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Wound Care & Infection: Nursing Diagnoses, Care Plans, Assessment & Interventions

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Written by
Kathleen Salvador, MSN, RN
Maegan Wagner, BSN, RN, CCM Avatar
Reviewed by
Maegan Wagner, BSN, RN, CCM

A wound is any damage to the skin, tissues, or organs. Compromised integrity of the skin, mucous membranes, or organs can result in a wound and infection.

Wounds may be acute or chronic as well as closed (under the skin’s surface, such as with hematomas) or open, where the skin is broken, and tissue may be exposed, such as with animal bites, lacerations, or surgical incisions.

In this article:

Wound Infection

When a pathogen can penetrate the host’s defense mechanism (skin) and overwhelm the immune system and defense cells, infection occurs. Poor aseptic technique and contamination are common causes of wound infection. Chronic conditions that weaken the immune system or slow healing, like diabetes mellitus or HIV, may put the patient at an increased risk for wound infection.

Wounds that are not properly treated can progress to serious or life-threatening infections, such as:

Wound Healing

Tissue integrity restoration (wound healing) begins immediately after skin injury. Any delay or disruption in the wound healing process can lead to infection.

Wound healing has 4 phases:

  • Hemostasis (occurs immediately): Blood vessel constriction, coagulation, and platelet aggregation occur to stop bleeding and form a clot to seal the wound.
  • Inflammation (0-4 days): The immune system (neutrophils and macrophages) attempts to control the formation of infection in the wound. Swelling and redness occur.
  • Proliferation (2-24 days): Granulation tissue fills the wound bed, and epithelial cells cover the wound.
  • Maturation (24+ days): Collagen continues to strengthen the wound, and a scar may form.

Types of Wound Healing

  • Primary intention: The edges of the wound are closed (approximated) using staples, sutures, glue, or steri-strips. This is commonly seen with lacerations or surgical wounds.
  • Secondary intention: If the wound cannot be closed, it heals by producing granulation tissue, such as with some pressure ulcers. This type of healing has a higher risk of infection.
  • Tertiary intention: This type of wound has to remain open or will be closed at a later time once the infection is resolved.

Factors Affecting Wound Healing

A combination of factors affects the body’s ability to heal. The nurse should consider the following:

Nursing Process

A wound can result from various causes. It’s crucial to ensure that damaged skin is properly cleaned and covered to prevent the development of infection and additional damage.

The elimination of dead tissue, control of exudate, prevention of bacterial overgrowth, nutrition and fluid balance, comorbidities, cost-efficiency, and manageability for the patient and/or nursing staff are all factors in wound care.

A consultation with a wound care specialist or wound care certified nurse should be considered to help manage complex or chronic wounds.

Nursing Assessment

The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to wound care and infection.

Review of Health History

1. Determine the patient’s general symptoms.
Symptoms of an infected wound include:

  • Purulent discharge from the wound
  • Skin discoloration
  • Swelling
  • Foul smelling odor
  • Warm, tender, painful, or inflamed skin

Concerning systemic symptoms that may signal severe infection include:

  • Fever
  • Chills
  • Lymphadenopathy near the wound

2. Assess the underlying cause.
Wounds can occur due to various causes, from accidents to immobility to surgery. Wound infection occurs when bacteria enter damaged skin and begin to proliferate. Poor hygiene, inefficient wound care, and contamination can cause wound infection. The risk for infection is higher if: 

  • The wound is large, deep, or jagged
  • Dirt or animal/human saliva enters the wound
  • A rusty nail or other contaminated object penetrates the skin

3. Identify the patient’s medical risk factors.
Pre-existing patient conditions like diabetes mellitus or immunosuppression may put the patient at risk for wounds. Other risk factors include:

4. Review the patient’s surgical record.
Patients undergoing surgical procedures have an increased risk of wound infection. Note the following surgical characteristics:

  • Poor surgical technique
  • Prolonged hospital stay 
  • Intraoperative contamination 
  • Hypothermia

5. Review the patient’s medication list.
Immunosuppressants or other medications may delay wound healing. Note the following medications:

  • Hydroxyurea
  • Chemotherapeutic drugs
  • Steroids
  • NSAIDs
  • DMARDs (disease-modifying antirheumatic drugs)

6. Inquire about the patient’s nutritional status.
Protein deficiency and inadequate vitamins and minerals will impede wound healing. Water is also crucial to promote blood circulation, tissue oxygenation, and skin elasticity. Ask the patient about their dietary and water intake.

Physical Assessment

1. Determine the type of the wound.
Wound type determination is crucial as this affects the type of wound care required. The nurse is most likely to encounter the following types of wounds:

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

2. Assess and document wound findings.
Assess and document wound characteristics at each dressing change or per facility protocol, including:

  • Location
  • Size (length x width x depth)
  • Drainage present
  • Wound bed (granulation tissue, slough, eschar, etc.)
  • Wound edges and surrounding skin (periwound)
  • Presence of tunneling or undermining
  • Signs of infection

3. Utilize the acronym T.I.M.E. for assessment.
The nurse can remember the acronym T.I.M.E when evaluating wounds. It stands for:

  • Tissue: Epithelial (pink) or granulation (red) tissue indicates healing, while slough (yellow/gray) or necrotic (black) tissue indicates dead tissue.
  • Infection/Inflammation: Inflammation is expected for healing, but infection is not. Bacteria present in the wound may delay healing and spread, causing systemic infection.
  • Moisture: A moist environment allows for cleansing, provides nutrients, and promotes tissue repair. Excess moisture can cause maceration of the skin, while too little causes the wound to dry out. The nurse should assess for purulent (thick, yellow, green), serous (thin, yellow-clear), or sanguinous (bloody) exudate.
  • Edges: Monitor the wound’s edges for discoloration, tunneling, and undermining that indicate poor healing. Also, assess the periwound for erythema, swelling, or maceration.

4. Ask the patient to rate their pain.
Many wounds cause pain. Pain assessment tools can help evaluate the severity of wound pain and determine if current treatment regimens are effective. 

Diagnostic Procedures

1. Obtain a sample for culturing.
A swab of the wound is the easiest and most cost-effective method to identify the pathogen-causing infection.

2. Prepare for biopsy or aspiration.
A tissue biopsy is the most accurate method to detect bacteria, though it is invasive and can be painful and costly. Aspiration of fluid is reserved to assess for microbes below the surface of the skin, such as with an abscess.

3. Send samples for further investigation.
The following laboratory values can be assessed for the presence of infection:

  • White blood cell (WBC) count
  • C-reactive protein (CRP)
  • Procalcitonin (PCT)
  • Presepsin
  • Microbial DNA
  • Bacterial protease activity (BPA)

4. Prepare the patient for imaging.
Imaging tests can be performed for the following reasons:

  • Plain X-rays: soft-tissue infection
  • Computed tomography: soft-tissue infection or intra-abdominal abscesses
  • Magnetic resonance imaging: extent of infection in tissue and bone
  • Ultrasound: skin and soft-tissue infection

5. Determine issues with peripheral perfusion.
Assess peripheral perfusion using the ankle-brachial and toe-brachial indexes (ABI/TBI) if peripheral artery disease is suspected. Perform monofilament testing to determine pressure sensitivity, especially if the patient has diabetes or peripheral neuropathy.

Nursing Interventions

Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to wound care.

Provide Appropriate Wound Care

1. Remove nonviable tissue.
Debridement is necessary for some wounds to remove necrotic tissue for healing to occur. Debridement methods include:

  • Autolytic debridement: moist topical dressings 
  • Enzymatic debridement: prescribed ointments
  • Sharp wound debridement: surgical procedure performed by a trained professional 

2. Control moisture.
Moisture is necessary for healing, but excessive drainage must be controlled. The nurse may consider hydrofiber or alginate dressings to control moisture. Some wounds may require frequent dressing changes.

3. Pack the wound as needed.
Wounds with tunneling should be packed with moistened sterile gauze or hydrogel-impregnated dressings to keep the wound bed moist.

4. Protect the periwound skin.
The nurse can protect the skin around wounds by applying barrier creams/powders, protective wipes, or barrier wafers to the area.

5. Apply a wound vac.
Wound vacs (vacuum-assisted closure) are an option for open wounds, skin grafts, flaps, or pressure ulcers. They use a foam dressing and suction to remove fluid and decrease pressure to promote healing and wound closure.

6. Manage pain.
Wound care can be painful for the patient, so the nurse should premedicate with prescribed analgesics prior to performing dressing changes.

Prevent or Manage Infection

1. Perform aseptic or clean technique as required.
Aseptic technique, which uses sterile gloves and equipment to prevent introducing bacteria, is necessary for some wounds, such as burns or surgical wounds. Clean technique, on the other hand, uses non-sterile gloves and equipment and is often used for pressure ulcers and simple wounds such as skin tears.

2. Administer antibiotics as ordered.
Wounds displaying signs of infection may require topical antibiotics or silver dressings while signs of systemic infection require oral or IV antibiotic therapy. Targeted antimicrobial therapy is administered based on culture and sensitivity results.

3. Stress the importance of cleaning wounds immediately.
When skin breakdown occurs, cleaning the wound immediately with soap and water is paramount to reduce the risk of infection. This is especially important with “dirty” wounds such as an animal bite or if foreign material like glass, dirt, metal, or gravel enters the wound. If the patient is unable to clean the wound properly, encourage them to seek medical assistance. 

4. Do not use peroxide or alcohol to clean wounds.
Remind the patient to never clean a wound with hydrogen peroxide or rubbing alcohol as these products are too harsh and can damage healthy tissue, delaying healing.

5. Emphasize hand hygiene.
It is vital to wash the hands before and after providing wound care.

6. Keep wounds covered.
Some patients believe that wounds need to “breathe” to heal, but this is a myth. Educate the patient that wounds need to stay covered with a dressing as moisture helps a wound heal and prevents bacteria from entering the wound.

Promote Wound Healing

1. Promote nutrition and hydration.
A high-protein diet is recommended for tissue growth and repair. If consuming enough protein is difficult for the patient, a protein-enriched drink can be used as a supplement. Vitamin C is also an important antioxidant that promotes tissue regeneration. Encourage adequate fluid intake for nutrient and oxygen delivery to the wound bed. 

2. Educate on strategies to reduce skin breakdown.
The nurse can educate the patient and family on tips to reduce further tissue injury, such as:

  • Minimize pressure with frequent turning and repositioning
  • Always wear shoes or socks to protect the feet
  • Control swelling in the lower extremities with compression stockings
  • Keep skin clean and dry, especially if the patient is incontinent

3. Document the wound and wound care provided.
Complete documentation of the wound site should occur with every dressing change. Include any changes in size, exudate, color, smell, and the type of cleanser and dressing applied. Some facilities may utilize photographs to document wound progression.

4. Refer to a wound care clinic.
Chronic or non-healing wounds may require referral to a wound care clinic for assessment and specialty wound dressings or other treatments, such as hyperbaric oxygen therapy.

Nursing Care Plans

Once the nurse identifies nursing diagnoses for wound care, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for wound care.

Acute Pain

Acute pain associated with wound infection is caused by nervous system dysfunction (neuropathic pain) or tissue damage (nociceptive pain).

Nursing Diagnosis: Acute Pain

  • 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

Expected outcomes:

  • Patient will be able to verbalize the resolution of pain to the wound.
  • Patient will report a decrease in pain on a 0-10 scale after the administration of pain medication.
  • Patient will be able to perform daily activities without complaints of pain in the wound.

Assessment:

1. Assess using a pain scale.
Pain is subjective and requires a description from the patient. Use a pain scale to let the patient communicate the intensity of wound pain.

2. Identify the type of pain.
Wound pain can originate from tissue injury (nociceptive pain) or abnormal functioning of the nervous system (neuropathic pain). Ask the patient to describe the pain.

3. Palpate the surrounding skin for tenderness or pain.
The surrounding skin of the wound can be tender and painful upon palpation. Initially, pain is a common reaction to an injury, but persistent pain may also be an indication of an infection.

Interventions:

1. Premedicate prior to wound care.
Wound care can be painful. Administer analgesia and allow it to take effect before providing wound care interventions.

2. Educate on pain control.
Ensure the patient understands their prescribed pain medication regimen. Unresolved pain can negatively impact wound healing. NSAIDs can control inflammation while neuropathic pain dulls burning and discomfort from nerve pain. Break-through pain may need to be controlled with opioids.

3. Prevent surrounding symptoms.
Excessive dryness, drainage, edema, and skin maceration can also contribute to wound pain. Prevent these complications by keeping the extremity elevated and changing wound dressings at appropriate intervals.

4. Splint the wounded site.
A splint will prevent the wounded part from moving and protect it against further injury and pain.

Impaired Skin Integrity

Impaired skin integrity results in damage to the skin allowing bacteria to enter and cause infections.

Nursing Diagnosis: Impaired Skin Integrity

  • Skin injury from shearing, pressure, or trauma
  • Burns
  • Moisture
  • Surgical incisions
  • Impaired circulation
  • Poor skin turgor
  • Edematous tissues
  • Conditions that delay the wound healing process (such as diabetes mellitus)

As evidenced by:

  • Discharge from the wound
  • Skin discoloration
  • Erythema
  • Foul smelling odor
  • Tight skin sutures (for surgical wound infection)
  • Warm, tender, painful, and inflamed skin
  • Prolonged or delayed healing

Expected outcomes:

  • Patient will remain free of purulent drainage in the wound.
  • Patient will demonstrate clean wound edges.
  • Patient will verbalize an understanding of wound care management.
  • Patient will be able to participate in performing wound care.

Assessment:

1. Assess the wound with each dressing change.
Assess the size, color, depth, and presence of drainage or tunneling to determine whether treatment is effective or not.

2. Classify the type of wound.
Identifying the type of wound is necessary for successful wound repair. Wounds can be categorized into five groups: avulsion, abrasion, puncture, laceration, and incisions. It can also be categorized according to duration (acute or chronic), skin damage (open or closed), or cleanliness and condition (from clean to infected).

3. Use a risk assessment tool.
An evaluation of risks can be done by taking a patient’s medical history, performing physical exams, and running lab tests. Alcohol, smoking, and comorbidities (such as diabetes and hypertension) are common risk factors for poor wound healing.

4. Obtain a wound culture.
Wounds can be swabbed to monitor for the presence of bacteria such as MRSA which can guide treatment.

Interventions:

1. Disinfect the site with antiseptic.
Use antiseptic wound cleansers to clean the wound. Refrain from using alcohol or harsh chemicals on the skin.

2. Decontaminate the skin injury.
Remove any foreign objects to decontaminate the wound. Complete in a timely and consistent manner to revascularize and remove any necrotic tissue, which may lead to infections.

3. Remove any dying tissue.
Debridement will ensure that the wound is kept free of necrotic tissue, which could be a source of pathogenic infections.

4. Apply appropriate wound dressings.
Non-adherent saline wraps (saline-soaked gauze) and absorbent material are effective to prevent wound infection and promote tissue re-epithelialization. Secure the dressing with soft gauze tape. Asepsis in wound care will prevent further contamination of wounds.

5. Manage the wound based on the stages of healing.
At various phases of healing, a wound will require changes to the wound care treatment such as changes in cleansers, ointments, or dressings.

6. Keep the wound moist.
For some wounds, a moist environment speeds up the healing of a wound by maintaining hydration, boosting angiogenesis (bloody supply) and collagen formation, and accelerating the breakdown of dead tissue and fibrin. It also alleviates the pain and enhances the appearance of the wound.

7. Apply topical antibiotics and antiseptics as recommended.
Topical antibiotics eliminate bacteria, whereas topical antiseptics stop the spread of microbes (such as chlorhexidine and iodine solutions). These treatments are covered by a secondary dressing suitable for use in infected wounds. Use carefully as directed by the doctor or wound care specialist.

8. Remove sutures for surgical wounds.
Sutures or adhesive strips should be removed 10–14 days after their application (or 3-5 days if the wound is on the head) once the skin begins to approximate. Adhesive glue will naturally peel off after 1-2 weeks.

9. Refer to a wound care specialist.
Refer to a wound care professional if the wound has not begun to heal after two weeks or has not fully healed after six. The care and treatment of acute, chronic, and non-healing wounds require the expertise of a wound specialist.

Ineffective Protection

Some patients may be unable to guard against skin breakdown, increasing the risk of wound development and infection.

Nursing Diagnosis: Ineffective Protection

  • Inadequate primary defenses
  • 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.
A wound that is not properly treated can result in a life-threatening infection. Changes in the patient’s temperature, pulse rate, and blood pressure can indicate systemic toxicity.

2. Assess and monitor the patient’s nutritional status.
The patient’s nutrition and hydration status plays an important role in ensuring protection against infection and skin breakdown. Proper hydration and intake of nutrients ensure skin elasticity, collagen production, tissue regeneration, and immune system function.

3. Assess the patient’s ability to perform ADLs.
The nurse should assess the patient’s ability to ambulate/reposition to protect themselves against pressure injuries. Assess if the patient can perform basic ADLs such as bathing and toileting to ensure the skin is kept clean and dry from sweat, dirt, urine, and feces.

Interventions:

1. Administer antibiotic therapy as indicated.
Antibiotic therapy is prescribed to fight off an existing infection or as prophylaxis against one. This will promote protection from further complications.

2. Refer the patient to a dietitian.
A dietitian can help formulate a well-balanced meal plan for the patient that supports the immune system and promotes optimal wound healing.

3. Educate the patient about infection control measures.
Infection control measures like handwashing are crucial to prevent introducing bacteria into a wound. Educate the patient or caregiver to always wash their hands before and after touching a wound.

4. Provide proper wound care.
Ensure wound care is appropriate for the type of wound. If the patient or caregiver provides wound care, demonstrate how to clean and cover the wound effectively. Educate on signs of wound infection, such as redness or swelling, and when to contact their healthcare provider.

Ineffective Tissue Perfusion

Certain comorbidities and lifestyle factors increase the risk of poor tissue perfusion, complicating wound healing.

Nursing Diagnosis: Ineffective Tissue Perfusion

  • Inadequate primary defenses
  • Circulatory compromise
  • Tissue trauma or injury
  • Smoking
  • Malnutrition
  • Sedentary lifestyle/Immobility
  • Chronic conditions (diabetes, vascular disease, etc.)
  • Insufficient knowledge of how comorbidities affect wound healing

As evidenced by:

  • Edema
  • Skin discoloration
  • Paresthesia
  • Pain
  • Altered skin characteristics
  • Delayed peripheral wound healing
  • Decreased or absent peripheral pulses
  • Intermittent claudication
  • Abnormal ankle-brachial index

Expected outcomes:

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

Assessment:

1. Assess and monitor the results of diagnostic tests.
A skin perfusion pressure test measures the health of blood vessels, and a transcutaneous oximetry test measures the amount of oxygen in the skin, which can be useful in predicting wound healing.

2. Note signs of ineffective tissue perfusion in the wound or surrounding area.
Skin discoloration, hair loss on the legs, skin cool to the touch, decreased pulses, paresthesias, edema, and muscle weakness are signs of venous or arterial insufficiency that may prolong wound healing.

3. Consider comorbidities affecting perfusion.
Chronic conditions such as diabetes mellitus, hypertension, or vascular diseases affect circulation and peripheral tissue perfusion, which may complicate wound healing.

Interventions:

1. Instruct on proper foot care.
Patients with diabetes or conditions that affect circulation are vulnerable to injury and should keep their feet protected with well-fitting footwear. Instruct on inspecting the legs and feet daily for blisters or skin irritation.

2. Encourage walking or exercise.
Walking is generally recommended to improve blood flow as long as the wound is not located on the bottom of the feet. If ambulation is painful or unsafe, instruct the patient on exercises such as ankle circles or seated calf raises.

3. Elevate lower extremities and apply compression only for venous disease.
Elevation of the legs and compression stockings are recommended for venous insufficiency to relieve edema that could worsen perfusion and wound healing. This is the opposite for arterial insufficiency, as elevation and compression restrict blood flow.

4. Stress smoking cessation.
Quitting smoking is crucial for patients who are affected by vascular conditions, as smoking damages blood vessels and contributes to plaque buildup, inhibiting tissue perfusion.

5. Refer the patient for hyperbaric oxygen therapy (HBOT).
Wounds that exhibit delayed healing require the attention of a wound care specialist and may benefit from HBOT, which increases oxygen delivery to tissues.

Knowledge Deficit

Knowledge deficit associated with wound care can be caused by the lack of or insufficient knowledge about wound care.

Nursing Diagnosis: Knowledge Deficit

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

As evidenced by:

  • Verbalization of lack of knowledge
  • Requesting further information
  • Nonadherence to wound care management
  • Development of wound infection or worsening complication

Expected outcomes:

  • Patient will be able to verbalize an understanding of wound care management.
  • Patient will demonstrate adherence to the wound care treatment plan.
  • Patient will verbalize strategies to prevent wound infection.

Assessment:

1. Assess the patient’s knowledge of wound care and healing.
Patients’ knowledge about wound care and wound healing will determine the type of teaching the patient needs.

2. Ask the patient to demonstrate wound care.
Letting the patient or caregiver demonstrate wound care will allow the nurse to observe the adherence to proper wound care techniques. The nurse can then provide feedback.

3. Identify causes of misunderstanding about wound care.
Cultures and beliefs about wound care practices can affect the acceptance and adherence to treatment.

4. Assess for wound care resources.
Chronic wounds can be expensive, especially wound vac treatments, surgical procedures, and frequent outpatient wound care follow-up visits. Patients who cannot afford treatments may not adhere, worsening outcomes. Assess the need for financial and other resources.

Interventions:

1. Teach the patient about wound care and wound healing.
Ensure the patient understands their specific plan of care. Educate on why certain supplies are used and why techniques are important to prevent infection.

2. Allow time for inquiries.
Providing time for the patient and caregiver to clarify can build trust and decrease misinformation. It will also encourage cooperation between the patient and caregiver.

3. Involve caregivers.
Many wounds may be difficult for patients to reach or see. Ensure caregivers are confident in their abilities to provide adequate wound care.

4. Emphasize practicing infection control measures and aseptic procedures in wound care.
Promote hand hygiene before touching wounds and after touching soiled dressings. Instruct on how to store supplies and how to perform wound dressing changes to prevent introducing bacteria.

5. Refer the patient to a social worker or case manager.
Social workers/case managers promote health by assisting patients in receiving resources such as home health care, transportation, equipment, and more.

6. Refer to a dietitian.
Patients with both acute and chronic wounds should receive appropriate nutrition counseling since dietary habits can affect wound healing. Proper skin and wound healing require adequate intake of protein, vitamins, and fluids.

References

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Kathleen Salvador, MSN, RN
Kathleen Salvador is a registered nurse and a nurse educator holding a Master’s degree. She has more than 10 years of clinical and teaching experience and worked as a licensed Nursing Specialist in JCI-accredited hospitals in the Middle East. Her nursing career has brought her through a variety of specializations, including medical-surgical, emergency, outpatient, oncology, and long-term care.