Wound Care & Tissue Integrity Nursing Care Plan

1. Structured assessment and documentation

• Assess and measure the wound at a set interval — typically weekly and at every dressing change for exudate and pain.
• Use a consistent measuring technique: greatest length head-to-toe, greatest width perpendicular, depth with a moistened swab.
• Document tunneling and undermining using clock positions with the patient's head as 12 o'clock.
• Photograph with a scale and date per policy, and use the same validated tool each time so changes are comparable.
• Escalate when a wound fails to reduce in area by roughly 20–40% over four weeks — the plan, not the effort, needs changing.

2. Cleansing and debridement

• Irrigate with normal saline or a non-cytotoxic wound cleanser at moderate pressure to remove debris without damaging granulation tissue.
• Avoid routine hydrogen peroxide, full-strength povidone-iodine and chlorhexidine on healthy granulating tissue.
• Support the appropriate debridement method: autolytic with moisture-retentive dressings, enzymatic, mechanical, sharp/surgical or biologic.
• Never debride stable, dry, intact eschar on an ischemic heel — keep it dry and protected and refer for vascular assessment.
• Assess arterial perfusion before debriding or applying compression to a lower-limb wound.

3. Selecting dressings

• Match the dressing to exudate: alginates and foams for heavy exudate, hydrocolloids for light, hydrogels to donate moisture to a dry bed.
• Use non-adherent contact layers over fragile granulation and for painful dressing changes.
• Apply silver, iodine or honey dressings for critical colonization as ordered, and reassess rather than continuing indefinitely.
• Protect periwound skin with a barrier film or ointment and size the dressing to the wound.
• Manage negative-pressure wound therapy per protocol: verify seal, monitor canister output and character, and report bleeding or loss of seal.
• Change dressings on schedule rather than routinely daily; unnecessary changes cool the wound and disrupt healing.

4. Preventing and treating infection

• Assess at each change for increasing pain, friable bleeding granulation, foul odor, increased or changed exudate and stalled progress.
• Obtain tissue or Levine-technique swab cultures as ordered rather than swabbing slough or drainage.
• Give systemic antibiotics for spreading or systemic infection; topical antimicrobials for local burden.
• Use clean or sterile technique per facility policy and change gloves between the dirty and clean parts of the procedure.
• Monitor for systemic signs: fever, tachycardia, leukocytosis, confusion in older adults, and rising glucose in diabetics.

5. Treating the underlying cause

• For pressure injuries: reposition on an individualized schedule, use a pressure-redistribution surface, keep the head of bed at or below 30 degrees when possible, float heels and manage incontinence.
• For venous ulcers: apply compression therapy after confirming adequate arterial supply, and elevate the legs above heart level several times daily.
• For arterial ulcers: never apply compression, protect from trauma and cold, and refer urgently for revascularization assessment.
• For diabetic foot ulcers: enforce total offloading, inspect both feet daily, and drive glycemic control.
• Address incontinence with a structured toileting plan and barrier products.

6. Nutrition, pain and systemic support

• Screen nutrition on admission and refer to dietetics; target increased protein, adequate calories, vitamin C and zinc as prescribed.
• Encourage hydration, which is often the overlooked half of a nutrition plan.
• Premedicate 30 minutes before dressing changes and use non-adherent products and warmed solutions to reduce procedural pain.
• Support smoking cessation; nicotine directly impairs wound perfusion.
• Optimize glycemic control, treat anemia and review medications that impair healing such as corticosteroids.

7. Teaching and continuity

• Teach the dressing change with return demonstration and written, illustrated instructions.
• Ensure supplies, home health referral and follow-up appointments are arranged before discharge.
• Teach the specific signs that require a call rather than a generic 'watch for infection'.
• Involve the wound-ostomy-continence nurse for complex, non-healing or atypical wounds.
• Address prevention of recurrence explicitly: footwear, compression stockings, repositioning and skin checks.

What are the nursing diagnoses for Wound Care & Tissue Integrity?

Priority nursing diagnoses for Wound Care & Tissue Integrity: Impaired tissue integrity; Risk for infection; Acute pain.

What are the nursing interventions for Wound Care & Tissue Integrity?

Assess and measure the wound at a set interval — typically weekly and at every dressing change for exudate and pain. Use a consistent measuring technique: greatest length head-to-toe, greatest width perpendicular, depth with a moistened swab. Document tunneling and undermining using clock positions with the patient's head as 12 o'clock. Photograph with a scale and date per policy, and use the same validated tool each time so changes are comparable. Escalate when a wound fails to reduce in area by roughly 20–40% over four weeks — the plan, not the effort, needs changing. Irrigate with normal saline or a non-cytotoxic wound cleanser at moderate pressure to remove debris without damaging granulation tissue.

What are the nursing care goals for Wound Care & Tissue Integrity?

The client's wound will show a measurable decrease in surface area at each reassessment interval. The wound bed will progress toward 100% granulation with no slough or eschar. The client will remain free of local and systemic wound infection. The periwound skin will remain intact and free of maceration. The client will report dressing-change pain controlled to an agreed level. The client will meet protein and calorie targets and maintain glucose within range. The client or caregiver will correctly perform the dressing change before discharge.

What should you assess in a patient with Wound Care & Tissue Integrity?

Wound pain at rest and during dressing changes, with its character and timing; Reports of increasing pain, which often precedes visible infection; Itching, burning or numbness around the wound; Impact on sleep, mobility, work and body image; Understanding of the cause and of the care plan; Location, length, width and depth in centimeters, with tunneling and undermining by clock position; Tissue type by percentage: granulation, slough, eschar, epithelializing; Exudate volume, color, consistency and odor; Wound edges: attached, rolled (epibole), macerated or undermined; Periwound skin: intact, macerated, erythematous, indurated or excoriated; Signs of infection: erythema, warmth, edema, purulence, fever, elevated white count; Perfusion indicators: pulses, ankle-brachial index, capillary refill, temperature of the limb; Nutritional markers: weight trend, albumin, prealbumin, glucose and HbA1c