Nursing Diagnosis Related to Wound Care: A Comprehensive Guide for Nurses

A wound, defined as any disruption to the integrity of the skin, tissues, or organs, represents a significant concern in healthcare. These injuries can range from minor abrasions to severe traumas, each carrying the risk of infection and complications. Effective wound care is paramount in nursing practice, requiring a thorough understanding of wound healing processes, potential complications, and appropriate interventions. Central to providing optimal wound care is the application of relevant nursing diagnoses, which guide the development of individualized care plans.

Wounds can be categorized in various ways, such as acute or chronic, and closed or open. Acute wounds, like surgical incisions or lacerations, typically heal predictably and within a reasonable timeframe. Chronic wounds, such as pressure ulcers, diabetic foot ulcers, or venous stasis ulcers, often fail to progress through the normal healing stages and can persist for extended periods. Open wounds involve a break in the skin, exposing underlying tissues, while closed wounds, like bruises or hematomas, occur without a skin break.

Wound infection is a major complication that can significantly impede healing and pose serious health risks. It arises when pathogens breach the body’s defenses and proliferate within the wound. Factors such as poor hygiene, inadequate wound care techniques, and compromised immune systems increase the susceptibility to infection. Untreated wound infections can escalate into severe conditions, including cellulitis, sepsis, and osteomyelitis, potentially becoming life-threatening.

The body’s natural response to injury is wound healing, a complex process aimed at restoring tissue integrity. This process unfolds in four overlapping phases: hemostasis, inflammation, proliferation, and maturation. Any disruption in these phases can delay healing and increase the risk of infection. Nurses play a crucial role in supporting each phase of wound healing through meticulous assessment, appropriate interventions, and patient education.

This article provides a comprehensive guide to understanding nursing diagnoses related to wound care. It delves into the essential aspects of wound healing, infection, nursing assessment, interventions, and the application of specific nursing diagnoses to facilitate effective wound management and promote optimal patient outcomes.

Wound Infection

Wound infection occurs when pathogenic microorganisms successfully invade and multiply within a wound site, overcoming the host’s defense mechanisms. The skin, our primary protective barrier, is compromised in wounds, allowing pathogens to penetrate and potentially overwhelm the immune system. Several factors contribute to wound infection, with inadequate aseptic techniques and environmental contamination being prominent culprits. Furthermore, underlying health conditions that weaken the immune system or impair the healing process, such as diabetes mellitus and HIV, significantly elevate the risk of wound infections.

The consequences of untreated wound infections can be severe, progressing to serious and potentially life-threatening complications. These include:

• Cellulitis: A bacterial infection of the skin and subcutaneous tissues, characterized by redness, warmth, swelling, and pain.
• Abscess: A localized collection of pus within tissues, often requiring drainage.
• Sepsis: A systemic inflammatory response to infection, potentially leading to organ dysfunction and death.
• Osteomyelitis: An infection of the bone, often resulting from the spread of infection from a nearby wound.
• Necrotizing Fasciitis: A severe and rapidly progressing infection that destroys fascia and subcutaneous tissue, commonly known as “flesh-eating bacteria.”

[ALT Text: Visual representation of Wound Infection Signs, highlighting redness, swelling, pus, pain, and heat around the wound area, key indicators for nursing assessment]

Wound Healing

Wound healing, the body’s intricate process of tissue restoration, commences immediately after a skin injury occurs. This complex sequence of events aims to repair damaged tissues and restore skin integrity. Any disruption or delay in the wound healing process not only prolongs patient discomfort but also significantly increases the susceptibility to infection and other complications.

Wound healing is typically described in four distinct, yet overlapping phases:

• Hemostasis (Immediate): This initial phase is triggered immediately upon injury. Blood vessels constrict to minimize blood loss, and coagulation pathways are activated to initiate clot formation. Platelets aggregate at the wound site, further contributing to clot formation and sealing the wound to stop bleeding.
• Inflammation (0-4 days): The inflammatory phase is characterized by the body’s immune response to injury. Neutrophils and macrophages, key immune cells, migrate to the wound site to combat pathogens and prevent infection. This phase is clinically recognized by swelling, redness, heat, and pain at the wound site.
• Proliferation (2-24 days): During proliferation, the focus shifts to tissue regeneration and wound closure. Granulation tissue, a matrix of new connective tissue and blood vessels, begins to fill the wound bed. Epithelial cells migrate from the wound edges to cover and resurface the wound, a process known as epithelialization.
• Maturation (24+ days): The final phase, maturation, involves the remodeling of collagen within the newly formed tissue. Collagen fibers reorganize and strengthen, increasing the tensile strength of the wound. A scar, composed of collagen, may form as a result of this process. Scar tissue is typically less elastic and has reduced tensile strength compared to the original, uninjured skin.

Types of Wound Healing

Wound healing can proceed through different mechanisms depending on the nature and characteristics of the wound:

• Primary Intention: This type of healing occurs when the wound edges are closely approximated and brought together, typically using sutures, staples, adhesive strips (Steri-Strips), or surgical glue. Primary intention healing is commonly observed in surgical incisions, lacerations with clean edges, and well-reduced fractures. This method of healing results in minimal scarring due to the close apposition of wound edges.
• Secondary Intention: Secondary intention healing is employed when wound edges cannot be easily approximated, often due to tissue loss, infection, or extensive damage. In these wounds, healing occurs through the formation of granulation tissue from the base of the wound upwards, followed by epithelialization from the wound margins. Secondary intention healing is characteristic of pressure ulcers, full-thickness burns, and infected wounds. This type of healing typically results in more significant scarring and a longer healing time compared to primary intention.
• Tertiary Intention (Delayed Primary Closure): Tertiary intention, also known as delayed primary closure, is a combination of primary and secondary intention healing. In this scenario, the wound is initially left open, often to allow for drainage of infection or edema. Once the infection is controlled and the wound bed is clean and granulating, the wound edges are approximated and closed, typically with sutures or staples. Tertiary intention is often used for contaminated wounds, surgical wounds at high risk of infection, or wounds with significant edema.

Factors Affecting Wound Healing

Numerous intrinsic and extrinsic factors can influence the body’s ability to heal wounds effectively. Nurses must be cognizant of these factors to provide holistic and individualized wound care. Key factors affecting wound healing include:

• Nutritional Status: Adequate nutrition, particularly protein, vitamins (especially Vitamin C and zinc), and minerals, is essential for tissue repair and regeneration. Malnutrition impairs collagen synthesis, immune function, and overall healing capacity.
• Stress: Psychological and physiological stress can negatively impact wound healing. Stress hormones can suppress the immune system and delay the inflammatory and proliferative phases of healing.
• Comorbidities: Underlying health conditions such as diabetes mellitus, cardiovascular disease, peripheral vascular disease, and autoimmune disorders can significantly impair wound healing. Diabetes, for instance, can lead to neuropathy, impaired circulation, and compromised immune function, all of which hinder wound healing.
• Age: Both very young and older individuals may experience impaired wound healing. Infants have immature immune systems, while older adults often have age-related physiological changes, such as decreased collagen synthesis and impaired immune response, which can delay healing.
• Obesity: Obesity is associated with impaired wound healing due to factors such as poor vascularity in adipose tissue, increased inflammation, and higher risk of infection.
• Medications: Certain medications, such as corticosteroids, chemotherapy drugs, and immunosuppressants, can suppress the immune system and interfere with the inflammatory and proliferative phases of wound healing.
• Alcohol Use: Excessive alcohol consumption can impair immune function, nutritional status, and blood flow, all of which can negatively affect wound healing.
• Smoking: Smoking significantly impairs wound healing by reducing blood flow and oxygen delivery to tissues due to vasoconstriction and carbon monoxide exposure. It also interferes with collagen synthesis and increases the risk of infection.
• Friction and Shearing: Mechanical forces like friction and shearing can cause tissue damage and breakdown, particularly in patients with limited mobility. These forces disrupt blood flow and can lead to pressure ulcers and other wounds.
• Poor Mobility: Immobility reduces circulation and increases pressure on certain areas of the body, predisposing patients to pressure ulcers and hindering wound healing.
• Knowledge Deficits: Lack of patient and caregiver knowledge regarding proper wound care techniques, infection prevention, and factors that promote healing can lead to suboptimal wound management and delayed healing.

[ALT Text: Visual Diagram illustrating Factors Affecting Wound Healing, encompassing patient-related factors like age and nutrition, and external factors like infection and medication]

Nursing Process

The nursing process provides a systematic framework for delivering patient-centered wound care. It encompasses assessment, diagnosis, planning, implementation, and evaluation, ensuring a comprehensive and individualized approach to wound management.

A wound can arise from a multitude of causes, necessitating a meticulous nursing approach to ensure proper cleaning, protection, and prevention of infection and further tissue damage. Effective wound care nursing encompasses several key considerations, including:

• Debridement of devitalized tissue: Removing necrotic tissue to promote healthy tissue growth.
• Management of wound exudate: Controlling drainage to maintain a moist wound environment without maceration.
• Prevention of bacterial overgrowth: Implementing infection control measures to minimize the risk of wound infection.
• Optimization of nutrition and fluid balance: Ensuring adequate nutritional support to facilitate tissue repair and hydration.
• Consideration of patient comorbidities: Addressing underlying health conditions that may impact wound healing.
• Cost-efficiency of care: Providing effective wound care while considering resource utilization.
• Manageability of care for the patient and/or nursing staff: Developing a wound care regimen that is practical and sustainable for both the patient and healthcare providers.

In cases of complex or chronic wounds, consulting a wound care specialist or a wound care certified nurse is highly recommended. These experts possess specialized knowledge and skills to manage challenging wounds and optimize healing outcomes.

Nursing Assessment

The initial step in the nursing process for wound care is a comprehensive nursing assessment. This involves gathering subjective and objective data to gain a holistic understanding of the patient’s wound and overall health status. The assessment includes physical, psychosocial, emotional, and diagnostic data collection.

Review of Health History

1. Determine the patient’s general symptoms. Recognizing the signs and symptoms of wound infection is crucial for prompt intervention. Key symptoms of an infected wound include:

• Purulent discharge: Thick, opaque drainage that may be yellow, green, or creamy in color.
• Skin discoloration: Erythema (redness) or increased discoloration around the wound.
• Swelling: Increased edema or induration around the wound site.
• Foul odor: Malodorous discharge emanating from the wound.
• Warmth: Increased temperature of the skin surrounding the wound compared to adjacent tissue.
• Tenderness or pain: Increased pain or tenderness to palpation at the wound site.
• Inflamed skin: Visible signs of inflammation, such as redness, heat, swelling, and pain.

Systemic symptoms may indicate a more severe, spreading infection, requiring immediate medical attention. These concerning systemic symptoms include:

• Fever: Elevated body temperature.
• Chills: Shivering and feeling cold.
• Lymphadenopathy: Swollen lymph nodes in the region near the wound, indicating lymphatic involvement in the infection.

2. Assess the underlying cause. Understanding the etiology of the wound is essential for effective management. Wounds can result from various causes, ranging from accidental injuries to immobility and surgical procedures. Wound infection typically occurs when bacteria enter compromised skin and begin to proliferate. Factors contributing to wound infection include poor hygiene, ineffective wound care practices, and contamination of the wound. The risk of infection is heightened in specific wound scenarios:

• Large, deep, or jagged wounds: These wounds provide a larger surface area and deeper tissue penetration for bacteria to colonize.
• Wounds contaminated with dirt or animal/human saliva: These sources introduce a diverse range of microorganisms into the wound.
• Puncture wounds from rusty nails or contaminated objects: These wounds can introduce tetanus and other pathogens deep into the tissue.

3. Identify the patient’s medical risk factors. Pre-existing medical conditions and risk factors can significantly impact wound healing and increase susceptibility to infection. These medical risk factors include:

• Diabetes mellitus: Impaired circulation, neuropathy, and immune dysfunction associated with diabetes increase the risk of wound infection and delayed healing.
• Immunosuppression: Conditions or treatments that suppress the immune system, such as HIV, cancer, organ transplantation, and immunosuppressant medications, increase the risk of infection.
• Renal failure: Impaired kidney function can lead to fluid and electrolyte imbalances, malnutrition, and compromised immune function, affecting wound healing.
• Obesity: As mentioned earlier, obesity is associated with impaired wound healing and increased infection risk.
• Advancing age: Age-related physiological changes can impair wound healing and increase vulnerability to infection.
• Neuropathy: Nerve damage, often associated with diabetes, can lead to decreased sensation, increasing the risk of unnoticed injuries and delayed wound healing.
• Peripheral vascular disease (PVD): Reduced blood flow to the extremities in PVD impairs oxygen and nutrient delivery to wound sites, hindering healing.
• Treatments or medications: Chemotherapy, radiation therapy, and immunosuppressant medications can compromise the immune system and impede wound healing.

4. Review the patient’s surgical record. Surgical procedures inherently carry a risk of wound infection. Specific surgical characteristics can further elevate this risk:

• Poor surgical technique: Inadequate aseptic technique during surgery can introduce pathogens into the surgical site.
• Prolonged hospital stay: Longer hospitalizations increase exposure to nosocomial pathogens and the risk of surgical site infections (SSIs).
• Intraoperative contamination: Contamination of the surgical field during the procedure can lead to SSI.
• Hypothermia: Intraoperative hypothermia can impair immune function and wound healing.

5. Review the patient’s medication list. Certain medications can interfere with wound healing processes. Medications of concern include:

• Hydroxyurea: Used to treat certain cancers and sickle cell disease, can suppress bone marrow function and impair wound healing.
• Chemotherapeutic drugs: Many chemotherapy agents suppress the immune system and impair cell proliferation, hindering wound healing.
• Steroids (corticosteroids): Steroids suppress inflammation and immune function, which are essential for wound healing.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs can interfere with platelet function and the inflammatory phase of wound healing.
• Disease-modifying antirheumatic drugs (DMARDs): DMARDs, used to treat autoimmune diseases, can suppress the immune system and impair wound healing.

6. Inquire about the patient’s nutritional status. Adequate nutrition is fundamental for wound healing. Protein deficiency and inadequate intake of essential vitamins and minerals, such as vitamin C and zinc, will impede tissue repair. Hydration is also crucial for maintaining blood circulation, tissue oxygenation, and skin elasticity. Assess the patient’s dietary intake, including protein, vitamin, mineral, and fluid consumption.

Physical Assessment

1. Determine the type of the wound. Identifying the wound type is critical as it dictates the appropriate wound care strategies. Nurses commonly encounter various wound types, including:

• Skin tears: Traumatic wounds resulting from shearing or friction forces, often seen in older adults with fragile skin.
• Diabetic foot ulcers: Ulcerations on the feet of individuals with diabetes, often due to neuropathy, poor circulation, and foot deformities.
• Arterial ulcers: Ulcers caused by insufficient arterial blood flow, typically located on the lower legs and feet, often painful and dry.
• Venous stasis ulcers: Ulcers resulting from venous insufficiency, typically found in the lower legs, often characterized by edema and exudate.
• Pressure ulcers (bedsores): Localized injuries to the skin and underlying tissue, caused by prolonged pressure, often over bony prominences.
• Surgical wounds: Incisions created during surgical procedures.
• Traumatic wounds: Wounds resulting from physical injury, such as lacerations, abrasions, punctures, and burns.

2. Assess and document wound findings. Thorough and consistent wound assessment and documentation are essential for monitoring wound progression and treatment effectiveness. Wound characteristics should be assessed and documented at each dressing change and according to facility protocols. Key assessment parameters include:

• Location: Anatomical site of the wound.
• Size: Length, width, and depth of the wound, typically measured in centimeters.
• Drainage: Type, color, odor, and amount of wound exudate (e.g., serous, sanguinous, serosanguineous, purulent).
• Wound bed: Description of the tissue present in the wound bed (e.g., granulation tissue, slough, eschar, exposed muscle or bone).
• Wound edges and surrounding skin (periwound): Assessment of wound edges (e.g., approximated, unapproximated, rolled, epibole) and periwound skin (e.g., erythema, edema, maceration, induration).
• Presence of tunneling or undermining: Assessment for extensions of the wound beneath the skin surface.
• Signs of infection: Evaluation for clinical signs of wound infection (as described previously).

3. Utilize the acronym T.I.M.E. for assessment. The T.I.M.E. acronym provides a structured approach to wound bed preparation and assessment, guiding clinicians in addressing key factors that impede healing:

• Tissue: Evaluate the tissue type present in the wound bed. Epithelial tissue (pink and newly formed) and granulation tissue (red and beefy) indicate healing progression. Slough (yellow or gray, stringy or mucinous) and necrotic tissue (black, dry, leathery eschar) represent nonviable tissue that hinders healing and should be removed.
• Infection/Inflammation: While inflammation is a natural part of the healing process, infection is a pathological state that delays healing and can spread systemically. Assess for clinical signs of infection.
• Moisture: Maintaining a moist wound environment is crucial for optimal healing. Moisture facilitates cell migration, nutrient delivery, and autolytic debridement. However, excessive moisture can lead to maceration (skin softening and breakdown), while insufficient moisture can cause the wound to dry out and impede healing. Assess the type and amount of wound exudate to guide dressing selection and moisture management.
• Edges: Monitor the wound edges for characteristics that may indicate healing progression or impediments. Well-approximated and epithelializing edges are desirable. Non-advancing or rolled edges (epibole), tunneling, and undermining can signal delayed healing. Also, assess the periwound skin for erythema, swelling, or maceration, which can affect wound healing.

4. Ask the patient to rate their pain. Pain is a common symptom associated with wounds, particularly infected wounds. Pain assessment is essential to evaluate the severity of wound pain and determine the effectiveness of pain management strategies. Utilize validated pain assessment tools, such as numerical rating scales (0-10), visual analog scales, or faces pain scales (for children or individuals with communication difficulties), to quantify and monitor pain levels.

Diagnostic Procedures

Diagnostic procedures play a crucial role in identifying wound infections, determining the causative pathogens, and assessing factors that may impede wound healing.

1. Obtain a sample for culturing. Wound cultures are essential for identifying the specific microorganisms causing infection and guiding appropriate antimicrobial therapy. Swabbing the wound is a non-invasive, readily available, and cost-effective method for obtaining a specimen for culture and sensitivity testing.

2. Prepare for biopsy or aspiration. In certain situations, more invasive diagnostic procedures may be necessary. A tissue biopsy, involving the removal of a small tissue sample from the wound bed, is considered the gold standard for detecting bacteria and identifying the depth of infection. However, it is an invasive and potentially painful procedure. Aspiration of fluid from the wound, particularly from deeper lesions or suspected abscesses, can be performed to assess for microbial presence below the skin surface.

3. Send samples for further investigation. Laboratory blood tests can provide valuable information in assessing for systemic infection and overall patient status. The following laboratory values may be assessed:

• White blood cell (WBC) count: Elevated WBC count, particularly neutrophils, often indicates infection.
• C-reactive protein (CRP): An acute-phase reactant protein that increases in response to inflammation and infection. Elevated CRP levels can suggest systemic inflammation.
• Procalcitonin (PCT): Another acute-phase reactant, PCT is often more specific for bacterial infections than CRP. Elevated PCT levels can indicate bacterial infection severity.
• Presepsin: A biomarker released during bacterial infection, presepsin levels can help in early diagnosis and prognosis of sepsis.
• Microbial DNA: Molecular diagnostic tests can detect microbial DNA in wound samples, aiding in pathogen identification, particularly for fastidious or slow-growing organisms.
• Bacterial protease activity (BPA): Elevated BPA levels in wound fluid can indicate increased bacterial burden and proteolytic activity, contributing to tissue damage.

4. Prepare the patient for imaging. Imaging studies can be valuable in evaluating deeper tissue infections and complications. Common imaging modalities used in wound care include:

• Plain X-rays: Useful in detecting soft-tissue gas in gas gangrene or osteomyelitis.
• Computed tomography (CT) scans: Provide detailed cross-sectional images of soft tissues and bones, helpful in identifying soft-tissue infections, abscesses (including intra-abdominal abscesses), and osteomyelitis.
• Magnetic resonance imaging (MRI): Offers superior soft-tissue detail and is excellent for delineating the extent of infection in tissues and bones, particularly in cases of osteomyelitis and deep soft-tissue infections.
• Ultrasound: A non-invasive and readily available imaging modality that can be used to assess skin and soft-tissue infections, abscesses, and fluid collections.

5. Determine issues with peripheral perfusion. Adequate peripheral perfusion is essential for wound healing, particularly in lower extremity wounds. If peripheral artery disease (PAD) is suspected, assess peripheral perfusion using non-invasive vascular studies:

• Ankle-brachial index (ABI): Compares blood pressure in the ankle to blood pressure in the arm to assess for PAD. An ABI of ≤ 0.9 indicates PAD.
• Toe-brachial index (TBI): Similar to ABI but measures blood pressure in the toe, useful in patients with calcified ankle arteries, such as those with diabetes.
• Monofilament testing: Assesses protective sensation in the feet, particularly important in patients with diabetes or peripheral neuropathy, to identify individuals at risk for foot ulcers.

[ALT Text: Image depicting a Wound Culture Procedure, showing a nurse swabbing a wound to collect a specimen for microbiological analysis in a laboratory setting]

Nursing Interventions

Nursing interventions are crucial for promoting wound healing, preventing complications, and managing patient comfort. These interventions are tailored to the individual patient’s wound characteristics, health status, and needs.

Provide Appropriate Wound Care

1. Remove nonviable tissue. Debridement, the removal of necrotic or devitalized tissue, is a fundamental intervention in wound care. Necrotic tissue impedes healing, harbors bacteria, and can contribute to infection. Various debridement methods are available:

• Autolytic debridement: Utilizes the body’s own enzymes and moisture to break down necrotic tissue. This is achieved by applying moisture-retentive dressings, such as hydrogels or hydrocolloids, to the wound.
• Enzymatic debridement: Involves the topical application of prescribed enzymatic ointments containing enzymes that selectively digest necrotic tissue, such as collagenase.
• Sharp wound debridement: A surgical procedure performed by a trained healthcare professional (physician, advanced practice nurse, or physician assistant) using sharp instruments (scalpel, scissors, curette) to excise necrotic tissue.

2. Control moisture. Maintaining optimal wound moisture balance is essential for healing. A moist wound environment promotes cell migration, angiogenesis, and autolytic debridement. However, excessive moisture can lead to maceration and periwound skin breakdown. Strategies for moisture management include:

• Selecting appropriate dressings: Hydrofiber dressings, alginate dressings, and foam dressings are highly absorbent and effective in managing wounds with moderate to heavy exudate.
• Frequent dressing changes: More frequent dressing changes may be necessary for wounds with significant drainage to prevent maceration.

3. Pack the wound as needed. Wounds with tunneling or undermining require packing to prevent premature closure of the wound edges, promote healing from the base of the wound, and prevent abscess formation. Wound packing techniques include:

• Moistened sterile gauze: Sterile gauze moistened with sterile saline can be gently packed into tunnels or undermined areas, ensuring not to overpack, which can impede circulation.
• Hydrogel-impregnated dressings: Gauze or ribbon dressings impregnated with hydrogel can provide moisture and conform to wound contours, suitable for packing tunnels and undermining.

4. Protect the periwound skin. The skin surrounding the wound (periwound skin) is vulnerable to breakdown due to wound exudate, adhesive dressings, and friction. Protecting the periwound skin is crucial for preventing wound enlargement and promoting patient comfort. Periwound protection strategies include:

• Barrier creams/powders: Topical barrier creams or powders containing zinc oxide or petrolatum can create a protective layer on the periwound skin, shielding it from moisture and irritants.
• Protective wipes: Skin protectant wipes can be applied to the periwound skin to create a barrier against adhesive trauma and exudate.
• Barrier wafers: Thin hydrocolloid or silicone wafers can be applied to the periwound skin to provide a barrier and protect against friction and maceration.

5. Apply a wound vac. Wound vacuum-assisted closure (VAC) therapy, also known as negative pressure wound therapy (NPWT), is an advanced wound care modality used for various wound types, including open wounds, skin grafts, flaps, and pressure ulcers. Wound VAC systems apply controlled negative pressure to the wound bed through a specialized foam dressing and suction device. Benefits of wound VAC therapy include:

• Removal of exudate and infectious materials.
• Reduction of edema.
• Promotion of granulation tissue formation.
• Wound contraction and closure.

6. Manage pain. Wound care procedures, particularly dressing changes and debridement, can be painful for patients. Effective pain management is essential to enhance patient comfort and cooperation with wound care. Pain management strategies include:

• Premedication with analgesics: Administering prescribed analgesics, such as acetaminophen, NSAIDs, or opioids, prior to painful wound care procedures, allowing sufficient time for the medication to take effect.
• Topical anesthetics: Topical anesthetic creams or gels containing lidocaine or prilocaine can be applied to the wound site prior to dressing changes to reduce pain.
• Non-pharmacological pain management: Employing non-pharmacological pain relief measures, such as distraction, relaxation techniques, and positioning, to complement pharmacological analgesia.

Prevent or Manage Infection

1. Perform aseptic or clean technique as required. Infection prevention is paramount in wound care. The choice between aseptic and clean technique depends on the wound type, location, and patient’s immune status:

• Aseptic technique (sterile technique): Employs sterile gloves, sterile instruments, and sterile dressings to minimize the introduction of microorganisms into the wound. Aseptic technique is typically indicated for high-risk wounds, such as surgical wounds, burns, and wounds in immunocompromised patients.
• Clean technique (non-sterile technique): Utilizes clean gloves and clean instruments and dressings. Clean technique is often appropriate for chronic wounds, pressure ulcers, and simple wounds like skin tears in non-immunocompromised patients.

2. Administer antibiotics as ordered. Wounds exhibiting clinical signs of infection may require antimicrobial therapy. Antibiotic selection depends on the severity of infection, causative pathogens (if identified), and patient factors:

• Topical antibiotics or silver dressings: May be used for localized wound infections or as adjunctive therapy. Silver-impregnated dressings have antimicrobial properties and can be effective in reducing bacterial bioburden in wounds.
• Oral or intravenous (IV) antibiotic therapy: Indicated for systemic infections or wounds with spreading cellulitis, lymphangitis, or systemic signs of infection. Targeted antimicrobial therapy is guided by wound culture and sensitivity results to ensure effective pathogen coverage.

3. Stress the importance of cleaning wounds immediately. Prompt wound cleaning is crucial for reducing bacterial contamination and preventing infection, especially in traumatic wounds. Educate patients and caregivers on immediate wound cleaning:

• Cleanse wounds immediately with soap and water: Gently wash the wound with mild soap and water to remove debris and contaminants.
• Seek medical assistance for “dirty” wounds: Advise patients to seek medical attention for wounds contaminated with dirt, animal bites, human bites, or foreign material (glass, metal, gravel), as these wounds have a higher risk of infection and may require tetanus prophylaxis or rabies management.

4. Do not use peroxide or alcohol to clean wounds. Educate patients and caregivers to avoid using hydrogen peroxide or rubbing alcohol to clean wounds. These agents are cytotoxic to healthy tissue and can impair wound healing:

• Hydrogen peroxide and rubbing alcohol are too harsh: These agents can damage fibroblasts and keratinocytes, essential cells for wound healing, and delay tissue regeneration.
• Use sterile saline or wound cleansers instead: Recommend using sterile saline solution or commercially available wound cleansers for wound irrigation and cleaning.

5. Emphasize hand hygiene. Hand hygiene is the cornerstone of infection prevention. Reinforce the importance of meticulous hand hygiene to patients, caregivers, and healthcare providers:

• Wash hands before and after wound care: Thorough handwashing with soap and water or using an alcohol-based hand sanitizer should be performed before and after any wound contact or dressing change.

6. Keep wounds covered. Counteract the misconception that wounds need to “breathe” to heal. Educate patients that wound dressings are beneficial for healing:

• Wounds heal best in a moist environment: Dressings maintain a moist wound environment, which promotes cell migration and healing.
• Dressings protect wounds from bacterial contamination: Covering wounds with dressings acts as a barrier against external pathogens, reducing the risk of infection.

Promote Wound Healing

1. Promote nutrition and hydration. Adequate nutrition and hydration are fundamental for supporting the body’s healing processes. Nutritional recommendations for wound healing include:

• High-protein diet: Protein is essential for tissue repair and collagen synthesis. Recommend a diet rich in protein sources, such as meat, poultry, fish, eggs, dairy products, beans, and lentils.
• Vitamin C supplementation: Vitamin C is a crucial antioxidant and cofactor for collagen synthesis. Encourage consumption of vitamin C-rich foods (citrus fruits, berries, peppers) or consider vitamin C supplementation as recommended by a healthcare provider.
• Adequate fluid intake: Hydration is essential for maintaining blood volume, nutrient delivery, and tissue oxygenation. Encourage adequate fluid intake, aiming for at least 8-10 glasses of water per day, unless contraindicated by medical conditions.

2. Educate on strategies to reduce skin breakdown. Preventing further skin injury is crucial, especially in patients at risk for pressure ulcers or skin tears. Educate patients and families on preventive strategies:

• Minimize pressure with frequent turning and repositioning: For patients with limited mobility, implement a regular turning and repositioning schedule (e.g., every 2 hours) to relieve pressure on bony prominences.
• Always wear shoes or socks to protect the feet: Especially important for individuals with diabetes or neuropathy, to prevent foot injuries and ulcers.
• Control swelling in the lower extremities with compression stockings: For patients with venous insufficiency, compression stockings can reduce edema and improve circulation, promoting wound healing and preventing venous ulcers.
• Keep skin clean and dry: Maintain skin hygiene, especially in incontinent patients, to prevent moisture-associated skin damage (MASD). Use gentle cleansers and moisture barriers as needed.

3. Document the wound and wound care provided. Comprehensive and accurate wound documentation is essential for tracking wound progress, communicating care plans, and ensuring continuity of care. Wound documentation should occur with every dressing change and include:

• Date and time of dressing change.
• Wound assessment findings (using T.I.M.E. framework).
• Type of wound cleanser used.
• Type of dressing applied.
• Patient’s tolerance of procedure.
• Any changes in wound status (size, exudate, wound bed, periwound).
• Photographs of the wound (as per facility policy).

4. Refer to a wound care clinic. Chronic or non-healing wounds may require specialized wound care management in a wound care clinic. Referral to a wound care clinic is recommended for:

• Wounds that fail to progress in healing despite standard care.
• Complex wounds requiring advanced wound dressings or therapies.
• Chronic wounds such as pressure ulcers, diabetic foot ulcers, and venous stasis ulcers.
• Wounds requiring hyperbaric oxygen therapy or other specialty treatments.

Nursing Care Plans

Nursing care plans provide a structured approach to organizing and delivering patient care based on identified nursing diagnoses. In wound care, nursing care plans help prioritize assessments and interventions to achieve short-term and long-term goals of care. The following are examples of nursing care plans for common nursing diagnoses related to wound care.

Acute Pain

Acute pain is a common manifestation associated with wound infection and tissue damage.

Nursing Diagnosis: Acute Pain

Related to:

• Loss of blood supply in the affected site
• Necrotic tissue
• Damaged nerve endings

As evidenced by:

• Verbal reports of pain
• Guarding the affected part
• Restlessness
• Tenderness or pain to touch
• Changes in vital signs (increased heart rate, blood pressure, respiratory rate)

Expected outcomes:

• Patient will verbalize a reduction in pain related to the wound.
• Patient will report a decrease in pain intensity on a 0-10 pain scale within a specified timeframe after pain medication administration.
• Patient will be able to perform daily activities with minimal pain related to the wound.

Assessment:

1. Assess using a pain scale. Pain is subjective and must be assessed based on the patient’s self-report. Utilize a validated pain scale (numerical rating scale, visual analog scale) to quantify pain intensity.

2. Identify the type of pain. Differentiate between nociceptive pain (due to tissue injury) and neuropathic pain (due to nerve damage). Ask the patient to describe the pain characteristics (e.g., sharp, burning, throbbing, aching) to help determine the type of pain.

3. Palpate the surrounding skin for tenderness or pain. Assess for tenderness and pain to palpation around the wound site. Persistent or increasing pain may indicate infection or delayed healing.

Interventions:

1. Premedicate prior to wound care. Administer prescribed analgesics (oral or topical) 30-60 minutes prior to dressing changes or debridement to minimize pain during procedures.

2. Educate on pain control. Ensure the patient understands their prescribed pain medication regimen, including medication name, dosage, frequency, and potential side effects. Educate on the importance of taking pain medication as prescribed to achieve adequate pain relief. Discuss different types of pain medications:

• NSAIDs: To control inflammation and mild to moderate pain.
• Neuropathic pain medications: For burning or shooting nerve pain.
• Opioids: For severe pain, used judiciously and as needed for breakthrough pain.

3. Prevent surrounding symptoms. Address factors that can exacerbate wound pain, such as:

• Excessive dryness or drainage: Maintain optimal wound moisture balance to prevent dryness or maceration, both of which can increase pain.
• Edema: Elevate the affected extremity to reduce edema, which can contribute to pain.
• Skin maceration: Protect periwound skin from maceration by using appropriate dressings and barrier creams.
• Frequent dressing changes: Minimize unnecessary dressing changes to reduce pain and disruption of the wound bed.

4. Splint the wounded site. Immobilizing the wounded area with a splint can reduce pain by limiting movement and preventing further injury or irritation.

Impaired Skin Integrity

Impaired skin integrity is a primary nursing diagnosis directly related to wounds, reflecting damage to the epidermis and/or dermis.

Nursing Diagnosis: Impaired Skin Integrity

Related to:

• Skin injury from shearing, pressure, or trauma
• Burns
• Moisture (excessive or insufficient)
• Surgical incisions
• Impaired circulation
• Poor skin turgor
• Edematous tissues
• Conditions that delay wound healing (e.g., diabetes mellitus)

As evidenced by:

• Discharge from the wound
• Skin discoloration (erythema, ecchymosis)
• Erythema (redness)
• Foul smelling odor (suggestive of infection)
• Tight skin sutures (in surgical wound infections)
• Warm, tender, painful, and inflamed skin
• Prolonged or delayed healing

Expected outcomes:

• Patient will exhibit absence of purulent drainage from the wound.
• Patient will demonstrate clean and well-approximated wound edges.
• Patient will verbalize understanding of wound care management principles.
• Patient will actively participate in performing wound care as able.

Assessment:

1. Assess the wound with each dressing change. Regular wound assessment is crucial to monitor healing progress and identify any changes or complications. Assess and document wound characteristics at each dressing change, including size, color, depth, drainage, wound bed, and periwound skin.

2. Classify the type of wound. Determine the wound type (skin tear, pressure ulcer, surgical wound, etc.) to guide appropriate wound care interventions. Classify wounds based on etiology, duration (acute/chronic), depth of tissue involvement (partial-thickness/full-thickness), and contamination level (clean/contaminated/infected).

3. Use a risk assessment tool. Identify patients at risk for impaired skin integrity using validated risk assessment tools, such as the Braden Scale for pressure ulcer risk. Risk assessment helps in implementing preventive measures. Evaluate patient risk factors, including medical history, physical examination findings, and laboratory results. Common risk factors include smoking, alcohol use, diabetes, and hypertension.

4. Obtain a wound culture. If signs of infection are present, obtain a wound culture to identify the causative pathogens and guide antimicrobial therapy selection, especially for suspected antibiotic-resistant organisms like MRSA.

Interventions:

1. Disinfect the site with antiseptic. Cleanse the wound with appropriate antiseptic wound cleansers, such as chlorhexidine or povidone-iodine, as prescribed. Avoid using alcohol or harsh chemicals directly on the wound, as they can damage healthy tissue.

2. Decontaminate the skin injury. Remove any foreign objects or debris from the wound to prevent infection and promote healing. Decontamination should be performed promptly and consistently. Revascularize and debride any necrotic tissue to remove potential sources of infection and promote healthy tissue growth.

3. Remove any dying tissue. Perform debridement as needed to remove necrotic tissue (slough, eschar) from the wound bed. Debridement promotes wound healing by removing barriers to tissue regeneration and reducing bacterial bioburden.

4. Apply appropriate wound dressings. Select wound dressings based on wound type, exudate level, wound bed characteristics, and treatment goals. Non-adherent saline wraps (saline-soaked gauze) and absorbent dressings can be effective for preventing wound infection and promoting re-epithelialization. Secure dressings with soft gauze tape or appropriate adhesive dressings. Maintain asepsis during dressing changes to prevent wound contamination.

5. Manage the wound based on the stages of healing. Wound care strategies should be adjusted based on the stage of wound healing. Different cleansers, ointments, or dressings may be indicated at various phases of healing.

6. Keep the wound moist. Maintain a moist wound environment, as appropriate for the wound type, to promote healing. Moisture supports hydration, angiogenesis, collagen formation, and autolytic debridement. It also helps alleviate pain and improve wound appearance.

7. Apply topical antibiotics and antiseptics as recommended. Use topical antibiotics or antiseptics as prescribed by a healthcare provider to treat or prevent wound infection. Topical antibiotics eliminate bacteria, while antiseptics inhibit microbial growth. Use these agents carefully and as directed by a physician or wound care specialist. Cover topical treatments with a secondary dressing suitable for infected wounds.

8. Remove sutures for surgical wounds. Remove sutures or adhesive strips at the appropriate time (typically 10-14 days after application, or 3-5 days for facial wounds) once the wound edges are well-approximated. Adhesive glue will typically peel off naturally within 1-2 weeks.

9. Refer to a wound care specialist. Refer patients with chronic, non-healing wounds, or complex wounds to a wound care specialist for comprehensive assessment and specialized management. Wound care specialists have expertise in managing acute, chronic, and non-healing wounds.

Ineffective Protection

Ineffective protection is a nursing diagnosis that addresses a patient’s decreased ability to protect themselves from internal and external threats, including skin breakdown and infection.

Nursing Diagnosis: Ineffective Protection

Related to:

• Inadequate primary defenses (broken skin, tissue trauma)
• Circulatory compromise
• Tissue trauma or injury
• Older age
• Malnutrition
• Immobility
• Incontinence
• Compromised immunity
• Ineffective health self-management

As evidenced by:

• Impaired tissue healing
• Maladaptive stress response
• Pressure ulcer development
• Weakness
• Neurosensory impairment
• Poor mobility

Expected outcomes:

• Patient will remain free from developing a wound infection.
• Patient will demonstrate interventions to improve protection against skin breakdown and wounds.

Assessment:

1. Assess and monitor the patient’s vital signs. Monitor vital signs (temperature, heart rate, blood pressure, respiratory rate) regularly. Changes in vital signs can indicate systemic infection or sepsis, a life-threatening complication of untreated wounds.

2. Assess and monitor the patient’s nutritional status. Evaluate nutritional status, including dietary intake, weight changes, and laboratory markers (albumin, prealbumin). Nutrition plays a critical role in immune function, skin integrity, and wound healing. Proper hydration and nutrient intake are essential for skin elasticity, collagen production, tissue regeneration, and immune system function.

3. Assess the patient’s ability to perform ADLs. Assess the patient’s ability to perform activities of daily living (ADLs), particularly mobility and hygiene. Evaluate the patient’s ability to ambulate, reposition themselves in bed or chair, bathe, and toilet independently. Assess for any limitations due to weakness, pain, neurosensory impairment, or immobility. Assess if the patient can maintain skin cleanliness and dryness to prevent skin breakdown.

Interventions:

1. Administer antibiotic therapy as indicated. Administer prescribed antibiotic therapy as directed for confirmed wound infections or as prophylaxis in high-risk wounds. Antibiotics help combat existing infections and prevent further complications.

2. Refer the patient to a dietitian. Consult a registered dietitian for nutritional assessment and counseling. A dietitian can develop a personalized meal plan to meet the patient’s nutritional needs, support immune function, and promote optimal wound healing.

3. Educate the patient about infection control measures. Provide comprehensive patient education on infection control measures, emphasizing hand hygiene as a primary preventive strategy. Teach proper handwashing techniques and the importance of handwashing before and after touching a wound or dressing.

4. Provide proper wound care. Implement appropriate wound care based on wound type, location, and patient needs. Demonstrate wound cleaning and dressing techniques to the patient and caregiver. Educate on signs and symptoms of wound infection (redness, swelling, pain, drainage, fever) and when to seek medical attention.

Ineffective Tissue Perfusion

Ineffective tissue perfusion is a nursing diagnosis relevant to wound care, particularly in patients with conditions that compromise blood flow.

Nursing Diagnosis: Ineffective Tissue Perfusion

Related to:

• Circulatory compromise (arterial or venous insufficiency)
• Tissue trauma or injury
• Smoking
• Malnutrition
• Sedentary lifestyle/Immobility
• Chronic conditions (diabetes mellitus, peripheral vascular disease, hypertension)
• Insufficient knowledge of how comorbidities affect wound healing

As evidenced by:

• Edema (peripheral edema, dependent edema)
• Skin discoloration (pallor, cyanosis, rubor, brownish discoloration in venous insufficiency)
• Paresthesia (numbness, tingling, burning sensations)
• Pain (intermittent claudication, rest pain)
• Altered skin characteristics (cool skin, dry skin, thin skin, hair loss on extremities)
• Delayed peripheral wound healing
• Decreased or absent peripheral pulses
• Intermittent claudication (leg pain with walking, relieved by rest)
• Abnormal ankle-brachial index (ABI < 0.9)

Expected outcomes:

• Patient will demonstrate adequate tissue perfusion as evidenced by effective wound healing and absence of infection.
• Patient will verbalize understanding of how comorbidities and lifestyle factors affect tissue perfusion and wound healing.

Assessment:

1. Assess and monitor the results of diagnostic tests. Review results of diagnostic tests related to peripheral perfusion:

• Skin perfusion pressure (SPP) test: Measures blood flow in small vessels of the skin to assess microcirculation.
• Transcutaneous oximetry (TcPO2) test: Measures oxygen tension in the skin, reflecting oxygen delivery to tissues.
• Ankle-brachial index (ABI): Assesses for peripheral artery disease.

2. Note signs of ineffective tissue perfusion in the wound or surrounding area. Assess for clinical signs of impaired peripheral perfusion in the wound and surrounding extremities:

• Skin discoloration: Pallor, cyanosis, rubor, brownish discoloration.
• Hair loss on legs and feet.
• Skin cool to the touch.
• Decreased or absent peripheral pulses (pedal, posterior tibial).
• Paresthesias.
• Edema.
• Muscle weakness in extremities.

These signs may indicate arterial or venous insufficiency, both of which can impair wound healing.

3. Consider comorbidities affecting perfusion. Assess for comorbidities that can compromise tissue perfusion, such as:

• Diabetes mellitus.
• Hypertension.
• Peripheral vascular disease.
• Cardiovascular disease.
• Renal disease.

These conditions can impair circulation and peripheral tissue perfusion, complicating wound healing.

Interventions:

1. Instruct on proper foot care. Educate patients, especially those with diabetes or PVD, on proper foot care to prevent injuries and promote foot health:

• Inspect legs and feet daily: Instruct patients to examine their feet and legs daily for blisters, cuts, redness, or skin irritation.
• Protect feet with well-fitting footwear: Advise wearing shoes or slippers at all times, even indoors, to prevent foot trauma.
• Avoid walking barefoot.

2. Encourage walking or exercise. Promote regular physical activity, as tolerated, to improve blood flow:

• Walking: Walking is generally recommended to improve circulation, unless the wound is located on the plantar surface of the foot.
• Ankle circles and seated calf raises: For patients with limited mobility, instruct on seated exercises to improve lower extremity circulation.

3. Elevate lower extremities and apply compression only for venous disease. Positioning and compression therapy recommendations vary depending on the underlying circulatory issue:

• Venous insufficiency: Elevate legs above heart level and apply compression stockings to reduce edema and improve venous return.
• Arterial insufficiency: Avoid leg elevation and compression, as these can further restrict arterial blood flow.

4. Stress smoking cessation. Emphasize the critical importance of smoking cessation for patients with vascular conditions. Smoking damages blood vessels, promotes plaque buildup, and significantly impairs tissue perfusion.

5. Refer the patient for hyperbaric oxygen therapy (HBOT). Consider referral to a wound care specialist or wound center for patients with wounds exhibiting delayed healing, particularly those with impaired tissue perfusion. HBOT may be beneficial for selected wounds to increase oxygen delivery to tissues and promote healing.

Knowledge Deficit

Knowledge deficit is a nursing diagnosis that addresses a patient’s lack of information or understanding related to wound care and management.

Nursing Diagnosis: Knowledge Deficit

Related to:

• Wound care process
• Importance of wound care
• Wound care resources

As evidenced by:

• Verbalization of lack of knowledge regarding wound care
• Requesting further information about wound care
• Nonadherence to prescribed wound care management plan
• Development of wound infection or worsening of wound complications

Expected outcomes:

• Patient will verbalize understanding of wound care management principles and procedures.
• Patient will demonstrate adherence to the prescribed wound care treatment plan.
• Patient will verbalize strategies to prevent wound infection and promote healing.

Assessment:

1. Assess the patient’s knowledge of wound care and healing. Evaluate the patient’s current understanding of wound care practices, wound healing processes, and infection prevention. Assess what the patient already knows about their wound and its care.

2. Ask the patient to demonstrate wound care. If the patient or caregiver will be performing wound care at home, have them demonstrate wound care techniques. Observe their technique and provide feedback and correction as needed.

3. Identify causes of misunderstanding about wound care. Explore potential barriers to understanding and adherence to wound care, including:

• Cultural beliefs: Cultural or traditional wound care practices may conflict with evidence-based recommendations.
• Misinformation: Patients may have misconceptions about wound care practices, such as the belief that wounds need to “breathe” or that hydrogen peroxide is beneficial for wound cleaning.
• Language barriers: Communication difficulties due to language differences can hinder effective patient education.
• Health literacy: Limited health literacy can make it challenging for patients to understand complex wound care instructions.

4. Assess for wound care resources. Evaluate the patient’s access to resources necessary for wound care management at home, such as:

• Financial resources: Wound care supplies, medications, and outpatient clinic visits can be costly. Assess the patient’s ability to afford necessary treatments.
• Transportation: Access to transportation for wound care appointments and obtaining supplies.
• Home support: Availability of caregiver support at home for wound care assistance.

Interventions:

1. Teach the patient about wound care and wound healing. Provide clear, concise, and individualized education about the patient’s specific wound care plan. Explain:

• Wound type and healing process.
• Purpose of each wound care procedure and dressing.
• Importance of infection prevention.
• Signs and symptoms of wound infection.
• Medications (if prescribed).
• Activity and mobility recommendations.
• Nutritional considerations.

2. Allow time for inquiries. Encourage questions and provide ample time for the patient and caregiver to ask questions and clarify any uncertainties. Address their concerns and provide reassurance.

3. Involve caregivers. If caregivers will be involved in wound care, include them in patient education sessions. Ensure caregivers are confident and competent in performing wound care procedures.

4. Emphasize practicing infection control measures and aseptic procedures in wound care. Reinforce the importance of infection control practices:

• Hand hygiene: Emphasize handwashing before and after wound care.
• Proper dressing change technique: Demonstrate and teach correct dressing change procedures to prevent wound contamination.
• Safe storage of wound care supplies: Instruct on proper storage of dressings and other wound care supplies to maintain sterility and prevent contamination.

5. Refer the patient to a social worker or case manager. If the patient has identified resource needs or financial concerns, refer them to a social worker or case manager. Social workers and case managers can assist patients in accessing resources such as home healthcare services, transportation assistance, durable medical equipment, and financial aid programs.

6. Refer to a dietitian. Refer patients with complex or chronic wounds to a registered dietitian for nutrition counseling. Dietitians can provide personalized dietary recommendations to optimize nutrition for wound healing, ensuring adequate intake of protein, vitamins, minerals, and fluids.