Watson caring theory-based encouragement interventions for pain and anxiety in stage III-IV pressure ulcer patients

Abstract

BACKGROUND

Infected stage III-IV pressure ulcers constitute a major challenge in the field of clinical nursing; patients often experience severe pain, serious infection, and malnutrition, and the healing process is typically slow. Furthermore, they frequently suffer from negative emotions such as anxiety and depression, which significantly impact their prognosis and quality of life. Traditional nursing focuses on wound treatment and infection control, but pays relatively insufficient attention to psychological and emotional support for patients. The Watson Care Theory emphasizes person-centered holistic care. By establishing a trusting caring relationship, it enhances the patient’s inner strength and rehabilitation belief.

AIM

To explore the application effect of encouragement-based interventions guided by Watson’s caring theory in the care of patients with stage III-IV pressure ulcer infections, analyze its impact on pain and anxiety, and examine its correlation with prognostic indicators, thereby providing a theoretical basis and practical reference for clinical pressure ulcer care.

METHODS

A total of 156 patients with stage III-IV pressure ulcer infections admitted to the Wound Repair Center and Burn Wound Ward of The Affiliated Central Hospital of Shenyang Medical College from February 27, 2025, to August 27, 2025, were selected as the study subjects. They were randomly divided into a control group and a study group using a random number table, with 78 patients in each group. The control group received vacuum sealing drainage combined with conventional care, including dynamic wound monitoring and nutritional support. The study group received encouragement-based interventions guided by Watson's Caring Theory in addition to the control group's treatment. The intervention period for both groups was 8 weeks. The total effective rate of wound healing, wound healing time, and total hospitalization time were compared between the two groups. Levels of white blood cell count, red blood cell count, hemoglobin, serum albumin, high-sensitivity C-reactive protein, and microbial culture positivity rates were measured before and after treatment. Visual Analog Scale (VAS) scores, Braden pressure ulcer risk scores, and Self-Rating Anxiety Scale scores were evaluated. Adverse reactions and complications were recorded. Pearson correlation analysis or Spearman rank correlation analysis was used to explore the relationship between anxiety and various prognostic indicators.

RESULTS

The research group had a higher overall wound healing rate (92.00% vs 76.00%, P < 0.05), shorter wound healing times and total hospital stay (P < 0.05). At week 8, the research group had lower white blood cell counts, high-sensitivity C-reactive protein levels, and microbial positivity rates, while having higher red blood cell counts, hemoglobin, and albumin levels compared to the control group (P < 0.05). At weeks 4 and 8, the research group had lower VAS and Self-Rating Anxiety Scale scores than the control group, but higher Braden scores (P < 0.05). The incidence of complications was also lower in the research group than in the control group (8.00% vs 22.00%, P < 0.05).

CONCLUSION

Encouragement-based interventions guided by Watson’s caring theory can effectively alleviate pain and anxiety in patients with stage III-IV pressure ulcer infections, improve nutritional status and inflammatory responses, promote wound healing, shorten hospitalization time, and reduce the risk of complications. This approach demonstrates significant clinical application value and is worthy of promotion.

Key Words: Watson’s caring theory; Encouragement-based intervention; Stage III-IV pressure ulcers; Infection; Pain; Anxiety; Prognosis

Core Tip: Encouraging interventions based on Watson’s theory of caring can effectively alleviate pain and anxiety in patients with stage III-IV pressure ulcer infections, improve their nutritional status and inflammatory responses, and reduce the risk of complications, thereby demonstrating significant clinical application value.

INTRODUCTION

Pressure ulcers result from sustained pressure on the local skin, resulting in poor blood flow, tissue oxygen hypoxia and ischemia, and ultimately skin and dermal tissue necrosis. These types of lesions are more common in elderly patients who are bedridden or immobile, as well as in paralyzed patients or people with chronic diseases[1]. According to the staging criteria of the National Pressure Ulcer Advisory Committee, stage III and IV pressure ulcers are severe conditions, often accompanied by wound infection and deep tissue ulceration. This condition not only increases patient suffering and increases healthcare costs, but can also lead to life-threatening complications such as sepsis and osteomyelitis[2]. Clinical data suggest that for patients with stage III-IV infectious pressure ulcers, wound healing is typically prolonged, averaging 8-12 weeks, with frequent recurrences after healing. Furthermore, due to chronic pain and prognostic concerns, many patients experience negative emotions such as anxiety and depression, which can significantly impair immune function and delay wound healing[3,4]. Currently, nursing care for stage III-IV infectious pressure ulcers is primarily focused on local wound management. For example, negative pressure wound therapy can effectively dehydrate the wound and increase granulation tissue. However, this approach often ignores the mental state of the patient and it is difficult to disentangle the association between negative emotions and poor prognosis[5]. Watson’s theory of human care, proposed in 1979 by the American nurse researcher Jean Watson, has “human care” as its central concept. The theory emphasizes that the essence of nursing is to establish trusting relationships between nurses and patients to meet the patient’s physical, psychological, and social needs and ultimately help the patient regain health and dignity improve through verbal encouragement, emotional support, and information sharing. In recent years, Watson’s theory has made positive strides in the care of patients with chronic diseases such as diabetes and cancer. However, there are few studies on the use of this theory in patients with stage III-IV pressure infectious ulcers, and its precise impact on pain, anxiety, and clinical outcome remains unclear[8,9].

This study using a prospective randomized controlled trial, selected 156 patients with stage III-IV pressure ulcers and infection admitted to the Wound Repair Center and Burn Wound Ward of the Affiliated Central Hospital of Shenyang Medical College as the research subjects. Through a randomized controlled trial, the application effect of encouraging intervention based on Watson’s theory of human caring was explored, aiming to provide a scientific basis for optimizing the nursing plan for patients with stage III-IV pressure ulcers and infection.

MATERIALS AND METHODS

Research subjects and methods

Research subjects: Using a prospective randomized controlled trial, a total of 156 patients with stage III-IV pressure ulcers and infection who visited the Wound Repair Center and Burn Wound Ward of the Affiliated Central Hospital of Shenyang Medical College from February 27, 2025 to August 27, 2025 were selected as the research subjects.

Inclusion criteria: (1) Meeting the diagnostic criteria for stage III-IV pressure ulcers: According to the “International Pressure Ulcer Prevention and Treatment Guidelines (2019 Edition)”, stage III pressure ulcers are characterized by full-thickness skin loss with visible subcutaneous fat but no exposure of bone, tendon, or muscle, and the wound may have slough but does not cover the depth of tissue loss; stage IV pressure ulcers are characterized by full-thickness tissue loss with exposure of bone, tendon, or muscle, and the wound base may be covered with slough or eschar[10]; (2) Positive bacterial culture of wound exudate, confirmed as infection (colony count ≥ 10⁵ CFU/g or presence of local redness, increased pain, purulent exudate, etc. as infection symptoms)[11]; (3) Age 50-70 years old, bedridden for a long time (bedridden time ≥ 1 month, daily self-activity time < 2 hours); (4) Surgical treatment is required, such as debridement and flap transplantation, but the patient cannot tolerate general anesthesia due to heart and lung insufficiency (New York Heart Association functional classification II-IV and moderate to severe lung function impairment); (5) The patient is conscious and able to cooperate with the completion of Visual Analogue Scale (VAS) and Self-Rating Anxiety Scale (SAS) scoring and other scale evaluations; and (6) The patient and their family are informed and consent to participate in this study and sign the informed consent form.

Exclusion criteria: (1) Patients with concurrent malignant tumors, severe liver and kidney failure, coagulation disorders, etc.; (2) Patients with pressure ulcers complicated with sepsis; (3) Patients with mental disorders, cognitive impairments or communication disorders, unable to cooperate with the intervention and assessment; (4) Patients who have received other psychological interventions or analgesic drug treatments within the past month; and (5) Patients who withdraw from the study or lose contact during follow-up.

Dropout and exclusion criteria: (1) Severe adverse reactions occur during the study, requiring termination of the intervention; (2) Non-compliance with the study protocol, unauthorized changes to the treatment plan or acceptance of other intervention measures; and (3) Excessive loss of research data, affecting result analysis.

Methods

Both groups of patients were given basic care, including: (1) Position care: Assist the patient to turn over every 2 hours to avoid continuous pressure on the pressure ulcer area. The movement should be gentle to prevent damage to the wound surface; (2) Skin care: Clean the patient’s skin with warm water daily to keep it dry and clean. Avoid using irritating soaps or cleansers; and (3) Condition monitoring: Monitor the patient’s vital signs such as body temperature, heart rate, and blood pressure daily, and observe for symptoms such as fever and chills that may indicate worsening infection.

Control group: On the basis of routine care, the “negative pressure wound therapy (VSD) + continuous wound monitoring + nutritional support” routine care model was adopted. Specific measures are as follows: Negative pressure wound therapy care: (1) Wound debridement: The wound is thoroughly debrided by a surgeon to remove necrotic tissue and purulent secretions. A suitable VSD dressing [Wuhan VSD Medical Technology Co., Ltd. (specification: VSD-B-2-17.8 × 12.6X1, production batch number: 250623)] is selected based on the wound size, applied to cover the wound and sealed, and connected to a negative pressure suction device. The negative pressure value is set at -75 mmHg to -125 mmHg, and continuous negative pressure suction is maintained[12]; (2) The attending surgeon changes the VSD dressing every 5 days and examines the wound condition. The nurse’s daily care after VSD application includes: Checking whether the negative pressure source is within the specified range, whether the dressing has collapsed, whether the drainage tube is compressed or folded, and whether there is any blockage in the drainage tube; observing the volume, color, and consistency of the drainage fluid, and whether there is a large amount of fresh blood being suctioned out; and observing the pain condition of the wound; the nurse follows the doctor’s orders: 250 mL of saline + 80000 units of gentamicin for flushing to control infection. If the VSD drainage fluid or flushing fluid becomes turbid, the VSD is opened immediately, and the wound is observed while waiting for the doctor’s treatment, and early intervention is carried out. If the fluid is yellow and transparent or clear and transparent, it indicates no infection. Bacterial culture of the fluid is performed, and if no bacteria grow, the next step of treatment can be carried out; (3) Nutritional support care: Dietary guidance: Encourage the patient to consume high-protein, high-vitamin, and high-calorie foods such as eggs, milk, fish, fresh vegetables, and fruits. The daily protein intake should be controlled at 1.5-2.0 g/kg; and (4) Nutritional supplementation: For patients with difficulty in eating or poor nutritional status, enteral nutrition preparations or intravenous nutrition support are provided to improve nutritional status and promote wound healing.

Study group: On the basis of the control group, encouraging intervention based on Watson’s caring theory is combined. The intervention program is based on the 10 core elements of Watson’s caring theory and tailored to the characteristics of patients with pressure ulcers. It designs four dimensions of encouraging intervention measures: “emotional support, information encouragement, positive guidance, and social support”[13]. The intervention is implemented by specially trained nurses (2 senior nurses and 3 nurses). The specific measures are as follows: (1) Pre-intervention training: Before the intervention, the nurses are trained in Watson’s caring theory, encouraging communication skills, and pressure ulcer care knowledge. The training lasts for 2 weeks, with 4 hours of training per week. After the training, theoretical and operational assessments (both out of 100 points, with a passing score of 80 points) are conducted to ensure that the nurses have mastered the intervention methods and skills; (2) Emotional support intervention: Care elements: Forming a humanistic altruistic value system and instilling beliefs and hope. This includes establishing a trusting relationship: In the first week of the intervention, the nurses have one-on-one communication with the patients for 15-20 minutes each day, using listening and empathy to understand the patients’ pain and needs; (3) Emotional counseling: When patients show negative emotions such as anxiety and irritability, the nurses provide timely emotional counseling and encourage patients to express their inner feelings through the “emotional release method”; and (4) Family support linkage: Inviting family members to participate in the nursing process, organizing a family communication meeting once a week, lasting for 15-20 minutes, to inform the family of the patient’s treatment progress and care points, and guiding the family to provide emotional support to the patient, making the patient feel the warmth of the family and enhancing their confidence in treatment.

Information encouragement intervention: Care elements: Cultivating sensitivity to oneself and others and developing a helping-trusting relationship. The approach includes disease knowledge explanation, informing and encouraging about treatment progress, and self-care guidance: According to the patient’s recovery situation, guiding the patient to perform simple self-care, allowing the patient to participate in the care process and enhancing their sense of self-efficacy. Positive guidance intervention (care elements: Promoting and accepting positive and negative emotional expressions and systematically using scientific problem-solving methods for decision-making): This includes goal setting: Working with the patient to set phased treatment goals, such as “Our goal this week is to reduce the secretion from the wound and lower the pain score by 1 point”. When the patient achieves the goal, they are given verbal praise or small rewards; if the goal is not achieved, the nurse helps the patient analyze the reasons and adjust the goals and plans. Pain management guidance: Guiding the patient to use non-pharmacological methods to relieve pain, such as deep breathing relaxation training (twice a day, 10 minutes each time, guiding the patient to inhale slowly for 5 seconds); Negative emotion transformation: When the patient expresses concerns about the prognosis (such as “Will my pressure ulcer never heal?”), the nurse uses “problem-solving guidance” to analyze the reasons with the patient and estimate that as long as the patient adheres to nutritional support and wound care, the healing will improve. This helps the patient transform negative emotions into positive treatment motivation. Social support intervention (care elements: Promoting interpersonal interaction, providing spiritual support, and allowing existential phenomenological forces): For patients with insufficient family support, the hospital or community nursing service center is contacted to provide regular home care guidance (twice a week), daily care, and other services to solve the patient’s practical difficulties. Personalized spiritual support can also be provided based on the patient’s religious beliefs and cultural background to meet the patient’s spiritual needs and enhance their psychological resilience.

Main observation indicators

Prognostic-related indicators: (1) Wound healing effect: After 8 weeks of intervention, the wound healing effect was evaluated according to the “Guidelines for the Diagnosis, Treatment and Nursing of Pressure Ulcers (2018 Edition)”[14], and was classified as cured (wound completely closed with epithelial tissue covering), markedly effective (wound area reduced by ≥ 70%, granulation tissue full and no purulent secretion), effective (wound area reduced by 30%-69%, granulation tissue growing well and secretion reduced), and ineffective (wound area reduced by < 30% or expanded, granulation tissue growing poorly and still with purulent secretion). The total effective rate of wound healing (cured + markedly effective + effective) was calculated; (2) Wound healing time: The time from the start of intervention to complete wound closure was recorded (if not completely closed within 8 weeks, it was recorded as 8 weeks); and (3) Total hospital stay: The total number of days from admission to discharge of the patient was recorded.

Infection and nutrition indicators: 5 mL of fasting venous blood was collected from the patients before intervention and 8 weeks after intervention. The white blood cell count (WBC), red blood cell count (RBC), and hemoglobin (HBG) levels were detected using an automatic blood cell analyzer (Mindray BC-7500CS). The serum albumin (ALB) level was detected using an automatic biochemical analyzer (Lianyi AS-2450). The level of high-sensitivity C-reactive protein (hs-CRP) was detected using a fully automatic chemiluminescence immunoassay analyzer (XinChang MAGLUMI X8; the reagent kit was purchased from Shenzhen XinChang Bio-Medical Engineering Co., Ltd., China). Wound secretions were collected before intervention and 8 weeks after intervention, and the positive rate of microbial culture was detected using the bacterial culture method (a colony count > 10⁵ CFU/g was considered positive).

Pain, pressure ulcer risk and anxiety emotion indicators: The following scales were used to assess the patients before intervention, 4 weeks after intervention, and 8 weeks after intervention: (1) VAS[15]: The score range for this scale is 0-10, where 0 indicates no pain and 10 indicates severe pain. It is used to assess the level of pain a patient experiences; (2) Braden Scale[16]: The total score for this scale is 6-23. It is used to assess the risk of pressure ulcers in patients. It includes six dimensions: Sensory perception, moisture level, mobility, mobility, nutritional status, friction, and shear force. A higher score indicates more severe pain, and a lower score indicates a higher risk of pressure ulcers; and (3) SAS[17]: This scale consists of 20 items, each with a score range of 1 to 4. It is used to assess the level of anxiety a patient experiences. The standard score is the total score × 1.25. A score ≥ 50 indicates the presence of anxiety. A higher score indicates a more severe degree of anxiety. The anxiety index is calculated using a standard score of ≥50, which is calculated by multiplying the total score by 1.25. A higher score indicates a more severe level of anxiety.

Occurrence of adverse reactions and complications: Adverse reactions and complications during the intervention period were recorded for both groups of patients, including VSD dressing allergy, adverse reactions to analgesic drugs, and complications such as wound bleeding, aggravated wound infection, recurrence of pressure ulcers, and pulmonary infection. The total incidence was calculated.

Statistical analysis

Data processing was performed using the statistical software SPSS 26.0. Continuous data were expressed as mean ± SD, and independent sample t-tests were used for group comparisons. Count data were expressed as n (%), and χ² tests were used for group comparisons. Pearson correlation coefficient analysis was used for continuous data following a normal distribution, and Spearman rank correlation coefficient analysis was used for continuous data not following a normal distribution. A P value < 0.05 was considered statistically significant.

RESULTS

Baseline data analysis

There was no statistically significant difference between the two groups of patients in terms of general data such as age, gender, pressure ulcer stage, reasons for bed rest, underlying diseases, and infection degree (P > 0.05), and they were comparable. For details, please refer to Table 1.

Table 1 Comparison of general data of the two groups of patients (n = 78), n (%)/mean ± SD.

Index	Control group (n = 78)	Study group (n = 78)	t/χ² value	P value
Age (year)	62.35 ± 5.12	61.87 ± 4.98	0.587	0.557
Gender			0.164	0.686
Male	44 (56.40)	45 (57.69)
Female	34 (43.60)	33 (42.31)
Pressure ulcer stage			0.321	0.571
Phase III	48 (61.54)	51 (65.38)
Phase IV	30 (38.46)	27 (34.62)
Reasons for bed rest			1.235	0.540
Sequelae of stroke	35 (44.87)	33 (42.31)
Parkinson’s disease	18 (23.08)	20 (25.64)
Alzheimer’s disease	18 (23.08)	16 (20.51)
Other	7 (8.97)	9 (11.54)
Underlying diseases			0.876	0.645
Hypertension	53 (67.95)	55 (70.51)
Diabetes	35 (44.87)	34 (43.59)
Coronary heart disease	25 (32.05)	27 (34.62)
Degree of infection			0.512	0.774
Mild infection (WBC 10-15 × 109/L)	30 (38.46)	31 (39.74)
Moderate infection (WBC 15-20 × 109/L)	33 (42.31)	32 (41.03)
Severe infection (WBC > 20 × 109/L)	16 (20.51)	15 (19.23)

WBC: White blood cell.

Comparison of prognostic indicators between the two groups

Following eight weeks of intervention, the study group's overall effective rate of wound healing was much greater than the control groups, and Table 2 shows that the study group’s wound healing time and overall hospital stay were significantly shorter (P < 0.05).

Table 2 Comparison of prognostic indicators between the two groups (n = 78), n (%)/mean ± SD.

Index	Control group (n = 78)	Study group (n = 78)	Statistic	P value
Wound healing effect			u = 2.357	0.018
Recovery from illness	22 (28.21)	35 (44.87)
Conspicuous effect	25 (32.05)	24 (30.77)
Effective	12 (15.38)	13 (16.67)
Void of effect	19 (24.36)	6 (7.69)
Total effective rate (%)	75.64	92.31	χ2 = 8.050	0.005
Wound healing time (day)	52.36 ± 7.82	43.15 ± 6.54	t = 7.981	< 0.001
Total length of stay (day)	58.24 ± 8.15	49.37 ± 7.26	t = 7.176	< 0.001

Comparison of infection and nutritional indicators between the two groups before and after intervention

Prior to the intervention, all indicators showed no significant changes between the two groups (P > 0.05). After eight weeks, both groups exhibited significant improvements (increased RBC, HBG, and ALB; decreased WBC, CRP-C, and microbiological positive); however, the study group showed significantly bigger gains (P < 0.05, Table 3).

Table 3 Comparison of infection and nutritional indicators between the two groups before and after intervention, n (%)/mean ± SD.

Index	Time point	Control group (n = 78)	Study group (n = 78)	t/χ² value	P value
WBC (× 109/L)	Before intervention	16.87 ± 3.25	17.02 ± 3.18	-0.291	0.771
	After 8 weeks of intervention	11.23 ± 2.15	8.56 ± 1.87	8.275	< 0.001
RBC (× 1012/L)	Before intervention	3.52 ± 0.48	3.48 ± 0.51	0.565	0.573
	After 8 weeks of intervention	4.01 ± 0.53	4.58 ± 0.49	-7.245	< 0.001
HBG (g/L)	Before intervention	102.35 ± 12.68	101.87 ± 13.02	0.238	0.812
	After 8 weeks of intervention	115.62 ± 11.85	128.43 ± 10.96	-7.246	< 0.001
ALB (g/L)	Before intervention	32.15 ± 3.56	31.87 ± 3.42	0.513	0.609
	After 8 weeks of intervention	35.82 ± 3.18	39.65 ± 2.87	-8.092	< 0.001
CRP-C (mg/L)	Before intervention	45.62 ± 8.75	46.13 ± 8.52	-0.367	0.714
	After 8 weeks of intervention	28.35 ± 7.12	16.87 ± 6.35	10.732	< 0.001
Positive microbial culture	Before intervention	92 (92.00)	93 (93.00)	0.018	0.894
	After 8 weeks of intervention	45 (45.00)	22 (22.00)	11.874	0.001

WBC: White blood cell; CRP-C: C-reactive protein; RBC: Red blood cell; HBG: Hemoglobin; ALB: Albumin.

Comparison of pain, pressure ulcer risk and anxiety indicators between the two groups before and after intervention

Prior to the intervention, there were no significant differences in VAS, Braden, and SAS scores between the two groups (P > 0.05). At 4 weeks and 8 weeks, both groups showed a significant decrease in VAS and SAS scores compared to before the intervention, and a significant increase in Braden scores, although the study group showed a significantly greater improvement (P < 0.05, Table 4).

Table 4 Comparison of Visual Analogue Scale score, Braden score and Self-Rating Anxiety Scale score between the two groups before and after intervention, mean ± SD.

Index	Time point	Control group (n = 78)	Study group (n = 78)	t value between groups	P value
VAS score	Before intervention	7.82 ± 1.25	7.76 ± 1.31	0.293	0.770
	After 4 weeks of intervention	5.23 ± 1.08	3.15 ± 0.96	12.714	< 0.001
	After 8 weeks of intervention	3.18 ± 0.87	1.56 ± 0.72	12.666	< 0.001
Braden score	Before intervention	12.35 ± 1.87	12.28 ± 1.93	0.230	0.818
	After 4 weeks of intervention	14.52 ± 1.65	16.87 ± 1.52	-9.256	< 0.001
	After 8 weeks of intervention	16.23 ± 1.48	18.56 ± 1.37	-10.206	< 0.001
SAS score	Before intervention	65.32 ± 7.85	64.87 ± 8.02	0.354	0.724
	After 4 weeks of intervention	52.15 ± 6.93	40.23 ± 6.15	11.364	< 0.001
	After 8 weeks of intervention	45.68 ± 6.32	35.12 ± 5.87	10.816	< 0.001

VAS: Visual Analogue Scale; SAS: Self-Rating Anxiety Scale.

Comparison of adverse reactions and complications between the two groups

No serious adverse reactions occurred in either group. Adverse reaction incidence: 6.00% (study) vs 8.00% (control), P > 0.05. Complication incidence: 8.00% vs 22.00%, P < 0.05 (Table 5).

Table 5 Comparison of adverse reactions and complications between the two groups, n (%).

Indicators	Control group (n = 78)	Study group (n = 78)	χ2 value	P value
Adverse reactions			0.000	1.000
VSD dressing allergy	3 (3.85)	2 (2.56)
Adverse drug reactions (nausea, dizziness)	3 (3.85)	2 (2.56)
Overall incidence	6 (7.69)	5 (6.41)
Complications			5.100	0.024
Bleeding from wounds	2 (2.56)	1 (1.28)
The wound infection was aggravated	5 (6.41)	1 (1.28)
Recurrence of pressure ulcers	4 (5.13)	2 (2.26)
Pulmonary infection	6 (7.69)	2 (2.56)
Overall incidence	17 (21.79)	6 (7.69)

VSD: Vacuum sealing drainage.

Typical case analysis

Case 1 (control group): A 43-year-old male patient was admitted with a diagnosis of stage IV pressure ulcer, osteomyelitis, and bone necrosis. The condition originated from a sacrococcygeal pressure injury that had persisted for two and a half years without healing, following long-term bed rest due to high-level paraplegia from a fall injury. The ulcer extended in depth to the sacrum and coccyx; the treatment regimen included VSD combined with routine nursing care. The admission date was March 13, and the discharge date was July 26, resulting in a total hospital stay of 135 days (Figure 1).

Figure 1 The pressure ulcer repair process in the control group patient. A: The sacrococcygeal area presented with a 7 cm × 9 cm area of scar contracture. Within this, a central 6 cm × 7 cm region exhibited erythema and swelling, featuring a 3 cm × 3 cm open wound that extended to the depth of the sacrum and coccyx. The surface of the sacrococcygeal bone appeared black and was covered with purulent slough; B: Postoperative view following debridement of the sacrococcygeal osteomyelitic lesion, muscle debridement for ulcer repair, and application of a vacuum sealing drainage system; C: Postoperative view after a gluteus maximus myocutaneous flap transfer and skin grafting.

Case 2 (study group): A 69-year-old male patient was hospitalized with grade IV acute wound infection. The patient had been bedridden for more than 5 years and had a 4-month history of shoulder injury prior to admission. Physical examination revealed a 5-cm fluid-filled abscess on the right shoulder; The surrounding skin was swollen and tender. The treatment plan included specific therapies based on Watson’s patient care philosophy, including the VSD technique and standard nursing therapies. The patient was admitted on May 28 and discharged on June 4 after 37 days of hospitalization. See Figure 2 for details.

Figure 2 The pressure ulcer repair process in the study group patient. A: A 5 cm diameter skin defect with purulent exudate was observed in the scapular region, surrounded by erythema and swelling; B: Postoperative view following the encouragement-based intervention (Watson’s theory), sequestrectomy of the scapula, synovectomy of the shoulder joint, and application of vacuum sealing drainage. The wound bed shows the growth of fresh granulation tissue. The ulcer area at this stage measured 7 cm × 7 cm; C: Postoperative view after surgical ulcer repair and capsular modification, showing the wound closed with absorbable sutures and one negative pressure drain in place.

DISCUSSION

Grade III-IV pressure ulcers are a common and severe feature of chronic trauma commonly seen in older adults requiring prolonged bed rest. The severe tissue damage that accompanies infection often leads to progressive oxidative stress and metabolic changes. Current interventions for acute pressure infection mainly focus on wound incision. These techniques effectively control local lesions, but often neglect the patient’s mental state and treatment compliance. Traditional nursing models lack comprehensive and humane care, therefore, limiting the development of general rehabilitation capacity[19]. Watson’s theory of human care aims to meet a person’s physical, emotional, and social health needs. By establishing a strong nurse-patient relationship and implementing standardized care, this concept benefits the physical and mental health of patients and is used in the management of chronic diseases and chronic wounds[20,21]. The results showed that the wound healing rate in the experimental group was significantly higher than that in the control group; Time to wound healing and hospitalization was reduced in the study group and Braden score increased. These results confirm that the intervention can accelerate wound healing, reduce wound healing time, and reduce the recurrence of pressure ulcers. Traditional pressure ulcer treatment follows the dysfunctional disease model, based on systemic wound management; vital sign monitoring and primary care. In contrast, our four-tier intervention model allows for a flexible and customized treatment plan. Emotional support: Continuous personal contact, empathetic listening and family involvement reduce patient anxiety and depression, reduce the need for empathetic responses and improve pain management, which provides a better chance of recovery[22]. Information mobilization: Through disease education, information about disease progression and instructions for self-care, patients’ negative mental perceptions can be reduced, anxiety about disease progression can be reduced and adherence to treatment can be improved, leading to improved multiple treatment strategies such as VSD and nutritional support[23]. Effective support: By setting therapeutic goals in stages III and IV, implementing non-pharmacological pain management and helping patients change their emotional state, patients’ coping mechanisms are improved, their ability to tolerate pain is improved and quality of life is improved in the transformation process from passive to receptive patient. Social support: For patients with limited family care, integrating family members ensures continuity of care after discharge, addressing gaps in therapeutic support, and reducing the risk of relapse, while maximizing long-term benefits[24].

Poor infection and malnutrition are the two leading causes of delayed healing of stage III-IV wounds. High-pressure ulcers and infection can trigger an autoimmune response, leading to elevated levels of inflammatory markers such as WBC and hs-CRP. Chronic inflammatory stress can accelerate protein degradation and inhibit nutritional function; malnutrition, in turn, reduces skin cell growth and impairs skin repair, increasing the risk of infection[25,26]. According to the data from this study, the levels of inflammatory markers and erythrocyte sedimentation rate in the study group were significantly lower than those in the control group, while the levels of RBC, HBG, and ALB were better than those in the control group, indicating that the injection can effectively treat concurrent infections accompanied by improvement in pathological conditions. Chronic stress activates the hypothalamic-pituitary-adrenal axis, which promotes cortisol production, inhibits immune cell function, and accelerates protein catabolism[27]. The results of the study have shown that the treatment significantly reduces patients' physical and mental stress, reduces the production of inflammatory cytokines, restores immunity, and increases the ability to clear pathogens from wounds. In addition, by providing personalized dietary guidance, nutritional education, and support for integration with family and community, patients’ adherence to nutritional treatment was significantly improved[28].

Pain and anxiety constitute the primary physiological and psychological symptoms experienced by patients with stage III to IV infections. Chronic wound pain disrupts sleep and concentration, subsequently triggering irritability and anxiety; this negative psychological state leads to heightened pain sensitivity and diminished pain tolerance, thereby severely compromising patients' motivation for recovery and overall quality of life[29,30]. In the present study, following four and eight weeks of intervention, the VAS and SAS scores of the intervention group were significantly lower than those of the control group. The deep breathing exercises and attention-diversion techniques introduced in this study aid in regulating autonomic nervous system activity; furthermore, by employing empathetic listening and guiding patients to articulate their emotions, these interventions help alleviate psychological distress. Additionally, encouraging patients to share their recovery experiences with one another—coupled with the implementation of proactive professional support strategies—helps dispel patients’ fears regarding the unknown, thereby bolstering their confidence in their recovery[31,32]. No serious adverse events occurred in either group, nor were there any significant differences in the incidence of dressing-related allergies or mild drug reactions. This suggests that the encouragement-based intervention, grounded in Watson’s theory of human caring, constitutes a safe and non-invasive mode of adjunctive care. The incidence of complications was lower in the intervention group than in the control group; an analysis of the underlying reasons reveals that the intervention measures improved infection control, nutritional status, and psychological well-being, thereby mitigating the precipitating factors for complications. Concurrently, systematic health education and self-care training empowered patients and their families to master skills such as wound observation and symptom recognition, enabling them to detect and address wound abnormalities at an early stage, thereby reducing the risk of infection exacerbation[33].

Unlike traditional psychological approaches that focus on depression or anxiety, this approach has the advantage of being holistic and humanistic. Cognitive-behavioral approaches emphasize accepting symptoms in a nonjudgmental manner and do not promote recovery; behavioral interventions are used to correct negative perceptions but are not related to the patient's relationships[34]. Behavioral interventions based on Watson's theory combine emotional management techniques, psychological discipline, training skills, and social support, are well-suited to the emotional, cognitive, and behavioral needs of patients with pressure ulcers, and may facilitate the use of multiple preventive therapies using a single approach. Larger studies are needed to ensure that all populations are included. Second, the 8-week treatment period and the long follow-up period make it difficult to assess long-term effects on different lifestyles and behaviors, and the follow-up period should be extended. Third, no subgroup analyses were performed, making it difficult to determine whether there were differences in the effects of behavioral care based on pressure ulcer type, disease, or age. Fourth, the evaluation is largely based on objective measures and indicators, with no real assessment of patients’ experiences of their mental health and nurses’ satisfaction, and quality assessment is still needed[35].

CONCLUSION

Encouraging interventions—operating across the four dimensions of emotional support, informational encouragement, positive guidance, and social support, and grounded in Watson’s theory of caring—can effectively alleviate pain, reduce anxiety, improve nutritional status, and lower the incidence of complications. This intervention model demonstrates a favorable safety profile, is readily implementable, provides a scientific and feasible new approach for the clinical nursing care of this patient population, and merits promotion and application in wound care departments and geriatric units across various levels of hospitals.