Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Clinical Signs and Symptoms of Infection
NON-LIMB-THREATENING INFECTION



LIMB-THREATENING INFECTION

SUPERFICIAL INFECTION

  • Non-healing
  • Bright red granulation tissue
  • Friable and exuberant granulation
  • New areas of breakdwon or necrosis
  • Increased exudates
  • Bridging of soft tissue and the epithelium
  • Foul odour

 

DEEP WOUND INFECTION

  • Pain
  • Swelling, induration
  • Erythema (>2cm)
  • Wound breakdown
  • Increased size or satellite areas
  • Undermining or tunneling 
  • Probing to bone
  • Anorexia
  • Flu-like symptoms
  • Erratic glucose control

SYSTEMIC INFECTION

In addition to deep wound infection:

  • Fever
  • Rigour
  • Chills
  • Hypotension
  • Multi-organ failure
     

 

(Falanga, 2000; Gardner et al., 2001; Lipsky et al., 2012; Schultz et al., 2003; Sibbald, Orsted, Schultz, Coutts, & Keast, 2003; Sibbald et al., 2000)