Nursing Management and Care Plan

Core Concepts

The Nursing Process as the Organizing Framework

The five steps form a cycle, not a one-time checklist:

• Assessment: collecting data — the patient's story (how the wound happened, how long it has been present, pain, fever, what the patient has tried), the physical exam (wound size, depth, color, drainage, odor, surrounding skin, pulses, sensation), and context (age, nutrition, diabetes, vascular disease, medications such as corticosteroids or anticoagulants, smoking, mobility).
• Diagnosis: translating the data into a nursing diagnosis — a clinical judgment about the patient's response to a health problem, such as "impaired skin integrity" or "risk for infection." Nursing diagnoses describe what nursing can treat or prevent, unlike medical diagnoses, which name the disease (e.g., "cellulitis").
• Planning: setting realistic, measurable goals with the patient — for example, "wound surface area will decrease by 25% within 2 weeks" — and choosing interventions to reach them.
• Implementation: carrying out the plan: cleansing and dressing wounds per orders, offloading pressure, supporting nutrition, managing pain, teaching the patient, and protecting the wound from further injury.
• Evaluation: comparing current findings with the goals. Is the wound smaller? Is drainage decreasing? If not, the plan is revised — which is why documentation must be accurate and ongoing.

Assessment: The Wound and the Whole Person

Wound assessment follows a consistent routine so findings from one day can be compared with the next: location; size (length, width, depth); wound bed (healthy red granulation tissue vs. yellow slough vs. black eschar); exudate (amount, color, odor); wound edges; and the condition of the skin around the wound (maceration, redness, warmth). The whole person matters just as much: temperature, pain, appetite, blood glucose if the patient has diabetes, and the ability to move and reposition. A wound that looks stable can be undermined by a patient who is febrile or unable to eat. Assessment also includes the patient's knowledge — what they understand about their wound and how to care for it — because discharge safety depends on it.

Nursing Diagnoses and Collaborative Planning

Common nursing diagnoses in this chapter include impaired skin integrity, risk for infection, acute pain, impaired physical mobility, and deficient knowledge. Each diagnosis is paired with measurable outcomes and specific interventions. Wound care is inherently collaborative: providers prescribe treatments, wound care specialists offer expertise, dietitians address nutrition, and physical therapists help with mobility — the nurse coordinates and communicates so the plan stays coherent. The patient is the center of the plan, and their preferences and goals shape what is realistic.

Implementation: Daily Care, Protection, and Education

Implementation in inflammation and healing is hands-on: cleansing wounds with the prescribed solution and technique, applying the correct dressing as ordered, protecting fragile skin, repositioning to relieve pressure, and using strict hand hygiene before and after every contact. Implementation is also education: teaching the patient what to eat (adequate protein and calories support healing), how to protect the wound, which signs of infection to report (increasing pain, redness, warmth, drainage, fever), and why follow-up appointments matter. Nurses carry out interventions within their scope of practice and according to institutional policy and provider orders — never improvising beyond what they are trained and authorized to do, and reporting anything unusual rather than trying to "fix" it alone.

Evaluation and Documentation

Evaluation happens at every encounter, not only at scheduled intervals. Objective measurements (wound dimensions, exudate amount) are more useful than vague words like "looks better," and every finding must be documented promptly and factually; photographs are taken per policy so the team can see trends. If a wound is not progressing, the nurse reports it and the plan changes — waiting "one more day" can cost a patient their limb or their life. Accurate documentation also protects the patient and the nurse by creating a clear record of what was observed, done, and taught.

Common Confusions