Registered Nurses' Association of Ontario

Assessment for Infection

  • People with pressure injuries are at increased risk for infection.
  • Assess pressure injuries for signs and symptoms of infection (i.e., superficial critical colonization/localized infection or deep and surrounding infection/systemic infection) on initial examination and at every visit, including at every dressing change.
  • Regular pressure injury assessments allow interprofessional teams to identify and treat wound infections while they are still in the early stages of development.
  • An assessment of the presence and degree of the person’s pain must be included as a component of any assessment for infection.
  • To guide the use of appropriate anti-infective agents, it is important to obtain a semi-quantitative wound culture swab (or tissue culture, in appropriate settings).
  • Prior to obtaining a sample, the wound bed should be cleaned of debris.
  • Tissue cultures and swabs should only be done once a clinician has reviewed the person’s wound history, conducted a physical exam of the pressure injury, and assessed the wound for signs of symptoms of infection.
  • A wound swab cannot diagnose a pressure injury infection; it should not be done routinely.
Clinical Management
Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition
Point of Care Resources