Nursing Care Plan for Wound Care
Also searched as: wound healing, chronic wound
General nursing management of an open wound from surgery, trauma, or a chronic condition such as diabetes or poor circulation. This plan covers wound-bed assessment and healing; for a bedsore specifically see the pressure injury care plan, and for an already-infected wound see the wound infection care plan.
🎓 Educational example. Adapt to your patient and have your instructor review it. Not medical advice.
Build your own Wound Care care plan in minutes → the free Care Plan Builder walks you from assessment to evaluation and exports a clean PDF.
What do you assess in the Wound Care care plan?
- Subjective: patient reports pain at the wound site, drainage soaking through dressings, or a wound that is not getting smaller
- Objective: wound size and depth measured, tissue type in the wound bed (granulation, slough, eschar), amount and color of exudate, periwound skin condition, odor, and healing slower than the expected timeframe
Which nursing diagnoses apply to Wound Care?
As evidenced by: visible tissue disruption, slow or stalled healing, wound present beyond the expected timeframe
Risk factors: open wound bed, moist dressing environment, comorbidities such as diabetes or poor circulation, malnutrition
What are the goals and expected outcomes for Wound Care?
Each goal below follows the SMART format: specific, measurable, achievable, relevant, time-bound.
- The wound will show measurable progress toward healing (smaller size or depth, more granulation tissue, less slough) at each dressing change or weekly assessment.
- The patient will remain free of wound infection throughout the healing course.
What are the nursing interventions for Wound Care, and why?
| Intervention | Rationale |
|---|---|
| Assess and measure the wound (length, width, depth, tissue type, exudate, periwound skin) at each dressing change and document the trend. | A structured, repeated assessment shows whether the wound is healing or stalling. |
| Select and apply a dressing matched to the wound bed and exudate level (for example an alginate for heavy drainage or a hydrogel for a dry wound), using clean or aseptic technique as ordered. | Moist wound healing speeds closure; the wrong dressing can macerate surrounding skin or dry out the wound bed. |
| Address factors that slow healing: optimize nutrition and protein intake, manage blood glucose, relieve pressure, and support blood flow. | Wound healing is a whole-body process, and unaddressed systemic factors stall it no matter how good the local dressing care is. |
| Teach the patient and family the dressing-change procedure, hand hygiene, and which signs (increasing redness, odor, drainage, fever) mean they should call the provider. | Wound care often continues at home between visits, so patients need to recognize a developing problem early. |
How do you evaluate the Wound Care care plan?
- Wound trends smaller with more granulation tissue and less nonviable tissue
- No signs of infection develop
- Patient/family demonstrate correct dressing-change technique
How do you document wound care in a nursing care plan?
Describe the wound the same way at every dressing change, so anyone reading the chart can see whether it is healing or stalling. A complete wound note usually covers:
- Location and type of wound, for example a surgical incision, a skin tear, or a diabetic foot wound.
- Size in centimeters (length, width, and depth), measured the same way each time, plus any tunneling or undermining described by clock position.
- The wound bed: how much of it is granulation tissue, slough, or eschar.
- Drainage: the amount (for example scant, moderate, or large) and the type (serous, serosanguineous, sanguineous, or purulent), and any odor after cleansing.
- The periwound skin: redness, warmth, swelling, or maceration.
- Pain before and during the dressing change, the dressing applied, and how the patient tolerated the procedure.
In the goals column, pair a short-term goal you can check at each dressing change (no new signs of infection) with a longer-term goal for the healing course (a smaller measurement at each weekly assessment). In the evaluation column, compare the new measurements with the last ones and record whether each goal was met, partially met, or not met. Follow your facility's wound documentation policy and the provider's orders; the Open RN wound care chapter listed below explains wound assessment in more detail.
Where do these Wound Care recommendations come from?
Stop rewriting care plans by hand
The free Care Plan Builder assembles a care plan for 91 conditions (assessment, diagnosis, SMART goals, interventions with rationale) that you can copy, print or save as PDF.
Build a care plan freeWound Care care plan: FAQ
What is the nursing diagnosis for Wound Care?
Common nursing diagnoses include: Impaired tissue integrity related to the open wound and its underlying cause; Risk for infection related to a break in the skin barrier. Choose the one your patient's assessment data supports.
What are nursing interventions for Wound Care?
Key interventions: Assess and measure the wound (length, width, depth, tissue type, exudate, periwound skin) at each dressing change and document the trend.; Select and apply a dressing matched to the wound bed and exudate level (for example an alginate for heavy drainage or a hydrogel for a dry wound), using clean or aseptic technique as ordered.; Address factors that slow healing: optimize nutrition and protein intake, manage blood glucose, relieve pressure, and support blood flow., each paired with a rationale.
Can I use this care plan for my assignment?
Use it as a study example and starting draft. Always adapt it to your specific patient and have it reviewed by your instructor. This is an educational tool, not medical advice.
For nursing education only, NOT medical advice and not a clinical decision-making tool. Nothing here should be used to assess, diagnose, or treat any real patient. Care plans and answers are unverified study drafts to review with your instructor or a licensed clinician and adapt to the individual patient and your institution’s protocols before any use.
Educational content based on standard nursing practice; not medical advice and not affiliated with NANDA-I/NIC/NOC. Always follow your institution's protocols and your instructor's guidance.