Abscess Nursing Diagnosis and Nursing Care Plan

Abscess Nursing Care Plans Diagnosis and Interventions

Abscess Nursing Care Plans Diagnosis and Interventions

An abscess appears like a large and deep bump or mass within or underneath the tissue of the body. An abscess is usually a collection of pus made up of living and dead white blood cells, fluid, bacteria, and dead tissue.

An abscess can be formed in the skin making it visible or in any part of the body which may cause tissue or organ damage.

Abscesses have become more common in recent years making frequent visits to the emergency department in the United States from 2005 at 3.2 million cases.

Signs and Symptoms of Abscess

Signs and symptoms of abscess vary depending on its location in the body or underneath the tissues such as

  • raised round lump with redness and swelling
  • the skin over the center may be thin with a pinpoint opening (punctum)
  • skin is tender and warm to touch
  • may look yellow or white due to the collection of pus underneath
  • pain in the area and surrounding tissue
  • severe toothache and sensitivity for mouth abscess
  • swelling of the gums, jaw, or cheeks
  • dysphagia and difficulty in opening the mouth
  • loss of appetite and weight loss
  • pain and tenderness in the area for deeper abscess
  • fever and chills
  • diaphoresis and fatigue

Causes of Abscess

Abscess forms when the tissue of the body becomes infected and the immune system acts to fight the infection by containing it.

It is usually caused by bacterial infections such as Staphylococcus aureus and Streptococcus pyogenes. When the bacteria enter the body, the white blood cells fight and create a collection of pus containing the bacteria, white blood cells, and dead tissue causing the abscess and death of nearby tissues.

Skin abscess is usually from a cut or any opening in the skin which allows the bacteria to enter and cause an infection. Internal abscesses are often caused by a complication of an existing condition or infection. Obstruction in the sebaceous gland, sweat glands, hair follicle, or a pre-existing cyst can also cause an abscess

Types of Abscess

Abscess are of different types depending on their location, such as

  • Skin Abscess. These are superficial also called cutaneous abscesses usually found under the skin.
  • Armpit abscess. Hidradenitis suppurativa (HS) usually causes the armpit abscess from red and tender bumps in the armpit.
  • Breast abscess. This often occurs in breastfeeding women or from untreated breast infections.
  • Anorectal abscess. Perianal abscess affects the skin around the anus. Pilonidal abscess affects the skin of the creases around the buttocks.
  • Boils. Small and painful bumps or nodules at the site of the sweat gland or hair follicle affecting the surrounding tissue.
  • Furuncles. This is caused by an infected hair follicle filled with pus affecting the surrounding tissue.
  • Carbuncles. This is the term used for a cluster of furuncles.
  • Mouth Abscess. It usually affects the teeth, gums, and throat.
  • Gingival abscess. It is also called a gum abscess because it affects the gums.
  • Periapical abscess. This forms at the tip of the tooth roots from dental injuries or cavities.
  • Periodontal abscess. This affects the bones and tissues that support the teeth from periodontitis or gum disease.
  • Tonsillar abscess. It is a pocket of pus behind the tonsils and is common among adolescents and young adults.
  • Peritonsillar abscess. It is quinsy or a build-up of pus between the tonsils and the wall of the throat.
  • Retropharyngeal abscess. This is found at the back of the throat, forming when the lymph nodes become infected.
  • Internal Abscess. It occurs less frequently and can be difficult to diagnose.
  • Abdominal abscess. It is located inside or near the liver, kidneys, pancreas, or other organs.
  • Spinal cord abscess. This usually occurs from an infection affecting the spinal cord.
  • Brain abscess. This may form from an infection in the brain, wound, or bloodstream entering the brain.
  • Bartholin’s cyst. Found inside one of Bartholin’s glands at the opening of the vagina.
  • Incisional abscess. It is usually presented as redness and swelling at the margins of surgical incision with purulent discharge.

Risk Factors to Abscess

Generally, people with weakened immune systems have an increased risk of acquiring certain abscesses more often because of the body’s decreased ability to ward off infections. This also includes

  • Exposure to an unsanitary environment
  • Exposure to persons with Staphylococcus infections or other types of skin infection
  • Poor hygiene
  • People with chronic skin disease
  • Poor circulation and obesity
  • Alcoholism, smoking, or IV drug abuse
  • People who had severe burns or trauma
  • People taking chronic steroid therapy and chemotherapy
  • People with cancer, diabetes, AIDS, sickle cell disease, peripheral vascular disorder, Crohn’s disease, and ulcerative colitis.

Complications of Abscess

An abscess may cause serious complications, including the following:

  • Febrile disease. Bacterial causes are usually present with high-grade fever and may lead to mortality if left untreated.
  • Sepsis. It is the body’s life-threatening response to infection, also called blood poisoning. When the bacteria move out of the affected tissue and the existing infection triggers an extreme immune response resulting in sepsis.
  • Endocarditis. The common cause of endocarditis is bacterial infections from a dental abscess and undetected tooth infection. Most bacterial cardiac infection such as abscess formation is associated with a high rate of complications and death.
  • Multiple abscesses or carbuncles. These are clusters of furuncles or boils that can cause a secondary infection such as cellulitis making it more painful.
  • Necrosis of the tissue. Liquefactive necrosis happens when an abscess with lots of inflammatory cells destroys the surrounding tissues into a liquid viscous mass.
  • Osteomyelitis. It is a serious bone inflammation that can result from an abscessed tooth or infected tissue.
  • Spread of infection. Infection can spread to the surrounding tissues and into the bloodstream causing acute febrile disease, lymph node involvement, sepsis, necrotizing fasciitis, and even death.

Diagnosis of Abscess

There are several tests available to diagnose and confirm an abscess depending on its location such as

  • Medical history. A complete medical history including past and present health conditions or infections and substance abuse must be disclosed because intravenous drug use has high rates of reported abscess cases.
  • Physical exam. An assessment of the area including the reported pain, signs and symptoms associated, palpation of the affected area, and lymph node involvement. A deeper or internal abscess may be difficult to assess and may need an imaging test.
  • Imaging test. This is used for the internal abscess to confirm the extent of the infection.
  • X-ray. This is used specifically for those with a history of intravenous drug use to check for any needle fragments, especially if fever is present to rule out endocarditis.
  • Ultrasound. It is the safest medical imaging test to determine the extent of pus formation and differentiate it from other conditions like cysts, cellulitis, and fasciitis.
  • CT scan. Create extensive images of the affected area with a cross-section view to check for deep tissue abscesses and organ involvement.
  • MRI scan. Create a clear image of the internal organs and structures involved.
  • Culture. Used to determine the causative agent and the appropriate treatment and antibiotics to be used.

Treatment for Abscess

A small superficial abscess may resolve on its own and drain spontaneously, however, it should not be poked, squeezed, or burst intentionally because the bacteria may spread easily causing another infection. The following interventions can help in relieving and getting rid of an abscess.

  • Medications. Used to relieve signs and symptoms of an abscess.
  • Analgesics. Given for moderate to severe pain as temporary relief.
  • Antibiotics. Broad-spectrum antibiotics may be given to treat the infection. For recurrent and unresponsive abscesses, a culture may be performed to determine the causative agent and give a specific antibiotic for the patient. Some people have methicillin-resistant Staphylococcus aureus (MRSA) and this should be determined by the culture of the pus.
  • Wound care. Applying a warm compress on the abscess may help relieve and shrink the abscess. Clean it with mild soap and water and keep the dressing clean.
  • Incision and Drainage. A local numbing agent will be applied and an incision will be made to allow the pus to drain. The open wound will be washed with saline and packed with surgical material to allow proper healing and prevent recurring.
  • Dental management. For dental abscesses, the dentist may perform surgical drainage procedures such as tooth extraction or root canal to treat the abscess and infection.
  • Needle aspiration. This may be performed for internal abscess using local or general anesthesia depending on the location. It will be guided with an ultrasound or CT scan using a drainage catheter allowing the abscess to drain.

Nursing Diagnosis for Abscess

Nursing Care Plan for Abscess 1

Hyperthermia

Nursing Diagnosis: Hyperthermia related to inflammatory process secondary to tooth abscess as evidenced by the elevated temperature at 104 degrees Fahrenheit and loss of appetite.

Desired Outcomes:

  • The patient will be able to display normal body temperature after 4 hours of nursing interventions.
  • The patient will be able to eat adequately nutritious food to heal properly.
Abscess Nursing InterventionsRationale
Assess and monitor the patient’s vital signs, especially the temperature every hour.This will help the nurse monitor progress in nursing management. 
Assess the patient’s mouth, teeth, and gums for color, moisture, texture, irritation, and location of the abscess using a padded tongue depressor.Proper inspection of the oral cavity will give the nurse an area of focus for treatment. Using a tongue depressor will give the nurse a better view of the oral cavity.
Assess the patient’s nutritional status, the pattern of intake, hydration, and the factors affecting those mentioned above.Those factors affecting nutritional intake and hydration should be properly addressed because they will help the patient heal properly.
Provide a mouth care routine and use warm saline to rinse the mouth. Use a soft-bristled toothbrush at regular intervals or every meal.These measures promote good oral hygiene and prevent the build-up of bacteria.
Apply a warm compress to the affected cheeks with the abscess.This helps relieve the swelling and pain that may also cause discomfort and fever.
Provide a tepid sponge bath, a cooling blanket, thin-loose clothing, and a comfortable environment.These measures will help in the reduction of the patient’s fever while establishing a comfortable environment.
Administer antipyretics and antibiotics as ordered.Antipyretics must be given while waiting for the antibiotics to take effect. The fever will resolve if proper antibiotics were given.
Referral to the Dentist for proper management of dental abscess.This should be done immediately to prevent the spread of infection that may lead to complications like endocarditis and sepsis.

Nursing Care Plan for Abscess 2

Impaired Swallowing

Nursing Diagnosis: Impaired Swallowing related to edema secondary to mouth abscess as evidenced by gagging and choking.

Desired Outcomes:

  • The patient will be able to take food with an adequate amount of nutrients to help with the healing process.
  • The patient will maintain adequate nutrition and hydration.
Abscess Nursing InterventionsRationale
Assess the patient’s impaired swallowing by using the Dysphagia Screening Test by asking the patient to cough, swallow, raise the tongue, clear throat, and drink fluid.This will help the nurse determine if the patient can tolerate solid food or will be needing alternative feeding and food preparation.
Assess the degree of swelling, the location, and the characteristic of the abscess.This will help the nurse provide management on the unaffected side to prevent a sudden burst of the abscess.
Assist the patient in a sitting or high Fowler’s position while feeding for up to 30 minutes after feeding.These positions maintain a patent airway and prevent aspiration while feeding and regurgitation after feeding.
Palpate the neck and massage the sides of the neck before feeding.Palpating the neck will allow the nurse to determine the degree of swelling. Massaging the neck before feeding will help stimulate the swallowing reflex.
Start feeding by introducing liquids first then transitioning to a soft diet then solid foods as tolerated.Starting with a liquid diet will help the nurse determine the patient’s ability to swallow before gradually transitioning to solid food as the swelling subside.
Prepare for tube feeding, parenteral nutrition, or IV fluids as ordered with a strict aseptic technique.This might be needed if the patient cannot tolerate soft and solid foods. IV fluids for adequate hydration.
Administer analgesics, anti-inflammatories, and antibiotics as ordered.Analgesics will help the patient with the discomfort and pain while feeding. Anti-inflammatory to decrease swelling. Antibiotics to treat the mouth abscess relieving the associated edema.
Referral to a nutritionist or dietitian.These professionals will give proper nutrition and food preparation guides to the patient.

Nursing Care Plan for Abscess 3

Impaired Tissue Integrity

Nursing Diagnosis: Impaired Tissue Integrity related to impaired circulation secondary to skin abscess as evidenced by discoloration in the affected area.

Desired Outcomes:

  • The patient will be able to restore adequate tissue perfusion as evidenced by normal skin color in the affected area.
  • The patient will maintain intact tissue integrity with the healing of skin abscess.
Abscess Nursing InterventionsRationale
Assess the patient’s skin, taking note of the skin turgor, sensation, location, characteristics, and the degree of tissue involvement of the skin abscess.This will help the nurse determine the source of impaired circulation and have data for comparison of continuous circulation impairment or progress after the nursing interventions.
Assess the vital signs and pain level of the patient.This will be the basis for determining an ongoing infection and relieving symptoms after the interventions.
Assess the patient’s range of motion on the affected part and frequent repositioning.A limited range of motion may increase the patient’s risk of developing tissue damage and pressure ulcers, especially along the bony prominences.
Assist the patient in the application of a warm compress on the abscess.Applying a warm compress on the abscess may help relieve pain, shrink the abscess, and improve circulation on the affected part due to its vasodilating effect.
Educate the patient about proper wound cleaning using mild soap and warm water with a clean or sterile dressing.Wound cleaning with warm water promotes vasodilation improving the circulation to the affected part. Proper wound cleaning and dressing promote healing and prevent the spread of infection.
Assist and instruct the patient to reposition the affected part frequently.Repositioning promotes adequate perfusion and circulation.
Educate about adequate nutrition and hydration.This will boost the immune system and speed up the healing process. Hydration promotes adequate skin perfusion and improves circulation.
8. Administer antibiotics as ordered.Skin abscesses will completely heal with proper antibiotic administration.

Nursing Care Plan for Abscess 4

Fatigue

Nursing Diagnosis: Fatigue related to increased metabolic rate secondary to infection as evidenced by low energy and general discomfort.

Desired Outcomes:

  • The patient will be able to express reduced feelings of fatigue and increased energy.
  • The patient will be able to engage in activities of daily living without being exhausted.
Abscess Nursing InterventionsRationale
Assess the patient’s current level of fatigue by using the short questionnaire of the Fatigue Severity Scale (FSS) to rate the severity of fatigue symptoms.This questionnaire will determine the current level of the patient’s fatigue and compare it after nursing interventions to determine improvements.
Assess the vital signs and laboratory values.The increased metabolic rate may increase body temperature, pulsations, and demand for oxygen which is reflected in the patient’s vital signs. Laboratory values can determine existing conditions that may cause easy fatigability like anemia.
Assist the patient in developing an activity plan for the day. Schedule rest periods in between activities.Involving the patient in activity planning will help the nurse establish a realistic activity schedule within the patient’s capacity and level of energy increasing compliance. Giving rest periods prevents exhaustion and increases fatigue.
Assist the patient in passive range of motion exercises and gradually increase to active range of motion as tolerated.The gradual transition of activities will help the nurse gauge the patient’s readiness before increasing to the next level of exercise.
Educating and assisting the patient with the proper use of assistive devices.Increase the patient’s tolerance and compliance to the scheduled activities of daily living, reducing the patient’s effort and exhaustion from activities.
Encourage adequate nutrition and hydration.Maintaining a healthy diet and adequate hydration will increase the patient’s immune system which can greatly help in the patient’s recovery.
7. Administer antibiotics as prescribed.The infection can only be resolved with proper antibiotics administration.

Nursing Care Plan for Abscess 5

Acute Pain

Nursing Diagnosis: Acute Pain related to infection secondary to internal abscess as evidenced by reports of pain at 9/10 pain scale and guarding behavior.

Desired Outcomes:

  • The patient will verbalize the reduction of pain at a 6/10 pain scale after 4 hours of nursing intervention.
  • The patient will be able to demonstrate ways to relieve pain independently.
Abscess Nursing InterventionsRationale
Assess and determine the location of pain and ask about the characteristic of pain, and alleviating, or relieving factors.This will give the nurse a focus on care and plan appropriate treatment for the patient.
Assess the vital signs and laboratory values.Vital signs are greatly affected by the patient’s pain. This will be baseline data to determine the progress of the treatment plan.
Provide comfort measures such as giving the patient a quiet, darkened, comfortable environment with minimal noise as possible.Fatigue can contribute to pain and this will reduce pain by promoting optimal rest and healing.
Provide a warm compress to the affected part.Warm compress relieves the pain by reducing swelling around the affected part promoting muscle relaxation.
Reposition the affected part frequently or with the patient’s preferred position.This will promote patient comfort and adequate rest.
Educate the patient about relaxation techniques and diversional activities such as deep breathing exercises, music therapy, guided imagery, etc.These techniques and activities will reduce muscle tension and promote optimal pain relief without using pharmacological interventions.
Administer analgesics, anti-inflammatories, and antibiotics as ordered.Analgesics will help the patient with the discomfort and pain while feeding. Anti-inflammatory to decrease swelling. Antibiotics to treat the mouth abscess relieving the associated edema.
Refer the patient to a pain specialist upon consent.The pain specialist will provide proper pain management for pain that is unresponsive to these interventions.
9. Referral to a specialist for a surgical procedure.The internal abscess must need specialist assessment to properly locate and drain the internal abscess relieving the pain immediately and preventing the spread of infection and complications.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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Anna C. RN, BSN, PHN

Anna C. RN, BSN, PHN
Clinical Nurse Instructor

Emergency Room Registered Nurse
Critical Care Transport Nurse
Clinical Nurse Instructor for LVN and BSN students

Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process.

Her experience spans almost 30 years in nursing, starting as an LVN in 1993. She received her RN license in 1997. She has worked in Medical-Surgical, Telemetry, ICU and the ER. She found a passion in the ER and has stayed in this department for 30 years.

She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

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