A wound, defined as any disruption to the skin’s integrity, tissues, or organs, can create a significant vulnerability to infection. This breach in the body’s natural defenses allows pathogens to invade, potentially overwhelming the immune system and leading to complications. Wounds can be categorized as acute or chronic, and either closed (like hematomas) or open, where the skin is broken, exposing underlying tissues, as seen in lacerations, bites, or surgical incisions. Understanding wound infection, its management, and the crucial role of nursing interventions is paramount in healthcare.
Understanding Wound Infection
Wound infection arises when pathogenic microorganisms successfully penetrate the host’s defense mechanisms, primarily the skin, and proliferate, surpassing the body’s immune response. Often, lapses in aseptic techniques and direct contamination are primary culprits in wound infections. Individuals with compromised immune systems or conditions that impede healing, such as diabetes mellitus or HIV, face a heightened risk of developing wound infections.
Untreated wound infections can escalate into severe, even life-threatening conditions, including cellulitis, osteomyelitis (bone infection), sepsis, and necrotizing fasciitis.
The Body’s Healing Process
Wound healing, the body’s innate process of restoring tissue integrity, commences immediately after an injury. Any disruption or delay in this intricate process can increase susceptibility to infection. Wound healing progresses through four distinct phases:
- Hemostasis (Immediate): This initial phase is characterized by blood vessel constriction to minimize blood loss, followed by coagulation and platelet aggregation to form a clot, effectively sealing the wound and initiating the repair process.
- Inflammation (0-4 days): The body’s immune system mobilizes neutrophils and macrophages to the wound site. Their primary role is to combat potential infection, clearing debris and initiating the inflammatory response, clinically manifested as swelling and redness.
- Proliferation (2-24 days): This phase marks the rebuilding of tissue. Granulation tissue, a matrix of new connective tissue and blood vessels, fills the wound bed. Simultaneously, epithelial cells migrate to cover and resurface the wound.
- Maturation (24+ days): The final phase involves remodeling and strengthening of the newly formed tissue. Collagen continues to be deposited, increasing the wound’s tensile strength. Scar tissue may form as a natural consequence of this phase.
Types of Wound Healing
Wound healing can occur through different mechanisms, each with implications for infection risk and care:
- Primary Intention: This occurs when wound edges are closely approximated and closed using methods such as sutures, staples, adhesive strips (Steri-Strips), or surgical glue. This method is typical for surgical incisions and clean lacerations, promoting rapid healing and minimizing scarring.
- Secondary Intention: In situations where wound edges cannot be easily approximated, such as in large open wounds or pressure ulcers, healing occurs through secondary intention. The wound heals from the base upwards, filling with granulation tissue. This process is slower and carries a higher risk of infection compared to primary intention healing.
- Tertiary Intention (Delayed Primary Closure): This approach is employed when a wound is initially left open, often to allow for drainage or to manage infection. Once the infection is controlled and the wound is deemed clean, it is surgically closed. This combines aspects of both primary and secondary intention healing.
Factors Influencing Wound Healing
Numerous factors can significantly impact the body’s capacity to heal. Nurses must consider these elements when assessing and managing patients with wounds:
- Nutritional Status: Adequate protein, vitamins (especially Vitamin C), and minerals are essential building blocks for tissue repair and regeneration. Malnutrition impairs the healing process.
- Stress: Psychological and physiological stress can negatively affect the immune system and delay wound healing.
- Comorbidities: Underlying health conditions, such as diabetes mellitus, peripheral vascular disease, and autoimmune disorders, can significantly compromise wound healing.
- Age: Both very young and older individuals may have impaired healing capabilities due to immature or declining physiological functions.
- Obesity: Adipose tissue has poorer blood supply and can increase inflammation, hindering wound healing and increasing infection risk.
- Medications: Certain medications, including corticosteroids, chemotherapy agents, and immunosuppressants, can interfere with the inflammatory and proliferative phases of wound healing.
- Alcohol Use: Excessive alcohol consumption can impair immune function and nutrient absorption, negatively impacting wound healing.
- Smoking: Nicotine constricts blood vessels, reducing oxygen and nutrient delivery to the wound site, significantly delaying healing and increasing infection risk.
- Friction and Shearing Forces: These mechanical forces can cause tissue damage and breakdown, particularly in patients with limited mobility.
- Poor Mobility: Immobility reduces circulation and increases pressure on certain areas, predisposing individuals to pressure ulcers and impeding wound healing.
- Knowledge Deficits: Lack of understanding regarding proper wound care can lead to inadequate self-management and delayed healing or infection.
The Nursing Process in Wound Care
The nursing process is foundational in wound care, providing a structured approach to patient management. It begins with a comprehensive assessment, leading to the identification of nursing diagnoses, planning and implementing interventions, and finally, evaluating the effectiveness of care. In wound management, this process is crucial for preventing infection, promoting healing, and optimizing patient outcomes.
A collaborative approach, potentially including wound care specialists, is often beneficial, especially when dealing with complex or chronic wounds.
Nursing Assessment: Gathering Crucial Data
The initial step in the nursing process is a thorough assessment, encompassing physical, psychosocial, emotional, and diagnostic data collection. In wound care, this involves both subjective and objective data to gain a holistic understanding of the patient’s condition.
Review of Health History: Uncovering Risk Factors
-
General Symptoms of Infection: It’s crucial to inquire about symptoms indicative of wound infection. These may include:
- Purulent drainage (pus) from the wound
- Increased pain or tenderness
- Redness (erythema) and swelling around the wound
- Foul odor emanating from the wound
- Warmth to the touch at the wound site
- Skin discoloration
Systemic symptoms suggesting a more serious, spreading infection warrant immediate attention. These include:
- Fever
- Chills
- Swollen lymph nodes (lymphadenopathy) near the wound site
-
Underlying Cause of the Wound: Determining the etiology of the wound is essential for targeted care. Wounds can arise from various causes, ranging from accidental injuries to surgical procedures or immobility-related pressure. Understanding how the wound occurred provides context for risk assessment and preventative strategies. Specifically, inquire about:
- Mechanism of injury (e.g., laceration, puncture, burn, surgical incision)
- Time of injury
- Setting of injury (e.g., clean environment vs. outdoors)
- Potential contamination (e.g., dirt, animal bites, foreign objects)
-
Medical Risk Factors: Pre-existing medical conditions significantly influence infection risk and wound healing. Identify and document any relevant patient comorbidities, including:
- Diabetes mellitus
- Immunosuppression (e.g., HIV/AIDS, autoimmune diseases)
- Renal failure
- Obesity
- Peripheral vascular disease
- Neuropathy
- Advanced age
-
Surgical History: For post-surgical wounds, review the surgical record for factors that could increase infection risk:
- Type of surgery and invasiveness
- Duration of surgery
- Surgical technique employed
- Intraoperative contamination events
- Prolonged preoperative hospital stay
- Hypothermia during surgery
-
Medication Review: Certain medications can impair wound healing and increase infection susceptibility. Obtain a comprehensive medication history, noting:
- Immunosuppressants
- Corticosteroids
- Chemotherapy drugs
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Disease-modifying antirheumatic drugs (DMARDs)
- Hydroxyurea
-
Nutritional Assessment: Nutritional status is a critical determinant of wound healing. Inquire about the patient’s dietary intake, focusing on:
- Protein intake
- Vitamin and mineral consumption
- Fluid intake (hydration status)
- Any recent weight loss or changes in appetite
Physical Assessment: Objective Signs of Wound Infection
-
Wound Type Determination: Accurate classification of wound type guides appropriate wound care strategies. Common wound types nurses encounter include:
- Pressure ulcers (pressure injuries)
- Diabetic foot ulcers
- Venous stasis ulcers
- Arterial ulcers
- Surgical wounds
- Traumatic wounds (lacerations, abrasions, punctures, burns)
- Skin tears
-
Wound Characteristics Documentation: Meticulous assessment and documentation of wound characteristics are essential at each dressing change and according to facility protocols. Key parameters to assess include:
- Location: Anatomical site of the wound.
- Size: Length, width, and depth (measured in centimeters or millimeters).
- Drainage (Exudate): Type, color, odor, and amount of drainage. Describe as serous (clear, watery), sanguineous (bloody), serosanguineous (mix of serous and sanguineous), or purulent (thick, yellow/green, pus-like).
- Wound Bed: Describe the tissue types present in the wound bed, such as:
- Granulation tissue (red, beefy, cobblestone appearance – indicates healing)
- Slough (yellow or tan, stringy or mucinous – nonviable tissue)
- Eschar (black or brown, leathery – necrotic tissue)
- Epithelial tissue (pink, new skin growing from the edges – indicates healing)
- Wound Edges and Periwound Skin: Assess the wound margins and surrounding skin (periwound) for:
- Well-approximated or un-approximated edges
- Erythema (redness)
- Edema (swelling)
- Maceration (softening of skin due to excessive moisture)
- Induration (firmness)
- Tunneling or Undermining: Presence of channels extending from the wound bed or tissue destruction under intact skin at the wound edges.
-
T.I.M.E. Acronym for Wound Assessment: The T.I.M.E. acronym provides a structured framework for wound assessment:
- T – Tissue: Assess tissue type in the wound bed (granulation, slough, eschar, epithelialization).
- I – Infection/Inflammation: Evaluate for signs of local infection (redness, warmth, swelling, pain, purulent drainage). Note that some inflammation is expected in the healing process, but excessive or signs of infection are not.
- M – Moisture: Assess wound moisture balance. Ideal wounds are moist but not excessively wet. Note the type and amount of exudate.
- E – Edges: Examine wound edges for undermining, tunneling, rolled edges (epibole – edges rolled under, preventing epithelial migration), and attachment to the wound bed.
-
Pain Assessment: Wound pain is a common symptom. Utilize a validated pain scale (e.g., numeric rating scale, visual analog scale) to quantify pain intensity and characteristics. Assess:
- Pain intensity (on a scale of 0-10)
- Pain quality (e.g., sharp, dull, burning, throbbing)
- Pain location and radiation
- Factors that exacerbate or alleviate pain
Diagnostic Procedures: Confirming Infection and Guiding Treatment
-
Wound Culture: Obtaining a wound swab for culture and sensitivity testing is a cost-effective method to identify the causative pathogens and guide antibiotic therapy. Different swabbing techniques exist; consult facility protocols for proper procedure (e.g., Levine technique).
-
Biopsy or Aspiration: In cases of deep or chronic wounds, or when surface cultures are inconclusive, tissue biopsy or aspiration may be necessary. Biopsy provides a more accurate representation of tissue pathogens but is invasive. Aspiration is useful for suspected abscesses to sample fluid from beneath the skin surface.
-
Laboratory Values: Blood tests can support the diagnosis of systemic infection and monitor the inflammatory response. Relevant laboratory markers include:
- White blood cell (WBC) count: Elevated WBC count can indicate infection.
- C-reactive protein (CRP): An acute-phase reactant that increases in response to inflammation and infection.
- Procalcitonin (PCT): A more specific marker for bacterial infection than CRP.
- Presepsin: Another biomarker that rises early in sepsis and bacterial infections.
- Microbial DNA assays: PCR-based tests to detect specific pathogens in wound samples.
- Bacterial protease activity (BPA): Enzymatic assays that can detect bacterial burden in wounds.
-
Imaging Studies: Imaging modalities may be used to assess the extent and depth of infection, particularly in deeper tissues or to rule out complications:
- Plain X-rays: Useful for detecting gas in soft tissues suggestive of gas gangrene or osteomyelitis.
- Computed tomography (CT): Provides detailed cross-sectional images to evaluate soft tissue infections, abscesses (including intra-abdominal), and osteomyelitis.
- Magnetic resonance imaging (MRI): Excellent for delineating the extent of soft tissue infection, particularly necrotizing fasciitis, and for detecting osteomyelitis early.
- Ultrasound: Can be used at the bedside to assess for fluid collections, abscesses, and cellulitis in skin and soft tissues.
-
Peripheral Perfusion Assessment: Adequate blood supply is crucial for wound healing. In patients with suspected peripheral artery disease or diabetes, assess peripheral perfusion using:
- Ankle-brachial index (ABI) and toe-brachial index (TBI): Non-invasive tests to assess arterial blood flow to the lower extremities.
- Monofilament testing: Evaluates protective sensation in the feet, particularly important for patients with diabetes and peripheral neuropathy, to identify risk for foot ulcers.
Nursing Interventions: Promoting Healing and Preventing Infection
Nursing interventions are fundamental to patient recovery and optimal wound management. These interventions are directed at promoting wound healing, preventing and managing infection, alleviating pain, and educating patients and caregivers.
Providing Appropriate Wound Care: Cornerstones of Healing
-
Debridement of Nonviable Tissue: Necrotic tissue (slough and eschar) impedes healing and provides a medium for bacterial growth. Debridement, the removal of nonviable tissue, is essential for wound bed preparation. Methods include:
- Autolytic Debridement: Utilizing the body’s own enzymes to break down necrotic tissue under moist dressings (e.g., hydrogels, hydrocolloids).
- Enzymatic Debridement: Application of topical enzymatic ointments (prescribed) to digest necrotic tissue.
- Sharp Debridement: Surgical removal of necrotic tissue using sharp instruments (scalpel, curette, scissors) performed by trained healthcare professionals.
- Mechanical Debridement: Physical removal of debris and necrotic tissue using methods like wet-to-dry dressings (less selective and can damage healthy tissue, use with caution), wound irrigation, or hydrotherapy.
- Biological Debridement: Use of sterile maggots to selectively ingest necrotic tissue (maggot debridement therapy – MDT).
-
Moisture Balance: Maintaining optimal wound moisture is critical. A moist wound environment promotes cell migration, angiogenesis, and autolytic debridement. However, excessive moisture can lead to maceration and periwound skin breakdown.
- Moist Dressings: Select dressings that maintain moisture balance, such as hydrogels, hydrocolloids, foams, and alginates.
- Manage Exudate: For wounds with high exudate levels, use highly absorbent dressings like alginates, foams, or superabsorbent polymers (e.g., gelling fiber dressings). Consider negative pressure wound therapy (NPWT or wound VAC) for heavily exudating wounds.
- Prevent Dryness: Avoid dressings that dry out the wound bed. If dryness is a concern, use hydrogels or moisture-retentive dressings.
-
Wound Packing: Deep wounds with undermining or tunneling require packing to prevent premature closure of the wound surface, ensuring healing from the base up and preventing abscess formation.
- Moist Packing: Pack wounds with moistened sterile gauze or hydrogel-impregnated dressings to maintain a moist wound bed and prevent desiccation of deeper tissues.
- Light Packing: Pack loosely to avoid excessive pressure on the wound bed and to allow for drainage.
-
Periwound Skin Protection: The skin surrounding the wound is vulnerable to irritation and breakdown from exudate, friction, and adhesives. Protect periwound skin with:
- Barrier Creams and Ointments: Apply moisture barrier creams or ointments to protect skin from exudate and moisture.
- Skin Sealants and Protective Wipes: Use skin protectants to create a barrier against adhesives and friction.
- Barrier Wafers and Dressings: Apply thin hydrocolloid or silicone dressings to periwound skin as a protective layer.
-
Wound Vac (Negative Pressure Wound Therapy – NPWT): NPWT is an effective intervention for various open wounds, including pressure ulcers, surgical wounds, grafts, and flaps. It involves applying a foam dressing to the wound, sealing it with an adhesive drape, and applying controlled negative pressure. NPWT promotes healing by:
- Removing excess exudate and edema
- Increasing blood flow to the wound bed
- Stimulating granulation tissue formation
- Drawing wound edges together
-
Pain Management: Wound care procedures, particularly dressing changes and debridement, can be painful. Proactive pain management is essential.
- Premedication: Administer prescribed analgesics (oral or IV) prior to painful procedures, allowing sufficient time for medication to take effect.
- Pain Assessment: Regularly assess pain levels and effectiveness of pain management strategies.
- Non-pharmacological Pain Relief: Employ non-pharmacological methods such as positioning, distraction, relaxation techniques, and therapeutic touch, in conjunction with analgesics.
- Topical Anesthetics: Consider topical anesthetic agents for painful dressing changes, as prescribed.
Preventing and Managing Wound Infection: Asepsis and Antimicrobials
-
Aseptic or Clean Technique: Select appropriate technique based on wound type and risk of infection.
- Aseptic Technique (Sterile Technique): Use sterile gloves, dressings, and instruments to prevent introduction of microorganisms. Indicated for high-risk wounds, surgical wounds, burns, and when managing immunocompromised patients.
- Clean Technique (Non-sterile Technique): Use clean (non-sterile) gloves and clean supplies. Appropriate for chronic wounds like pressure ulcers, venous ulcers, and for routine dressing changes in less critical wounds.
-
Antibiotic Administration: Antibiotics are indicated for wounds exhibiting clinical signs of infection or systemic infection.
- Topical Antibiotics: May be used for superficial wound infections. However, overuse should be avoided due to risk of antibiotic resistance and contact dermatitis. Silver-containing dressings also have antimicrobial properties.
- Systemic Antibiotics (Oral or IV): Necessary for deeper wound infections, cellulitis, sepsis, or osteomyelitis. Administer antibiotics as prescribed, based on culture and sensitivity results when available (targeted antimicrobial therapy).
-
Immediate Wound Cleaning: Emphasize the importance of prompt wound cleaning after injury to reduce bacterial load and infection risk.
- Soap and Water: For most minor wounds, gentle washing with mild soap and water is effective.
- Wound Irrigation: For deeper or contaminated wounds, irrigate with sterile saline solution to remove debris and contaminants.
-
Avoid Harsh Cleansing Agents: Educate patients to avoid using hydrogen peroxide or rubbing alcohol to clean wounds. These agents are cytotoxic to healthy tissue and can impair wound healing.
-
Hand Hygiene: Strict adherence to hand hygiene is paramount for preventing wound infections. Wash hands thoroughly with soap and water or use alcohol-based hand sanitizer before and after any wound care procedure.
-
Wound Coverage: Counter to the myth of “airing out” wounds, wounds should be kept covered with appropriate dressings. Dressings:
- Protect the wound from external contamination
- Maintain a moist wound environment conducive to healing
- Absorb exudate
- Provide physical support and protection
Promoting Wound Healing: Nutrition, Education, and Referrals
-
Nutritional Support: Optimize nutritional status to support tissue repair.
- High-Protein Diet: Encourage a diet rich in protein to provide amino acids necessary for tissue synthesis.
- Vitamin and Mineral Supplementation: Ensure adequate intake of vitamins (especially Vitamin C and zinc), and minerals crucial for wound healing.
- Hydration: Maintain adequate fluid intake to promote tissue hydration, nutrient delivery, and overall physiological function.
-
Patient Education for Skin Breakdown Prevention: Educate patients and caregivers on strategies to prevent further skin injury and promote healing:
- Pressure Relief: Frequent turning and repositioning (at least every 2 hours) for bedridden patients. Use pressure-redistributing support surfaces (mattresses, cushions).
- Foot Protection: Advise patients to wear appropriate footwear (shoes or socks) at all times to prevent foot injuries, especially for those with diabetes or neuropathy.
- Edema Management: For patients with lower extremity edema (e.g., venous insufficiency), teach leg elevation and use of compression stockings to reduce swelling.
- Skin Hygiene: Keep skin clean and dry, especially in areas prone to moisture (perineum, skin folds). Use gentle cleansers and moisture barriers as needed, particularly for incontinent patients.
-
Wound Documentation: Maintain comprehensive and accurate wound documentation at each dressing change, including:
- Date and time of assessment
- Wound location, size, depth
- Wound bed characteristics (tissue type, exudate, odor)
- Periwound skin condition
- Pain assessment
- Treatments performed (cleansing agents, dressings applied)
- Photographic documentation (as per facility policy) to track wound progression.
-
Wound Care Clinic Referral: For chronic, non-healing wounds, or complex wounds, refer patients to a specialized wound care clinic. Wound care specialists can provide advanced wound management strategies, specialized dressings, and therapies like hyperbaric oxygen therapy (HBOT).
Nursing Care Plans: Addressing Common Nursing Diagnoses
Nursing care plans provide a structured framework for addressing patient needs based on identified nursing diagnoses. Several nursing diagnoses are particularly relevant to wound care and infection risk.
Nursing Diagnosis: Risk for Infection
Related to:
- Breaks in skin integrity (wounds, incisions)
- Invasive procedures
- Compromised immune system
- Chronic diseases (e.g., diabetes mellitus)
- Malnutrition
- Advanced age
As Evidenced By:
- (This is a risk diagnosis, so there are no “as evidenced by” factors present. Instead, focus on risk factors identified in the assessment)
Desired Outcomes:
- Patient will remain free from signs and symptoms of wound infection throughout the episode of care.
- Patient will demonstrate understanding of infection prevention measures.
Nursing Interventions:
- Monitor for signs and symptoms of infection: Regularly assess the wound site and the patient for local and systemic signs of infection (as detailed in assessment section).
- Maintain aseptic/clean technique during wound care: Adhere to appropriate technique based on wound characteristics and risk.
- Promote hand hygiene: Ensure diligent handwashing by healthcare providers, patient, and caregivers.
- Educate patient and caregivers on infection prevention: Teach proper hand hygiene, wound care techniques, and signs and symptoms of infection to report.
- Optimize nutritional status: Promote adequate protein, vitamin, and mineral intake to support immune function and wound healing.
- Administer antibiotics as prescribed: For confirmed or suspected infections, administer antibiotics according to medical orders and monitor for effectiveness and side effects.
- Ensure proper wound dressing and management: Select and apply appropriate dressings to protect the wound, maintain moisture balance, and manage exudate.
- Promote rest and sleep: Adequate rest supports immune function and overall healing.
Nursing Diagnosis: Acute Pain
Related to:
- Tissue damage from wound
- Inflammatory process
- Nerve irritation
- Wound care procedures
As Evidenced By:
- Verbal reports of pain (using pain scale)
- Guarding behavior
- Facial grimacing
- Restlessness
- Changes in vital signs (increased heart rate, blood pressure, respiratory rate)
- Anxiety
Desired Outcomes:
- Patient will report pain at a manageable level (as defined by patient) within a specified timeframe.
- Patient will demonstrate effective pain management strategies.
- Patient will participate in wound care activities with minimal discomfort.
Nursing Interventions:
- Assess pain characteristics: Utilize pain assessment tools to determine pain intensity, quality, location, and aggravating/alleviating factors.
- Administer analgesics as prescribed: Provide pain medication (oral, IV, topical) as ordered, considering pain intensity and type.
- Premedicate before painful procedures: Administer analgesics prior to dressing changes or debridement to minimize discomfort.
- Non-pharmacological pain relief measures: Implement non-pharmacological techniques such as positioning, elevation of the affected limb, application of cold or heat (as appropriate), relaxation techniques, distraction, and guided imagery.
- Gentle wound care techniques: Perform dressing changes and wound care procedures gently and carefully to minimize pain.
- Educate patient on pain management: Teach patient about pain medication regimen, non-pharmacological pain relief options, and importance of reporting uncontrolled pain.
- Splint or support wound area: Immobilization or support of the wound site can reduce pain and promote comfort.
Nursing Diagnosis: Impaired Skin Integrity
Related to:
- Mechanical factors (pressure, friction, shear)
- Moisture (incontinence, excessive wound drainage)
- Impaired circulation
- Nutritional deficits
- Altered sensation
- Developmental factors (age extremes)
As Evidenced By:
- Disruption of skin surface (wound, ulcer, lesion)
- Damage to tissues
- Redness, swelling, blistering
- Drainage (serous, sanguineous, purulent)
- Pain or itching
- Delayed wound healing
Desired Outcomes:
- Patient will demonstrate progressive wound healing within an expected timeframe.
- Patient will maintain intact periwound skin.
- Patient will verbalize understanding of measures to protect skin integrity and promote wound healing.
Nursing Interventions:
- Assess wound characteristics regularly: Monitor wound size, depth, drainage, wound bed tissue, periwound skin, and signs of infection at each dressing change.
- Implement pressure relief measures: Reposition patient frequently, use pressure-redistributing support surfaces, and offload pressure from bony prominences.
- Manage moisture: Select dressings that effectively absorb exudate and maintain a moist wound environment. Protect periwound skin from maceration. For incontinence, implement skin care protocols to keep skin clean and dry.
- Promote adequate nutrition and hydration: Ensure sufficient protein, vitamins, minerals, and fluid intake to support skin repair and regeneration.
- Provide appropriate wound care: Cleanse wound as indicated, debride nonviable tissue, apply appropriate dressings, and pack wounds as needed.
- Educate patient and caregivers on skin care and wound care: Teach proper skin hygiene, pressure relief techniques, wound care procedures, and signs of complications.
- Consult wound care specialist: For complex or non-healing wounds, seek consultation from a wound care specialist for advanced management strategies.
Nursing Diagnosis: Knowledge Deficit (Wound Care Management)
Related to:
- Lack of exposure to information
- Misinformation
- Cognitive limitations
- Language barriers
- Lack of readiness to learn
As Evidenced By:
- Verbalization of lack of knowledge about wound care
- Inaccurate follow-through of wound care instructions
- Requests for information
- Development of wound complications due to inadequate self-care
Desired Outcomes:
- Patient will verbalize understanding of wound care plan, including dressing changes, infection prevention measures, and signs and symptoms to report.
- Patient will demonstrate correct wound care techniques (if self-care is expected).
- Patient will adhere to the prescribed wound care regimen.
Nursing Interventions:
- Assess patient’s current knowledge level: Determine what the patient already knows about wound care and identify knowledge gaps.
- Provide clear and concise wound care education: Explain the wound care plan in simple terms, using visual aids and written materials as appropriate. Tailor teaching to the patient’s learning style and level of understanding.
- Demonstrate wound care techniques: Show the patient (and caregiver) how to perform dressing changes, wound cleansing, and other necessary procedures. Allow for return demonstration and provide feedback.
- Provide written instructions: Give the patient written instructions on wound care, dressing change frequency, medications, and contact information for healthcare providers.
- Address patient’s questions and concerns: Encourage questions and address any misconceptions or anxieties the patient may have about wound care.
- Involve caregivers in education: Include family members or caregivers in teaching sessions to ensure they can support the patient’s wound care at home.
- Assess for learning barriers: Identify any factors that may hinder learning, such as language barriers, cognitive impairments, or visual/hearing deficits, and adapt teaching methods accordingly.
- Refer to resources: Provide information about community resources, support groups, or home health services that can assist with wound care management.
By utilizing the nursing process, implementing evidence-based interventions, and addressing relevant nursing diagnoses, nurses play a critical role in promoting wound healing, preventing infection, managing pain, and empowering patients to actively participate in their wound care journey. Continuous assessment, adaptation of care plans, and collaboration with the interdisciplinary team are essential for achieving optimal outcomes in wound management.
References
- Perry, A. G., Potter, P. A., & Ostendorf, P. S. (2018). Clinical nursing skills & techniques. (9th ed.). Elsevier Mosby.
- Gray, D., Enoch, S., & Harding, K. G. (2018). Wound assessment. BMJ (Clinical research ed.), 360, j5295.
- Leaper, D. J., Schultz, G., Carville, K., Fletcher, J., Swanson, T., & Drake, R. (2015). Extending the TIME framework: what have we learned in the past decade?. International wound journal, 12 Suppl 1, 19–34.
- World Union of Wound Healing Societies (WUWHS). (2020). Wound infection in clinical practice. WUWHS Consensus Document. London: MEP Ltd.
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019.
