Wound Infection Nursing Diagnosis and Nursing Care Plans

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Wound Infection Nursing Care Plans Diagnosis and Interventions

Wound Infection NCLEX Review and Nursing Care Plans

Wound infection occurs when opportunistic organisms invade and multiply inside the damaged area of the body.

Microorganisms such as bacteria, fungi, parasites, etc. may worsen an already compromised area and would compound further complications to the body (e.g., sepsis).

Prompt cleaning and dressing of cuts and other small wounds is the standard in preventing wound infections. However, patients with bigger, deeper wounds would need healthcare professionals to treat the condition.

Signs and Symptoms of Wound Infection

Small wounds, such as minor cuts and scratches, can usually be handled at home given the proper care. However, infection may set in for improperly cared wound and may present with the following clinical manifestations:

  • Warm skin around the wound
  • Greenish to yellowish discharge oozing from the wound
  • Foul smelling odor emanating from the wound
  • Presence of red streaks around the wound
  • Fever and chills
  • Aches and pains
  • Nausea and vomiting

Causes of Wound Infection

Wound infections occur when opportunistic organisms deposit and multiply inside the wound of a susceptible person. There are numerous ways microorganisms can enter wounds and they are the following:

  • Direct contact – It is the transfer of contaminated hands, materials, etc. that comes into contact with the wound.
  • Airborne dispersal – It is surrounding air that is contaminated with microorganisms that deposits and settles in the wound.
  • Self-contamination – It is the physical transfer of the patient’s own microbiological flora that is present in the skin, mucus membranes and gastrointestinal tract towards the wound.

The most common organisms responsible with wound infections include Staphylococcus aureus, Streptococcus pyogenes, Enterococci and Pseudomonas aeruginosa.

Risk Factors for Wound Infection

Wound infection risk increases if the following characteristics are observed:

  • The wound is large and deep; or has irregular, jagged edges
  • Foreign particles or dirt has entered the wound
  • The wound was due from an animal or another person’s bite
  • The wound was due to injuries involving a dusty, rusty or contaminated object.

In addition, certain health conditions and external factors can also increase infection risks.

  • Diabetes
  • Compromised blood circulation
  • Depressed immune system (i.e., patients on immunosuppressant medications, people living with HIV.)
  • Immobile patients, particularly those on chronic bed rest
  • Advancing age – the elderly are more at risk than other age groups
  • Nutrient and vitamin insufficiencies

On rare occasions, post-surgical site incisions can become infected. Contributing factors for surgical site wounds to get infected include the following:

  • Poor surgical technique
  • Long operation time, (i.e., more than 2 hours)
  • Intraoperative contamination
  • Prolonged preoperative stay
  • Hypothermia

Diagnosis of Wound Infection

Diagnosing wound infections involves the following:

  • Comprehensive patient history and physical assessment – Doing a complete history and physical assessment will assist the healthcare worker in identifying the cumulative risks and information that is needed to properly treat the patient’s wounds. During physical assessment of the wound, it is important to take note of the five signs of inflammation and they are:
  • Rubor, or the presence of redness
  • Calor, or the increased heat in the affected area
  • Tumor, or observance of swelling on the affected site
  • Dolor, or pain on or around the wound
  • Functio laesa, or the loss of function particularly if the wound is an area of movement (i.e., fingers)

Presence of these local signs and assessment of systemic symptoms of infections, such as fever, is sufficient enough to diagnose wound infections.

In addition, clinical assessment can be supplemented with other diagnostics in order to recognize underlying factors and the causative microorganisms of the wound infection. They are the following:

  • Imaging tests – Radiographic tests such as x-rays, CT-scans and MRI can be utilized especially for wounds that are extensive and deep so as to detect the extent of the damage to surrounding tissues.
  • Laboratory tests – Tests such as Complete Blood counts can help assess the patient’s WBC count, and if elevated, could indicate the presence of systemic infection. A patient’s elevated C-reactive protein and Erythrocyte sedimentation rate (ESR) would indicate an increase of protein in the blood, and therefore could be a characteristic of a systemic issue. Collection of material of a suspected infected wound, which will be tested for Gram stain and culture stain, is often warranted in order to recognize the causative agent so that appropriate antibiotics can be given for the patient.

Treatment for Wound Infection

Treating wound infection includes the following:

  1. Wound care. Wound care is an integral part in treating wounds. This involves a series of steps and they are:

  • Prepare the necessary materials. Make sure that they are clean or are disinfected prior to use.
  • Do hand hygiene, preferably washing of hands with soap and water.
  • Clean the wound using appropriate solution (sterile 0.9% sodium chloride solution, warm water if none). Avoid soap from coming in contact on the actual wound and only use it around the site.
  • Remove carefully debris that may still be present on the wound. If already with previous dressing, remove the previous dressing carefully and ensure pain medications are given prior manipulation.
  • If indicated, apply topical antibiotics over the wound.
  • Allow the skin to air dry before covering with dressing.

2. Medications. Antibiotics are the standard treatment for wound infections. They come in a variety of forms and may be used in tandem when treating an infected wound. Recognizing the causative agent is necessary in order to properly treat an infected wound. The following antibiotic drug classes are used in addressing wound infections:

  • Penicillins (first, second, third generation, etc.)
  • Cephalosporins (first, second, third, generation, etc.)
  • Macrolide antibiotics
  • Tetracycline antibiotics

More serious, debilitating and complicated infected wounds would need surgical management. Examples would be:

  • Surgical wound debridement – It is a surgical intervention wherein the surgeon excises and removes dead and infected tissues in and around the wound to allow for the regeneration of healthy tissue.
  • Skin grafting – For wounds that are considered non-healing, skin grafting may be done so as to prevent further complications brought by an open, infected wound. The procedure involves the harvest of healthy skin, either from the patient or a donor, and is surgically implanted over the affected area so as to promote healing by secondary intention.

Nursing Diagnosis for Wound Infection

Wound Infection Nursing Care Plan 1

Nursing Diagnosis: Impaired Skin Integrity related to compromised tissue structure secondary to wound infection as evidenced by localized pain and skin and tissue color changes in the affected area

Desired Outcome: The patient’s wound will decrease in size with increased granulation formation noted.

Wound Infection Nursing InterventionsRationale
Assess the etiology of the wound, taking note if it’s acute or chronic, burn, pressure ulcer, lesions, etc.Accurate assessment of wound etiology is needed so that proper and appropriate interventions are implemented.
Consider the patient’s nutritional status. Refer the patient for nutritional consultation as indicated.Adequate and appropriate nutritional supplementation is needed for good wound healing. Nutritional insufficiencies will increase the patient’s risk for further skin breakdown, thereby compromising wound healing and causing more serious conditions.
Provide wound care as needed.The type of wound and its management will differ and require different interventions. Skin wounds can be cared for with the use of wet or dry dressings, application of topical creams, hydrocolloid dressing (e.g., Duoderm) or vapor-permeable membrane covering (e.g., Tegaderm). Corneal injury would require the use of eye patch or shield. These dressings functions as substitute to the injured tissues during the restorative process.
Practice sterile dressing technique during wound care.Applying sterile dressing techniques during wound care reduces infection risks on already impaired and exposed tissue. The sterile technique comprises of establishing a sterile field for supplies, utilizing sterile instruments when handling the wound, cleaning of the wound using sterile solutions and covering the wound with sterile dressing.
Give pain medications to the patient before dressing changes as needed and as necessary. Some wounds that are deep or extensive may be painful for the patient. Giving pain medications before manipulation of the wound and dressing promotes patient comfort and compliance with the intervention.
Instruct the patient on proper skin and wound assessment. Include teaching the patient in recognizing signs and symptoms of infection, complications and wound improvement.Imploring the patient to his own care will ensure that objectives of care are achieved, especially interventions that prevent the development of complications.

Wound Infection Nursing Care Plan 2

Nursing Diagnosis: Deficient Knowledge related to rendering wound care secondary to wound infection as evidenced by inefficient activities in maintaining skin integrity.

Desired Outcome: The patient will be able to apply effective and appropriate wound care interventions independent from the assistance of a healthcare provider.

Wound Infection Nursing InterventionsRationale
Assess the patient’s ability to learn, particularly the ability to perform health-related care such as wound care.Cognitive challenges must be recognized early on so that the healthcare provider can formulate appropriate care interventions for the patient. 
Contemplate the patient’s learning style, specifically if the patient has previously learned and retained new information with regards to their care.Every individual has different learning needs. Some patients benefit from written over visual materials. Others prefer group dynamics over one-on-one instructions. Matching the learning style of the patient ensures appropriate and efficient mastery of skills and knowledge for better healthcare management.
Evaluate learning barriers of the patient. (e.g., financial concerns, perception of changes, cultural practices, etc.)Every patient brings forth their personal unique features, patterns and norms for every learning opportunity. Recognizing these values will aid the healthcare provider in formulating appropriate learning tools and allow the patient to readily accept these modifications for better care management. 
Include the patient in creating the healthcare plan for wound care, including establishment of goals and objectives.Goal setting ensures for understanding and active involvement of the patient regarding his healthcare goals. It instills to the patient the importance of compliance with the treatment plan.
Implore the teach-back technique for wound care to gauge the gained knowledge from what was taught:

The health worker provides information using plain language in a caring manner.

Inquire from the patient to explain the information taught in his own words.

Restate the information if the patient seems to find it difficult to repeat it accurately.

Ask again the patient to teach-back the information using his own words until the health worker determines that it is understood.

If still with challenges, consider other strategies.
      The teach-back technique utilizes specific steps in repetition in order to evaluate the knowledge gained by the learner. Patients who have difficulties doing this method can be considered cognitively impaired.
Offer immediate feedback on the patient’s performance.Timely feedback enhances learning by informing the learner of opportunities for improvement and correction of incorrectly done skills.

Wound Infection Nursing Care Plan 3

Nursing Diagnosis: Acute Pain related to compromised tissue structure secondary to wound infection as evidenced by localized pain and skin and tissue color changes in the affected area.

Desired Outcome: The patient will be able to describe satisfactory pain control with a Wong-Baker score of less than 3 to 4 on a scale of 0 to 10.

Wound Infection Nursing InterventionsRationale
Accomplish a complete pain assessment. Make sure to include the location, onset, duration, frequency, characteristics, predisposing factors, etc. utilizing the PQRST mnemonic which includes the following:

Provoking factors

Quality (characteristic)
Region (location)

Severity (e.g., numerical pain scale of 0-10)

Temporal (onset, duration, frequency)
A patient actively experiencing pain is the best determinant for evaluating his pain. Conducting an interview will help the health worker in determining appropriate and efficient pain management tactics.   Utilizing the PQRST mnemonic will aid in establishing a complete assessment.    
Determine the patient’s pain perception.Allowing the patient opportunities to express freely regarding their perception of pain ensures for creation of better pain care plans.
Evaluate the patient’s willingness to explore a variety of pain control techniques.The patient may be hesitant to try some non-pharmacological techniques for addressing pain when compared to traditional pain control measures. Exploring these therapies with the patient will ensure different approaches that may effectively control the patient’s pain.
Ensure that pain medications are administered before pain becomes too severe and before each dressing changes. Providing adequate and appropriate pain control promotes patient comfort and prevents breakthrough pain from occurring. Furthermore, administering pain medications before each dressing application ensures patient cooperation.
Offer cognitive-behavioral therapy as alternatives for pain control such as:

Distraction      

The Relaxation response  

Guided imagery
   
Repatterning of negative thinking  
     
Involves decreasing one’s pain awareness by redirection to non-painful stimuli such as watching TV, playing video games, etc.  

Undue stress may compound painful stimuli. Examples of relaxation techniques such as music therapy, and deep breathing may help in managing pain.  

Utilizing mental pictures helps the patient to refocus their pain perception  

Redirection of negative thinking may address unrealistic expectations that may otherwise compound pain perceptions.
Assess the effectiveness of analgesics as ordered and observe for clinical manifestations of untoward effects.Effects of administered medications should be assessed to evaluate the effectiveness of treatment and timely correction of side effects that may occur.

Wound Infection Nursing Care Plan 4

Nursing Diagnosis: Risk for Ineffective Health Maintenance related to lack of previous similar experience secondary to wound infection

Desired Outcome: The patient and the caregiver will be able to verbalize understanding of the importance of appropriate wound care. 

Wound Infection Nursing InterventionsRationale
Evaluate the patient and the caregiver’s knowledge regarding wound care, including their ability to render care at home.Patients with manageable wounds would no longer need hospitalizations and therefore would be discharged from the hospital. With these, evaluating the patient and his caregiver’s knowledge and skills in wound care would ensure continuous management even at home.
Evaluate the patient and the caregiver’s perception of wound healing.Some types of wounds may take weeks to months to heal (such as pressure ulcers). Assessing their knowledge regarding factors that may shorten or prolong wound healing is necessary for preventing complications.
Instruct the patient and the caregiver to report worsening wound condition or for signs of infection: fever, foul-smelling discharge from the wound, malaise, chills, etc. Educating the patient and caregivers to recognize warning signs of wound infection ensures the application of timely interventions and prevention of complications.
Instruct the patient and caregiver on wound care, having them perform a return demonstration to be assessed by the health worker.This measure will enable the learners of actual and immediate application of newly acquired knowledge. Furthermore, immediate feedback and corrective actions can be given first hand by the health worker to ensure that standards of wound care are maintained even at home.
Offer written instructions plus additional resources regarding wound care.Home care management, especially when given long term, requires detailed instructions to ensure adherence to therapeutic management.

Wound Infection Nursing Care Plan 5

Nursing Diagnosis: Risk for Infection (Cross-contamination) related to open and extensive wounds secondary to wound infection

Desired Outcome: The client will be able to remain free of clinical manifestations of localized or systemic infections as evidenced by absence of foul, purulent wound discharge.

Nursing Stat Facts
Nursing Stat Facts
Wound Infection Nursing InterventionsRationale
Evaluate the patient’s nutritional state.Patients in serious need of proper nutrition (those with serum albumin of < 2.5 mg/dl), are at higher risks for developing and the spreading of infection. Patients with open and extensive wounds would need substantial amounts of protein for better wound healing.
Evaluate the characteristics of the wound specifically the odor, color affected tissues, and wound drainage.Presence of foul-smelling discharge from the wound would indicate an infection. Gray to yellow coloring of the tissues would be suggestive of infection. Green or yellow colored wound discharge is highly suggestive of infection.
Evaluate the patient’s temperatureA body temperature of 38 Celsius and above is considered a fever. Fever usually is indicative of infection unless the patient is immunocompromised or diabetic.
Constantly assess for the patient’s white blood cell count (WBC)Elevated WBC’s could indicate the presence of infection and is the body’s way of addressing it. However, in older individuals, WBC’s may slightly be elevated during an infection due to limited marrow reserves. 
Administer prescribed antibiotics as ordered.Compliance with the prescribed antibiotic regimen prevents the occurrence of complications and antibiotic resistance.

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. (2018). 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

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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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