What is a wound infection?

A wound infection occurs when bacteria enters a break in the skin. The infection may involve just the
skin, or affect deeper tissues or organs close to the wound.

General signs and symptoms of a wound infection include:

 Redness or discoloration

 Swelling

 Warmth

 Pain, tenderness

 Scaling, itching

 Pustules, pus drainage

The skin may harden or tighten in the area and red streaks may radiate from the wound. Wound
infections may also cause fevers, especially when they spread to the blood. 

How is a wound infection treated?

Treatment will depend on how severe the wound is, its location, and whether other areas are affected.
It may also depend on your health and the length of time you have had the wound.

 Medicine will be given to treat the infection and decrease pain and swelling.
 Wound care may be done to clean your wound and help it heal. A wound vacuum may also be
placed over your wound to help it heal. Care for your wound as directed. Keep your wound
clean and dry. You may need to cover your wound when you bathe so it does not get wet. Clean
your wound as directed with soap and water or wound cleaner. Put on new, clean bandages as
directed. Change your bandages when they get wet or dirty.
 Hyperbaric oxygen therapy (HBO) may be used to get more oxygen to your tissues to help them
heal. The pressurized oxygen is given as you sit in a pressure chamber.
 Surgery may be needed to clean the wound or remove infected or dead tissue. Surgery may also
be needed to remove a foreign object.
Focus on assessment

At 4pm, Ms. BB went to Medical Hospital. She went to the clinic because of having an open
wound. Patient verbalized that, “May mga sugat ako.” The nurse observed the disruption of
skin surface at the lower extremity and the wound is 5mm in diameter.

Nursing Diagnosis

Impaired skin integrity related to inflammatory response secondary to infection.

Goals and Outcomes

After 8 hours of nursing intervention the patient will be able to:

 Improve in wound healing as evidenced by intact skin or minimized presence of wound.
 Remains free of infection, as evidenced by absence of signs and symptoms of infection.
 Early recognition of infection to allow for prompt treatment.
 Patient is able to do own wound care, knows more when it comes to preventive measures to
infection and manifesting good/better wound healing.

Nursing Intervention and Rationale

1. Assess skin. Note the color, turgor and
sensation. Describe and measure wounds and
observe changes.
2. Demonstrate good skin hygiene, e.g.,
washes thoroughly and pat dry carefully.
3. Instructed family to maintain clean, dry
clothes, preferably cotton fabric.
4. Emphasized importance of adequate
nutrition and fluid intake.
5. Demonstrate to family members on how to
make a guava decoction to apply to the
wound as alternative disinfectant.
6. Provide and applied wound dressings
carefully.
Establishes comparative baseline providing
opportunity for timely intervention.
Maintaining clean, dry skin provides a barrier
to infection. Patting skin dry instead of
rubbing reduces risk of dermal trauma to
fragile skin.
Skin friction caused by stiff or rough clothes
leads to irritation of fragile skin and increases
risk for infection.
Improved nutrition and hydration will
improve skin condition.
Providing the family with alternative solution
assists them in optimal healing with less
expensive resources.
Wound dressings protect the wound and the
surrounding tissues.
Nursing Assessment

 Assess for the presence of local infectious processes in the skin or mucous membranes.
Rationale: Signs and symptoms include localized swelling, localized redness, pain or tenderness,
loss of function in the affected area, palpable heat.
 Monitor for signs and symptoms of infection.
Rationale: Signs and symptoms of infection vary according to the body area involved.

Nursing Intervention

 Maintain strict asepsis for dressing changes, wound care, intravenous therapy, and catheter
handling.
Rationale: Aseptic technique decreases the chances of transmitting or spreading pathogens to or
between patients. Interrupting the chain of infection is an effective way to prevent the spread of
infection.
 Wash hands or perform hand hygiene before having contact with the patient. Also impart these
duties to the patient and their significant others. Know the instances when to perform hand
hygiene or “5 moments for hand hygiene”:
1. Before touching a patient.
2. Before clean or aseptic procedure (wound dressing, starting an IV, etc).
3. After body fluid exposure risk
4. After touching a patient
5. After touching the patient’s surroundings.
Rationale: Friction and running water effectively remove microorganisms from hands. Washing
between procedures reduces the risk of transmitting pathogens from one area of the body to
another. Wash hands with antiseptic soap and water for at least 15 seconds followed by alcohol-
based hand rub. If hands were not in contact with anyone or anything in the room, use an
alcohol-based hand rub and rub until dry. Plain soap is good at reducing bacterial counts but
antimicrobial soap is better, and alcohol-based hand rubs are the best.
 Educate clients and SO about appropriate methods for cleaning, disinfecting, and sterilizing
items.
Rationale: Knowledge of ways to reduce or eliminate germs reduces the likelihood of
transmission.

Nursing Responsibilities

Treatment and Diagnostic Tests

 The risk of wound infection can be minimized with prompt and proper wound cleansing and
treatment. Many superficial bacterial infections and viral infections will resolve on their own
 without treatment. Other bacterial infections may require only a topical antimicrobial, and some
cases require incision and drainage.
 Deeper infections, and those that are persistent, typically require antibiotics. The choice is based
upon the results of wound culture and antimicrobial susceptibility tests. People with antibiotic-
resistant bacteria or with an infection in a location that is difficult for drug therapy to penetrate
(such as bone) may require extended treatment and/or treatment with intravenous
(IV) medications.
 Wounds may also require removal of dead tissue (debridement) and/or drainage, sometimes
more than once. Topical antimicrobials and debridement are also used for burn treatment. With
extensive injuries, grafting and other surgeries may be required.
 Treatment plans can be affected by the presence of underlying conditions that can slow wound
healing, such as diabetes, malnutrition, HIV/AIDS, and other disorders that compromise
the immune system. A healthcare practitioner may need to perform tests to detect these
underlying conditions.

Laboratory tests

Examples of common tests include:

Bacterial culture – This is the primary test used to diagnose a bacterial infection. Results are usually
available within 24-48 hours.

Gram stain – This is usually performed in conjunction with the wound culture. It is a special staining
procedure that allows bacteria to be evaluated under the microscope. The results are usually available
the same day and provide preliminary information about the microbe that may be causing the infection.

Antimicrobial susceptibility – A follow-up test to a positive wound culture, this is used to determine the
bacteria's likely susceptibility to certain drugs and helps the healthcare practitioner select appropriate
antibiotics for treatment. Results are typically available in about 24 hours. This testing can identify
resistant bacteria such as MRSA.

Other tests may include:

KOH prep – This is a rapid test performed to detect fungi in a sample. The sample is treated with a
special solution, placed on a slide, and examined under a microscope.

Fungal culture – This is ordered when a fungal infection is suspected. Many fungi are slow-growing and
may take several weeks to identify.

AFB testing – This is ordered when a mycobacterial infection is suspected. Most AFB are slow-growing
and may take several weeks to identify.

Blood culture – This is ordered when infection from a wound may have spread to the blood.

Molecular testing to detect genetic material of a specific microbe

Basic metabolic panel (BMP) or Comprehensive metabolic panel (CMP) – This may be ordered to detect
underlying conditions that can affect wound healing, such as a glucose test to detect diabetes.

Complete blood count (CBC) – An elevated white blood cell (WBC) count may be a sign of infection.

Non-laboratory tests

In some cases, imaging scans such as ultrasounds or x-rays may be ordered to evaluate the extent of
tissue damage and to look for areas of fluid/pus.