A wound is any skin breakdown or tissue injury that disrupts structural integrity and leads to functional loss. 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 due to trauma or surgery.
Wounds may also be classified due to cleanliness:
- Class 1 wounds (clean): Uninfected, with no inflammation, and primarily closed. Respiratory, genital, or urinary tracts are not affected.
- Class 2 wounds (clean-contaminated): Lack of unusual contamination. Affects the respiratory, genital, or urinary tracts in controlled conditions.
- Class 3 wounds (contaminated): Fresh, open wounds from poor sterile techniques or leakage. Incisions result in acute or lack of purulent inflammation.
- Class 4 wounds (dirty-infected): Result from poor interventions for traumatic wounds. Most commonly result from microorganisms present in perforated surgical sites.
Wound infection occurs when bacteria enter damaged skin and begin to proliferate. When the microorganism can penetrate the host’s defense mechanism (skin) and overwhelm the immune system and defense cells, infection occurs.
Poor aseptic technique and contamination cause wound infection. Pre-existing client conditions like diabetes mellitus or compromised immune systems may put the client at risk. Typically, an infection develops in 3 to 6 days following a skin injury.
Staphylococcus aureus (the most common skin flora), methicillin-resistant staphylococcus aureus (MRSA), and pseudomonas aeruginosa are the most common bacteria strains found in patients with infected wounds.
Symptoms of an infected wound include:
- Purulent discharge from the wound
- Skin discoloration
- Edema and swelling
- Foul smelling odor
- Warm, tender, painful, and inflamed skin
- Elevated white blood cell count
Tissue integrity restoration (wound healing) immediately takes place after skin injury. Any delay or disruption in the wound healing process can lead to infection. Wound healing has 4 main phases:
- Hemostasis: Cessation of bleeding (coagulation, platelet aggregation, and activation of intrinsic and extrinsic coagulation pathways)
- Inflammation: Immune system (neutrophils and macrophages) attempts to control the formation of infection in the wound
- Proliferation: Scar tissue development (granulation tissue fills the wound bed and epithelial cells cover the wound)
- Maturation: Collagen synthesis (collagen I replaces collagen III to close the wound)
Nursing Process
A wound can result from a variety of reasons and it’s important to make sure that wounds are cleaned and properly dressed to prevent the development of infection and additional damage.
The elimination of dead tissue, control of exudate, prevention of bacterial overgrowth, maintenance of adequate fluid balance, 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. Interventions may include surgical debridement, complex wound dressings, wound vacs, hyperbaric oxygen treatment, and more.
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
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
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
Related to:
- 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.
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
Related to:
- 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
- Britto, E. J., Nezwek, T. A., & Robins, M. (2022, June 5). Wound dressings – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK470199/
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Herman, T. F., & Bordoni, B. (2022, April 28). Wound classification – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK554456/
- Ignatavicius, MS, RN, CNE, ANEF, D. D., Workman, PhD, RN, FAAN, M. L., Rebar, PhD, MBA, RN, COI, C. R., & Heimgartner, MSN, RN, COI, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (9th ed., pp. 1386-1388). Elsevier.
- Labib, A. M., & Winters, R. (2021, December 29). Complex wound management. StatPearls. https://www.statpearls.com/ArticleLibrary/viewarticle/132786
- Nagle, S. M., Stevens, K. A., & Wilbraham, S. C. (2022, July 4). Wound assessment – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK482198/
- Negut, I., Grumezescu, V., & Grumezescu, A. M. (2018, September 18). Treatment strategies for infected wounds. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6225154/
- Ozgok Kangal, M. K., & Regan, J. P. (2022, May 8). Wound healing – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK535406/
- Silvestri, L. A., Silvestri, A. E., & Grimm, J. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
