subjective Data:
- Affected area feels hot and tender to touch.
- Local pain reported by the patient.
- Patient exhibits protectiveness towards the site.
Objective Data:
- Damaged or destroyed tissue (e.g., cornea, mucous membranes, integumentary, subcutaneous).
- Skin and tissue color changes (red, purplish, black).
- Swelling around the initial injury.
- Pruritic/itchy skin.
- Dry, scaly skin.
- Thin, fragile skin.

These subjective and objective findings are crucial for formulating an accurate nursing diagnosis for wound care and developing a targeted care plan.

Nursing Diagnosis

Following a comprehensive assessment, nursing diagnoses for wound care are formulated to address the specific challenges of impaired skin integrity. These diagnoses are guided by the nurse’s clinical judgment and understanding of the patient’s unique condition. While nursing diagnoses provide a framework for care, their application may vary across clinical settings. Ultimately, the nurse’s expertise shapes the care plan to prioritize individual patient needs.

Examples of nursing diagnoses for wound care and impaired skin integrity include:

Impaired Skin Integrity related to prolonged pressure on bony prominences as evidenced by redness and non-blanchable areas on the sacral region and heels, and patient reports of pain and discomfort when repositioning secondary to CVA.
Impaired Skin Integrity related to friction and shear forces from frequent repositioning.
Impaired Skin Integrity related to insufficient nutritional intake as evidenced by delayed wound healing and dry, flaky skin.

These examples illustrate how specific nursing diagnoses for wound care are derived from assessment data and guide the development of personalized care plans.

Nursing Goals

Goals and expected outcomes for patients with impaired skin integrity, guided by nursing diagnosis for wound care, may include:

The patient reports any altered sensation or pain at the site of tissue impairment, indicating improved awareness and communication of symptoms.
The patient demonstrates an understanding of the plan to promote tissue healing and prevent further injury, reflecting effective patient education and engagement.
The patient describes measures to protect and heal tissue, including proper wound care techniques, showcasing acquired knowledge and self-management skills.
The patient’s wound decreases in size and exhibits increased granulation tissue, signifying progress towards healing and tissue regeneration.

These goals provide measurable outcomes for evaluating the effectiveness of the nursing diagnosis for wound care and the implemented interventions.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with impaired skin integrity, derived from nursing diagnosis for wound care, are multifaceted and aim to promote healing, prevent complications, and enhance patient comfort.

1. Skin and Wound Assessment

A detailed assessment is the foundation of effective nursing diagnosis for wound care. Visual examination and description of cutaneous lesions are key in diagnosing skin conditions and guiding treatment strategies (Kottner et al., 2020).

Determine etiology: Identify whether the wound is acute or chronic, a burn, dermatological lesion, pressure ulcer, or leg ulcer. Understanding the etiology is crucial for appropriate nursing diagnosis for wound care and selecting effective interventions. Systemic diseases, such as diabetes mellitus, and dermatological conditions significantly impact skin integrity (Kottner et al., 2020).

Assess the site and condition of impaired tissue integrity: Look for redness, swelling, pain, burning, and itching, which indicate inflammation and immune response. Repeated irritant exposure and friction can lead to adaptive skin responses, highlighting the skin’s dynamic interaction with its environment (Kottner et al., 2020).

Assess wound characteristics: Document type, location, color, size (length, width, depth), drainage, and odor. Thorough wound assessment is vital, including risk evaluation using tools like the Braden Scale (Ernstmeyer & Christman, 2021).

Type: Classify wounds as abrasions, lacerations, burns, surgical incisions, pressure injuries, or ulcers to guide specific interventions.
Location: Precisely document wound location using body diagrams for accurate tracking and communication.
Size: Regularly measure wound size to monitor healing progress. Measure length along the head-to-toe axis and width laterally.
Degree of tissue injury: Classify wounds as partial-thickness or full-thickness. Stage pressure injuries appropriately.
Color of wound base: Assess for healthy pink/red granulation tissue, unhealthy dark red tissue, slough (yellow/white), or necrotic tissue (brown/black) to determine healing stage.
Drainage: Evaluate drainage color, consistency, and amount (scant, minimal, moderate, copious) at each dressing change. Describe discharge as serosanguinous, sanguineous, serous, or purulent (Ernstmeyer & Christman, 2021).

Assess changes in body temperature: Monitor for fever, a systemic sign of inflammation, which may indicate infection. Fever results from pyrogens raising the hypothalamic set point for body temperature (El-Radhi, 2019).

Assess pain level: Pain is part of the inflammatory process, but its intensity may not always correlate with tissue damage. Consider neuropathic damage in conditions like diabetic ulcers, where pain perception may be altered (Ernstmeyer & Christman, 2021).

Monitor for infection signs: Inspect the wound site daily for color changes, redness, swelling, warmth, pain, or other infection signs. Early detection is crucial to prevent localized infections from progressing to systemic sepsis (Ernstmeyer & Christman, 2021).

Monitor periwound skin: Assess the skin surrounding the wound for signs of healing or complications. For primary intention healing, check for well-approximated edges and signs of dehiscence (Ernstmeyer & Christman, 2021).

Monitor skin care practices: Evaluate the patient’s skin cleansing routine, including soap type, water temperature, and frequency. Individualized skin care plans are necessary, as excessive cleansing can damage the skin barrier by altering pH, removing natural moisturizing factors, and disrupting lipid bilayers (Kottner et al., 2020).

Assess overall skin condition: Establish baseline data on skin condition. Healthy skin should have good turgor, be warm and dry, free from impairments, and exhibit quick capillary refill. Older adults are at higher risk due to age-related skin changes.

Assess for history of AIDS or immunological problems: Skin lesions like Kaposi sarcoma can be early manifestations of HIV/AIDS (American Cancer Society, 2018).

Assess for history of radiation therapy: Radiated skin is thin, friable, and prone to breakdown due to compromised blood supply and cellular damage (Nagle et al., 2022).

Evaluate mobility: Assess the patient’s ability to change position. Immobility is a major risk factor for skin breakdown. Tissue damage occurs if patients cannot reposition themselves without assistance (Ernstmeyer & Christman, 2021).

Assess for incontinence: Fecal and urinary incontinence contribute to skin breakdown. Stool enzymes and ammonia from urine are caustic to the skin. Incontinence pads can exacerbate skin damage (Murphree, 2017).

Assess for edema: Edematous tissue is prone to breakdown. Venous stasis inhibits oxygen and nutrient diffusion, increasing the risk of ulcers (Kottner et al., 2020).

Assess environmental moisture: Moisture from wound drainage, humidity, or incontinence can cause skin maceration. Moisture-associated skin damage (MASD) includes incontinence-associated dermatitis and peri-wound MASD (Murphree, 2017).

Assess for dermatitis or chemical irritants: These can cause inflammation, redness, and itching. Overexposure to cleansing products can damage the skin barrier (Kottner et al., 2020).

Assess for pruritus or mechanical trauma: Itching and scratching can disrupt skin integrity. Systemic diseases can cause pruritus, leading to secondary skin lesions (Butler & James, 2023).

Observe for itching and scratching: Scratching can lead to skin lesions and infection. Pruritus may indicate underlying skin or systemic disorders (Butler & James, 2023).

Assess for steroid use and pharmacological causes: Long-term steroid use thins the skin. Medications like hydroxyurea and chemotherapeutic drugs can impair wound healing (Nagle et al., 2022).

Determine factors affecting wound healing: Identify local factors (blood flow, oxygenation, infection) and systemic factors (nutrition, mobility, diabetes, smoking) that can delay healing (Ernstmeyer & Christman, 2021).

Monitor laboratory values: Track hemoglobin, WBC count, blood glucose, HbA1c, and wound cultures to assess for infection, anemia, and glycemic control, all of which impact wound healing (Ernstmeyer & Christman, 2021).

This comprehensive assessment provides the necessary data for accurate nursing diagnosis for wound care and the development of targeted interventions.

2. Providing Effective Skin and Wound Care

Protecting and enhancing skin integrity externally is crucial. Prevention of hazards is paramount, especially for vulnerable skin during illness or immobility. Effective skin and wound care, guided by nursing diagnosis for wound care, minimizes skin impairment and complications.

Promoting skin integrity

Clean, dry, and moisturize skin: Cleanse and moisturize skin, particularly bony prominences, twice daily or as needed. Avoid hot water and use medical-grade cornstarch powder instead of talc to prevent lung injury. Lipophilic moisturizers improve epidermal moisture content (Kottner et al., 2020).

Massage around affected areas: Massage only around, not on, reddened areas to enhance tissue perfusion. Direct massage on damaged skin can cause further injury. General massage can improve circulation, but avoid if open wounds or infections are present.

Implement incontinence management: Use incontinence plans to prevent chemical exposure from urine and stool. Management includes absorbent pads and improved toileting techniques (Banharak et al., 2021).

Instruct to avoid rubbing and scratching: Prevent further injury by advising against rubbing and scratching. Use gloves or trim nails if necessary. Vigorous rubbing can cause abrasions and skin breakdown.

Assess nutritional status: Evaluate nutritional status, including weight, weight loss, and serum albumin levels. Inadequate nutrition increases skin breakdown risk. Albumin levels below 2.5 g/dL indicate severe protein depletion. Monitor hemoglobin, pre-albumin, and weight to assess response to nutritional interventions.

Discuss nutrition: Emphasize the role of fluids, protein, vitamins B and C, iron, and calories in maintaining skin integrity and promoting wound healing. Ascorbic acid is essential for tissue repair.

Encourage adequate diet: Recommend a 2,000 to 3,000 kcal/day diet, higher if metabolic demands increase. High-protein, high-calorie diets, and iron supplements may be needed. Adequate nutrition and positive nitrogen balance are crucial for wound healing.

Encourage hydration: Recommend 2000 mL/day fluid intake unless medically restricted. Hydration maintains skin turgor and resilience. Monitor fluid tolerance in patients with cardiovascular limitations.

Collaborate with a dietician: Dieticians can assist in tailoring dietary plans to meet nutritional and hydration goals and address specific deficiencies (Ernstmeyer & Christman, 2021).

These interventions, informed by nursing diagnosis for wound care, are essential for promoting skin integrity and preventing further damage.

Providing wound care

Provide wound care as needed: Tailor wound care to the etiology. Use dressings like wet or dry dressings, topical creams, hydrocolloid dressings, or vapor-permeable membranes. Eye patches or shields protect corneal injuries. Dressings replace the protective function of damaged tissue.

Perform hand hygiene: Practice hand hygiene before and after wound care to prevent infection and cross-contamination.

Maintain sterile dressing technique: Use sterile techniques during wound care to minimize infection risk. This includes sterile fields, gloves, supplies, and instruments, chosen based on patient condition and agency policy (Doyle & McCutcheon, 2015).

Premedicate for dressing changes: Manage pain by premedicating before dressing changes for deep or extensive wounds (Ernstmeyer & Christman, 2021).

Cleanse wounds with appropriate solutions: Use physiologically compatible solutions like normal saline for routine cleansing. Avoid cytotoxic agents like hydrogen peroxide, betadine, and acetic acid (Ernstmeyer & Christman, 2021).

Plan for debridement: Debride necrotic tissue (eschar or slough) to promote healing, unless contraindicated. Debridement removes non-viable tissue, but dry eschar on heels may be left intact until vascular status is assessed (Ernstmeyer & Christman, 2021).

Maintain wound moisture: Use dressings to maintain a moist wound environment for granulation tissue development. Manage excessive exudate with absorbent dressings like alginate or hydrofiber to prevent maceration (Ernstmeyer & Christman, 2021).

Pack deep wounds: Pack deep wounds and tunneling wounds with dressings to maintain moisture and eliminate dead space. Use sterile gauze moistened with normal saline or hydrogel-impregnated dressings. Ensure easy removal to avoid damaging granulation tissue (Ernstmeyer & Christman, 2021).

Provide odor control: Address wound odor with frequent dressing changes, appropriate cleansing agents, topical antimicrobials, or debridement. Room deodorizers can be used after dressing changes (Ernstmeyer & Christman, 2021).

Protect periwound skin: Protect periwound skin from maceration with careful dressing application and skin barrier creams or wipes (Ernstmeyer & Christman, 2021).

Administer antibiotics: Use antibiotics as ordered. Topical agents may be effective for wound infections. Antimicrobial agents include polyhexamethylene biguanide (PHMB), silver, iodine, methylene blue/crystal violet, and honey (Sibbald et al., 2017).

Polyhexamethylene biguanide (PHMB): Disrupts bacterial cell membranes, effective for surface wounds with exudate.
Silver: Attacks cell membranes, DNA, and cytoplasmic organelles, suitable for critically colonized wounds.
Iodine: Multiple antimicrobial actions, use iodophors like povidone-iodine and cadexomer iodine cautiously, monitor thyroid function with prolonged use.
Methylene blue/crystal violet: Creates a redox environment inhibiting bacterial growth, useful for autolytic debridement.
Honey: Antibacterial and anti-inflammatory, acidic pH and high sugar content inhibit bacteria, use medical-grade honey.

Wrap blisters: Cover blisters with gauze or hydrocolloid dressings to prevent infection. Hydrocolloid dressings are occlusive and prevent infection (Ernstmeyer & Christman, 2021).

Prepare wound swabs: Obtain wound swabs during dressing changes if infection signs are present, and discuss wound culture and antibiotics with the provider (Ernstmeyer & Christman, 2021).

Assist with wound vac: Manage wound vac devices to remove fluid and reduce air pressure, promoting healing. Apply foam dressings, seal with film, and connect to suction (Ernstmeyer & Christman, 2021).

Administer advanced topical wound therapy: Consider advanced therapies for non-healing wounds, such as topical growth factors, placental/umbilical cord tissue allografts, acellular dermal matrices, and cell-based therapies (Jaffe & Wu, 2019).

Topical growth factor therapy: Stimulates fibroblast proliferation, for neuropathic ulcers extending to subcutaneous tissue.
Acellular extracellular matrices: Non-living tissues to accelerate healing and minimize scarring, for various wound types.
Placental tissue allografts: Deliver growth factors, antimicrobial and anti-inflammatory, for acute and chronic wounds.
Cell-based therapies: Deliver growth factors with cells, for partial and full-thickness wounds, and burns.

These comprehensive wound care interventions are guided by the principles of nursing diagnosis for wound care and are essential for promoting optimal healing.

3. Proper Suture and Staple Removal

Proper suture and staple removal, guided by nursing diagnosis for wound care, is crucial to prevent complications like dehiscence. Timing depends on wound healing and surgery extent.

Assess wound for suture removal: Remove dressings and assess wound healing. Sutures should remain until adequate wound closure and strength are achieved. Observe for wound separation during removal. If well-healed, remove all sutures at once (Ernstmeyer & Christman, 2021).

Irrigate wound: Irrigate with sterile normal saline before suture removal to remove debris and prevent contamination. Commercial wound cleansers are also suitable (Ernstmeyer & Christman, 2021).

Cut sutures properly: Cut sutures under the knot close to the skin, avoiding cutting both knot ends. Do not pull contaminated suture through tissue to prevent infection (Ernstmeyer & Christman, 2021).

Remove remaining sutures: Remove remaining sutures if the wound is well-approximated. Typically, alternate sutures are removed first, with remaining sutures removed later if approximation is maintained (Doyle & McCutcheon, 2015).

Apply Steri-Strips: Use Steri-Strips if separation occurs or after staple removal to support wound closure and minimize scarring. Apply sterile dressing or leave open to air to prevent infection (Doyle & McCutcheon, 2015).

Use staple extractor: Place the lower tip of the staple extractor under the staple, depress the handle to bend staple ends outward, and gently remove side to side (Doyle & McCutcheon, 2015).

Handle staple extractor carefully: Keep the handle closed and move the staple extractor away from the skin to avoid premature staple removal and skin scratching. Place staples on sterile gauze (Doyle & McCutcheon, 2015).

4. Drain Management

Effective drain management, guided by nursing diagnosis for wound care, prevents infection and enhances wound healing post-surgery. Regularly check drain site and function (Ernstmeyer & Christman, 2021).

Monitor tube placement: Check placement of tubes, catheters, and devices. Assess skin under tape for mechanical damage from pressure or friction (Murphree, 2017).

Practice hygiene: Perform hand hygiene before and after drain management, use non-sterile gloves and protective eyewear to prevent infection and body fluid exposure (Ernstmeyer & Christman, 2021).

Remove plug using sterile technique: Remove the plug from the drain spout using sterile technique, pointing away from face to avoid splashes, maintain plug sterility to prevent contamination (Ernstmeyer & Christman, 2021).

Compress drain: Compress drain after emptying contents. Tilt away from face and flatten to remove air and re-establish vacuum (Ernstmeyer & Christman, 2021).

Secure device and check patency: Secure drain device and check tube patency and placement. Ensure gravity facilitates drainage by positioning reservoir below the wound. Allow slack in tubing to accommodate movement (Ernstmeyer & Christman, 2021).

Remove tubing carefully: Firmly grasp tubing and remove with a swift, steady motion. Stop if strong resistance is felt and notify provider. Check if drainage tip is intact (Ernstmeyer & Christman, 2021).

Cleanse drain site: Cleanse old drain site using aseptic technique and cover with sterile dressing to prevent contamination and infection (Ernstmeyer & Christman, 2021).

Collaborate with WOCN: Consult wound, ostomy, and continence nurses (WOCN) for product selection, education, and prevention planning, especially for delayed or chronic wounds (Ernstmeyer & Christman, 2021).

5. Management of Burn Wounds

Burn wound management, guided by nursing diagnosis for wound care, requires specialized approaches to address the unique challenges of these injuries. Outpatient management is suitable for small burns not involving critical areas (Sheridan & Geibel, 2021).

Assessment of burn injuries

Evaluate using ABCs: Assess burn patients systematically using the American College of Surgeons Advanced Trauma Life Support (ATLS) methodology, emphasizing airway, breathing, and circulation in the primary survey (Sheridan & Geibel, 2021).

Assess burn extent and location: Examine corneal damage in facial burns before lid swelling obscures examination. Large burns cause systemic responses due to skin barrier loss and mediator release (Sheridan & Geibel, 2021).

Estimate burn size accurately: Use age-specific Lund-Browder diagrams for accurate burn size estimation. For adults, the rule of nines is an alternative, though less accurate for children. The palm surface represents about 0.5% of body surface area (Sheridan & Geibel, 2021).

Determine burn depth: Burn depth is often underestimated initially. Serial examinations are useful. Classify burns as first, second, third, or fourth degree (Sheridan & Geibel, 2021).

First-degree burns: Red, dry, painful, often superficial second-degree burns upon closer examination.
Second-degree burns: Red, wet, very painful, varying in depth and scarring potential.
Third-degree burns: Leathery, dry, insensate, waxy; require grafting for healing.
Fourth-degree burns: Involve subcutaneous tissue, tendon, or bone; depth difficult to assess initially.

Assess for infection signs: Diagnose burn wound infection based on signs like partial- to full-thickness conversion, worsening cellulitis, eschar separation, and tissue necrosis (Animalu & Chandrasekar, 2022).

Emergency burn management

Remove flame source: Extinguish flames by having the person drop and roll or smother flames with available materials. Instruct older adults or those with mobility issues to “stop, sit, and pat” to prevent injuries.

Cool the burn: Cool burned areas and adherent clothing briefly with cool water to halt burning. Avoid ice, prolonged cold soaks, or dressings to prevent hypothermia and worsen tissue damage.

Remove restrictive objects: Remove clothing and jewelry promptly to allow assessment and prevent constriction from edema. Adherent clothing can be left if cooled.

Cover the wound: Cover burns quickly with a clean, dry cloth to minimize contamination, maintain temperature, and reduce pain. Avoid ointments or salves.

Irrigate chemical burns: Irrigate chemical burns immediately with continuous running water. Brush off dry chemicals and remove contaminated clothing first.

Wound cleaning and dressing

Clean and dress wounds regularly: Gently clean debris and exudate regularly, usually daily. Lukewarm tap water and mild soap can be used for small burns. Soaking dressings in lukewarm water eases removal and reduces pain (Sheridan & Geibel, 2021).

Select proper dressings: Use topical dressings with viscous carriers and broad-spectrum antibacterial properties to prevent desiccation and colonization. Gauze wraps minimize clothing soiling and protect the wound (Sheridan & Geibel, 2021).

Provide pain management: Administer oral narcotics 30-60 minutes before dressing changes for pain control. Occlusive dressings often provide adequate pain management between changes (Sheridan & Geibel, 2021).

Wet dressings before removal: Saturate dressings with sterile normal saline to ease removal and reduce pain. Gently cleanse the wound, inspect for infection, pat dry, and redress (Sheridan & Geibel, 2021).

Modify dressings for splints: Adjust dressings to accommodate splints or positioning devices. Apply circumferential dressings distally to proximally to promote fluid return.

Assist with excision and grafting: For full-thickness burns, assist with early excision and grafting to prevent wound sepsis. Stage procedures for burns >40% TBSA. Use allografts or temporary materials when autograft material is limited (Sheridan & Geibel, 2021).

Medication administration

Apply topical antibacterials: Use topical agents effective against gram-positive and gram-negative organisms and fungi, that penetrate eschar without systemic toxicity, and are easy to apply (Sheridan & Geibel, 2021).

Silver: Broad spectrum, painless.
Aqueous 0.5% silver nitrate: Broad spectrum, but leeches electrolytes.
Mafenide acetate: Broad spectrum, penetrates eschar well.
Petrolatum: Bland, nontoxic.
Debriding enzymes: For selected partial-thickness wounds.

Assist with membrane application: Apply wound membranes for transient wound closure, providing protection and bacterial barrier (Sheridan & Geibel, 2021).

Porcine xenograft: Adheres to coagulum, good pain control.
Split-thickness allograft: Vascularizes, durable temporary closure.
Hydrocolloid dressings: Vapor and bacteria barrier, absorbs exudate.
Impregnated gauzes: Vapor and bacteria barrier, allow drainage.
Acticoat: Nonadherent, delivers silver for antisepsis.
Biobrane: Synthetic bilaminate, promotes tissue growth, temporary barrier.
Transcyte: Synthetic bilaminate with allogenic fibroblasts, temporary barrier.
Alloderm R: Cell-free allogenic dermis, requires autograft.
Integra R: Neodermis scaffold, requires delayed autograft.

Surgical management of burns

Assist with wound debridement: Assist with natural, mechanical, chemical, or surgical debridement to remove devitalized tissue and prepare for grafting (Sheridan & Geibel, 2021).

Natural debridement: Spontaneous separation of devitalized tissue.
Mechanical debridement: Surgical tool use, dressing changes, and wound cleaning. Avoid wet-to-dry dressings.
Chemical debridement: Topical enzymatic agents, often used with antibacterials.
Surgical debridement: Early excision and closure, crucial for major burns, followed by skin grafting.

6. Management of Pressure Injuries

Pressure injury management, guided by nursing diagnosis for wound care, requires immediate and comprehensive treatment. Consider wound stage and treatment purpose when choosing strategies (Kirman & Geibel, 2022).

Assessment and classification of pressure injuries

Classify pressure injuries: Use National Pressure Injury Advisory Panel (NPIAP) staging for reliable assessment (Kirman & Geibel, 2022).

Stage I: Nonblanchable erythema.
Stage II: Partial-thickness skin loss (abrasion, blister, shallow crater).
Stage III: Full-thickness skin loss, subcutaneous tissue damage, deep crater.
Stage IV: Full-thickness skin loss, extensive destruction, muscle/bone damage.
Unstageable: Full-thickness loss obscured by slough or eschar.
Deep tissue pressure injury: Intact or non-intact skin, nonblanchable deep red/purple discoloration.

Check bony prominences: Assess sacrum, trochanters, scapulae, elbows, heels, malleoli, knees, and back of head for breakdown risk due to pressure and ischemia. Darker skin may show red, blue, or purple hues in pressure areas.

Evaluate pressure sensation awareness: Assess patient awareness of pressure sensation. Lack of awareness increases risk of prolonged pressure and ischemia (Kirman & Geibel, 2022).

Use risk assessment tools: Utilize objective tools like Braden or Norton scales for pressure injury risk assessment.

Acute care: Assess every 24-48 hours or sooner if condition changes. Measure and document wound dimensions.
Long-term care: Assess on admission, weekly for four weeks, then quarterly and with condition changes.
Braden Scale: Assesses sensory perception, moisture, activity, mobility, nutrition, friction/shear.
Norton scale: Assesses physical condition, mental condition, activity, mobility, incontinence. Lower scores indicate higher risk.

Assess shear and friction: Evaluate shear (lateral pressure) and friction (rubbing) risks. Elevating bed head and moving patients without lift sheets are common causes of shear and friction (Ernstmeyer & Christman, 2021).

Assess support surface: Evaluate mattresses and cushions used, especially for bedridden or wheelchair-bound patients. Pressure reduction devices are needed to distribute pressure evenly below 32 mm Hg (Kirman & Geibel, 2022).

Assess mobility level: Use a risk assessment tool to evaluate immobility-related risk factors.

Level 4: No limitations.
Level 3: Slightly limited.
Level 2: Very limited.
Level 1: Completely immobile. (Ernstmeyer & Christman, 2021)

Monitor continence: Assess continence status and minimize skin exposure to moisture from incontinence, perspiration, or drainage. Urine and stool can cause skin erosion (Banharak et al., 2021).

Pay attention to high-risk areas: Focus on bony prominences, skin folds, sacrum, and heels for systematic inspection and early intervention. Pressure is highest at bony prominences (Kirman & Geibel, 2022).

Assess risk factors: Identify immobility, sensory/cognitive impairment, decreased perfusion, poor nutrition, friction/shear, moisture, and age-related skin changes as risk factors.

Provide relief from pressure

Check devices regularly: Check footboards, restraints, traction, and casts every 2 hours for proper placement and skin integrity. Repositioning ankles, elbows, and shoulders is also necessary. Inspect skin for redness or heat at each position change.

Use pressure-reducing devices: Use pillows, foam wedges, and pressure-reducing devices to redistribute pressure. Heel protectors and pillows under sacrum relieve pressure.

Maintain low bed head elevation: Keep head of bed low to reduce shear and friction. Recumbent position is preferred. Monitor for patient migration down the bed.

Implement pressure-relieving devices: Use devices commensurate with risk level (Kirman & Geibel, 2022).

Low-risk: Dense foam mattress overlay (at least 5 inches thick). Avoid thin egg-crate mattresses.
Moderate-risk: Water mattress, static or dynamic air mattress.
High-risk/Stage III or IV injuries: Low-air-loss beds or air-fluidized therapy.

Encourage ambulation: Encourage ambulation if possible to reduce pressure from immobility. Delay strenuous activity for 6 weeks post-wound closure (Kirman & Geibel, 2022).

Improve sensory perception: Improve cognition and sensory perception through stimulation, self-care encouragement, and support for active compensation for sensation loss.

Proper client positioning

Avoid positioning on impaired site: Do not position patients directly on pressure injuries. Turn and position at least every 2 hours and transfer carefully to relieve pressure (Kirman & Geibel, 2022).

Encourage frequent position changes: Advise patients to change position every 15 minutes and chair-bound patients every hour to relieve pressure.

Implement turning schedule: Turn bedridden patients every 2 hours, restricting time in one position. Keep head of bed at ≤30 degrees. Use lateral, prone, and dorsal positions unless contraindicated.

Improve tissue perfusion: Promote tissue perfusion through activity, exercise, and repositioning. Avoid massaging erythematous areas. Elevate edematous areas to promote venous return.

Medical management of pressure injuries

Prepare for hyperbaric oxygen therapy: Assist with hyperbaric oxygen therapy to stimulate vascular growth and preserve damaged tissue (Kirman & Geibel, 2022).

Administer muscle relaxants: Use muscle relaxants for spasticity or prepare for surgery if refractory to medication. Surgical options include neurosurgical ablation and contracture release (Kirman & Geibel, 2022).

Provide nutritional supplementation: Offer oral nutritional supplements enriched with arginine, vitamin C, and zinc to improve pressure injury healing (Kirman & Geibel, 2022).

Surgical management of pressure injuries

Prepare for surgical procedures: Prepare for surgery if injuries are extensive, complicated, or non-responsive to treatment. Procedures include debridement, incision and drainage, bone resection, and skin grafting.

Assist with diversion procedures: Assist with urinary or fecal diversion to optimize wound healing in incontinent patients (Kirman & Geibel, 2022).

Prepare for reconstruction: Prepare for pressure injury reconstruction to improve hygiene, appearance, resolve osteomyelitis/sepsis, reduce fluid/protein loss, and prevent malignancy. Stage 3 and 4 injuries often require flap reconstruction (Kirman & Geibel, 2022).

7. Client and Caregiver Education

Patient and caregiver education, guided by nursing diagnosis for wound care, empowers them to actively participate in care, improving self-management and outcomes.

Educate on nutrition and hydration: Teach proper nutrition, hydration, and tissue integrity maintenance methods. Adequate nutrition is crucial for pressure injury healing (Kirman & Geibel, 2022).

Teach wound assessment: Educate on skin and wound assessment and monitoring for infection, complications, and healing signs. Early assessment prevents serious problems (Ernstmeyer & Christman, 2021).

Instruct on wound care: Teach proper wound care, including handwashing, cleansing, dressing changes, and topical medication application. Accurate information improves self-care and reduces infection risk (Ernstmeyer & Christman, 2021).

Educate on when to notify provider: Instruct patients to report new infection signs or concerns about wound healing to the healthcare provider promptly (Ernstmeyer & Christman, 2021).

Inform against repeated bed elevation: Advise against repeated bed elevation and encourage lifting devices to prevent friction and shear.

Educate on pressure causes: Explain pressure injury causes to facilitate prevention strategies. Prolonged pressure leads to thrombosis and tissue necrosis.

Reinforce turning and mobility: Emphasize turning, mobility, and ambulation to enhance self-efficacy and compliance. Immobility increases pressure injury risk.

Educate on skin care: Teach proper skin care to prevent breakdown, including meticulous hygiene, especially in skin folds. Use bland lotions and avoid drying agents and powders.

Educate on pressure area inspection: Teach patients and caregivers to inspect pressure areas daily, using mirrors if needed, for early detection of pressure injuries.

Reinforce diaper checks: Emphasize regular diaper and incontinence pad checks and changes to prevent maceration and dermatitis.

Alert caregivers to environmental factors: Instruct caregivers to observe and remove environmental factors causing pressure, such as wrinkles in sheets or tubes.

Ensure strong support system: Emphasize that preventing recurrence is a lifelong process requiring a strong support system at home (Kirman & Geibel, 2022).

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources:

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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
This handbook provides an evidence-based approach to nursing interventions, using a three-step system for client assessment, nursing diagnosis, and care planning. It includes step-by-step instructions for implementing care and evaluating outcomes, enhancing diagnostic reasoning and critical thinking skills.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
This resource features over two hundred care plans reflecting current evidence-based guidelines, including new ICNP diagnoses, care plans on LGBTQ health issues, and electrolyte and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
A quick-reference tool for identifying correct diagnoses and efficient care planning. The 16th edition includes the latest nursing diagnoses and interventions, with an alphabetized listing covering over 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual helps identify interventions for planning, individualizing, and documenting care for over 800 diseases and disorders. It provides sample clinical applications, prioritized actions/interventions with rationales, and documentation sections for each diagnosis.

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health settings, focusing on interprofessional “patient problems.”

References and Sources

Recommended resources for the wound care and tissue integrity nursing care plan:

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