Chapter 4. Wound Care

4.3 Wound Infection and Risk of Wound Infection

Wound Infection

Wounds are not sterile because normal flora is a part of human existence. Even intentional wounds contain microbes which may include bacteria and fungi. It is important for the nurse to recognize that presence of bacteria in a wound does not necessarily mean infection. It is also important for the nurse to recognize their role in reducing risk of infection through standard precautions and by working with the patient and interdisciplinary team to mitigate factors that might contribute to patient risk. The wound infection continuum is characterized by increasing numbers and virulence of microorganisms and the host’s response to them.

Table 4.5 Wound Infection Continuum and S&S Associated with Each Stage
Contamination All wounds may acquire micro-organisms. If the ideal microbe environment does not exist and host defenses are strong, microbes cannot multiply. They are present but don’t affect wound healing.
Local Infection Subtle signs of local infection:

  • Hyper granulation (excessive “vascular” tissue)
  • Bleeding, friable granulation
  • Epithelial bridging and pocketing in granulation tissue
  • Wound breakdown and enlargement
  • Delayed wound healing beyond expectations
  • New or increasing pain
  • Increasing malodor
 Classic signs of local infection:

  • Erythema
  • Local warmth
  • Swelling
  • Purulent discharge
  • Delayed wound healing beyond expectations
  • New or increasing pain
  • Increasing malodor
Spreading Infection
  • Extending in duration
  • +/- erythema Lymphangitis Crepitus
  • Wound breakdown/dehiscence with or without satellite lesions
  • Malaise/lethargy or non-specific general deterioration
  • Loss of appetite
  • Inflammation, swelling of lymph glands
Systemic
  • Severe sepsis
  • Septic shock
  • Organ failure
  • Death
Data source: ©Wounds International. Adapted for this textbook with permission.

Factors that Increase the Risk of Wound Infection

Table 4.6 Considerations for Increased Risk of Wound Infection

Individual Factors
  • Poorly controlled diabetes
  • Prior surgery
  • Radiation therapy or chemotherapy
  • Conditions associated with hypoxia and/or poor tissue perfusion (e.g., anemia, cardiac or respiratory disease, arterial or vascular disease, renal impairment, rheumatoid arthritis, shock)
  • Immune system disorders (e.g., acquired immune deficiency syndrome, malignancy)
  • Inappropriate antibiotic prophylaxis, particularly in acute wounds
  • Protein-energy malnutrition
  • Alcohol, smoking, and drug abuse
  • +/- erythema Lymphangitis Crepitus
  • Age

Wound Factors
Acute wounds:

  • Contaminated or dirty wounds
  • Trauma with delayed treatment
  • Pre-existing infection or sepsis
  • Spillage from gastro-intestinal tract
  • Penetrating wounds over four hours
  • Inappropriate hair removal
  • Operative factors (e.g., long surgical procedure, hypothermia, blood transfusion)
 Chronic wounds:

  • Degree of chronicity/duration of wound
  • Large wound area
  • Deep wound
  • Anatomically located near a site of potential contamination (e.g., perineum or sacrum)

Both wound types:

  • Foreign body (e.g., drains, sutures)
  • Hematoma
  • Necrotic wound tissue
  • Impaired tissue perfusion
  • Increased exudate or moisture

Environment Factors
  • Hospitalization (increased risk of exposure to antibiotic resistant organisms)
  • Poor hand hygiene and aseptic technique
  • Unhygienic environment (e.g., dust, unclean surfaces, mold/mildew in bathrooms)
  • Inadequate management of moisture, exudate, and edema
  • Inadequate pressure off-loading
  • Repeated trauma (e.g., inappropriate dressing removal technique)
Data source: © Wounds International. Adapted for this textbook with permission.

 

Critical Thinking Exercises

  1. Gerry is 58 years old. He has a history of smoking and hypertension, and has been in a motorcycle accident resulting in significant abrasions to his arms and legs. What factors increase Gerry’s risk of wound infection?
  2. JT is 38 years old. Has had paraplegia and a wound on the right ischium for 18 months. What factors increase JT’s risk of wound infection?
  3. What are the commonalities in relation to risk of wound infection and risk of impaired wound healing?

Attributions

Table 4.5 and 4.6 International Wound Infection Institute, 2016

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Clinical Procedures for Safer Patient Care Copyright © 2018 by Thompson Rivers University is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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