Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Clinical Sign and Symptoms of Infection
Superficial, Increased Bacterial Burden (Critically Colonized) Deep Wound Infection Systemic Infection
Non-healing Pain Fever
Bright red granulation tissue Swelling, induration Rigors
Friable and exuberant granulation Erythema Chills
New areas of breakdown or necrosis on the wound surface (slough) Increased temperature Hypotension
Increased exudates that may be translucent or clear before becoming purulent Wound Breakdown Multiple organ failure
Foul odor Increased size or satellite areas


Probing to bone