An abscess is a localized collection of pus surrounded by inflamed tissue that can occur anywhere in the body. This nursing diagnosis focuses on identifying and treating abscesses, managing pain, preventing complications, and promoting optimal healing outcomes.
Causes (Related to)
Abscesses can develop due to various factors that contribute to their formation and severity:
- Bacterial infections, most commonly Staphylococcus aureus
- Compromised immune system function
- Poor hygiene practices
- Trauma or injury to the skin
- Medical conditions such as:
- Diabetes mellitus
- HIV/AIDS
- Obesity
- Peripheral vascular disease
- Risk factors including:
- Intravenous drug use
- Recent surgery
- Poor nutrition status
- Chronic skin conditions
Signs and Symptoms (As evidenced by)
Abscesses present with characteristic signs and symptoms that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- Severe localized pain
- Warmth in the affected area
- Throbbing sensation
- Increased pain with movement
- General malaise
- Fever and chills
- Fatigue
- Decreased range of motion
Objective: (Nurse assesses)
- Fluctuant, raised area
- Erythema surrounding the affected area
- Local temperature elevation
- Swelling and induration
- Purulent drainage if draining
- Elevated temperature
- Elevated white blood cell count
- Decreased mobility of affected area
Expected Outcomes
The following outcomes indicate successful management of an abscess:
- The patient will demonstrate signs of healing within 72 hours of treatment
- The patient will maintain optimal pain control
- The patient will remain free from systemic infection
- The patient will demonstrate proper wound care techniques
- The patient will maintain adequate nutrition for healing
- The patient will avoid complications
- The patient will return to normal activities as healing progresses
Nursing Assessment
Monitor Vital Signs
- Check temperature, pulse, blood pressure, and respiratory rate
- Document fever patterns
- Note any signs of systemic infection
Assess Abscess Characteristics
- Measure size and extent
- Document location and appearance
- Note the presence of drainage
- Assess surrounding tissue
- Monitor for spreading infection
Evaluate Pain Status
- Assess pain intensity
- Document pain characteristics
- Note aggravating factors
- Evaluate the effectiveness of pain management
- Monitor impact on daily activities
Check for Complications
- Monitor for sepsis
- Assess for deep tissue involvement
- Watch for adjacent organ involvement
- Check for cellulitis
- Document any systemic symptoms
Review Risk Factors
- Assess medical history
- Document contributing conditions
- Note previous abscess history
- Review medication history
- Check immune system status
Nursing Care Plans
Nursing Care Plan 1: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to inflammatory process and tissue destruction as evidenced by patient reports of pain rated 7/10 and guarding of affected area.
Related Factors:
- Inflammatory process
- Tissue destruction
- Increased pressure from fluid accumulation
- Local nerve irritation
Nursing Interventions and Rationales:
- Assess pain characteristics and intensity regularly
Rationale: Enables appropriate pain management and treatment evaluation - Administer prescribed analgesics
Rationale: Provides pain relief and promotes comfort - Apply warm compresses as ordered
Rationale: Promotes circulation and comfort
Desired Outcomes:
- The patient will report pain level ≤3/10
- The patient will demonstrate improved comfort
- The patient will maintain optimal pain management
Nursing Care Plan 2: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection Spread related to the presence of pathogenic organisms as evidenced by localized abscess formation.
Related Factors:
- Presence of bacteria
- Break in skin integrity
- Compromised immune function
- Poor tissue perfusion
Nursing Interventions and Rationales:
- Maintain sterile technique during care
Rationale: Prevents cross-contamination and further infection - Monitor for signs of spreading infection
Rationale: Enables early intervention for complications - Educate about proper hygiene
Rationale: Prevents recurrence and promotes healing
Desired Outcomes:
- The patient will remain free from systemic infection
- Infection will remain localized
- The patient will demonstrate proper wound care technique
Nursing Care Plan 3: Impaired Skin Integrity
Nursing Diagnosis Statement:
Impaired Skin Integrity related to inflammatory process as evidenced by disruption of skin surface and presence of purulent drainage.
Related Factors:
- Inflammatory response
- Bacterial invasion
- Altered circulation
- Mechanical factors
Nursing Interventions and Rationales:
- Perform wound care as ordered
Rationale: Promotes healing and prevents complications - Document wound characteristics
Rationale: Monitors healing progress - Maintain optimal wound environment
Rationale: Facilitates healing process
Desired Outcomes:
- The wound will show signs of healing
- The patient will maintain intact surrounding skin
- The patient will demonstrate proper wound care
Nursing Care Plan 4: Hyperthermia
Nursing Diagnosis Statement:
Hyperthermia related to inflammatory process as evidenced by elevated temperature and increased WBC count.
Related Factors:
- Inflammatory response
- Infection
- Increased metabolic rate
- Dehydration
Nursing Interventions and Rationales:
- Monitor temperature regularly
Rationale: Tracks fever progression and response to treatment - Administer antipyretics as ordered
Rationale: Reduces fever and associated discomfort - Promote adequate hydration
Rationale: Supports temperature regulation
Desired Outcomes:
- Temperature will return to the normal range
- The patient will maintain adequate hydration
- The patient will remain free from complications
Nursing Care Plan 5: Knowledge Deficit
Nursing Diagnosis Statement:
Knowledge Deficit related to unfamiliarity with abscess care and prevention as evidenced by questions about self-care and prevention of recurrence.
Related Factors:
- Lack of exposure to information
- Misinterpretation of information
- Limited previous experience
- Anxiety about condition
Nursing Interventions and Rationales:
- Provide education about wound care
Rationale: Enables proper self-care - Teach prevention strategies
Rationale: Reduces risk of recurrence - Demonstrate proper hygiene techniques
Rationale: Promotes healing and prevents complications
Desired Outcomes:
- The patient will verbalize understanding of care instructions
- The patient will demonstrate proper wound care technique
- The patient will identify signs of complications
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Korownyk C, Allan GM. Evidence-based approach to abscess management. Can Fam Physician. 2007 Oct;53(10):1680-4. PMID: 17934031; PMCID: PMC2231432.
- Menegas S, Moayedi S, Torres M. Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians. J Emerg Med. 2021 Mar;60(3):310-320. doi: 10.1016/j.jemermed.2020.10.043. Epub 2020 Dec 6. PMID: 33298356.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
- Thomas O, Ramsay A, Yiasemidou M, Hardie C, Ashmore D, Macklin C, Bandyopadhyay D, Bijendra Patel, Burke JR, Jayne D. The surgical management of cutaneous abscesses: A UK cross-sectional survey. Ann Med Surg (Lond). 2020 Nov 27;60:654-659. doi: 10.1016/j.amsu.2020.11.068. PMID: 33304582; PMCID: PMC7718210.
