- Acute Pain related to loss of blood supply in the affected site and damaged nerve endings as evidenced by verbal reports of pain and tenderness or pain to touch
- Impaired Skin Integrity related to skin injury from shearing, pressure, or trauma and conditions that delay the wound healing process (such as diabetes mellitus) as evidenced by discharge from the wound and warm, tender, painful, and inflamed skin
- Ineffective Protection related to inadequate primary defences and Compromised immunity as evidenced by impaired tissue healing and neurosensory impairment
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Verbal reports from the patient -Expressions of pain, such as crying -Unpleasant feeling (such as a prick, burn, or ache) Objective Data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behaviors | Acute Pain related to loss of blood supply in the affected site and damaged nerve endings as evidenced by verbal reports of pain and tenderness or pain to touch | 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. | 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. | Patient verbalized the resolution of pain to the wound. Patient reported a decrease in pain on a 0-10 scale after the administration of pain medication. Patient performed daily activities without complaints of pain in the wound. |
| Subjective Data: -Pain -Itching -Numbness to affected and surrounding skin Objective Data: -Changes to skin color (erythema, bruising, blanching) -Warmth to skin -Swelling to tissues -Observed open areas or breakdown, excoriation | Impaired Skin Integrity related to skin injury from shearing, pressure, or trauma and conditions that delay the wound healing process (such as diabetes mellitus) as evidenced by discharge from the wound and warm, tender, painful, and inflamed skin | 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. | 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. 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. 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. | Patient remained free of purulent drainage in the wound. Patient demonstrated clean wound edges. Patient verbalized the understanding of wound care management. Patient participated in performing wound care. |
| Subjective Data: -Older age -Malnutrition -Immobility -Incontinence -Compromised immunity Objective Data: -Impaired tissue healing -Maladaptive stress response -Pressure ulcer development -Weakness -Neurosensory impairment -Poor mobility | Ineffective Protection related to inadequate primary defences and Compromised immunity as evidenced by impaired tissue healing and neurosensory impairment | Patient will remain free from developing a wound infection. Patient will demonstrate interventions to improve protection against skin breakdown and wounds. | 1. Administer antibiotic therapy as indicated. Antibiotic therapy is prescribed to fight off an existing infection or as prophylaxis against one. This will promote protection from further complications. 2. Refer the patient to a dietitian. A dietitian can help formulate a well-balanced meal plan for the patient that supports the immune system and promotes optimal wound healing. 3. Educate the patient about infection control measures. Infection control measures like handwashing are crucial to prevent introducing bacteria into a wound. Educate the patient or caregiver to always wash their hands before and after touching a wound. 4. Provide proper wound care. Ensure wound care is appropriate for the type of wound. If the patient or caregiver provides wound care, demonstrate how to clean and cover the wound effectively. Educate on signs of wound infection, such as redness or swelling, and when to contact their healthcare provider. | Patient remained free from developing a wound infection. Patient demonstrated interventions to improve protection against skin breakdown and wounds. |