Pressure ulcers, sometimes called bedsores or Decubitus ulcers, are skin and tissue breakdown that arises from exertion of incessant pressure to the skin. Continuous stress to the skins’ integrity will eventually cause skin breakdowns. Show
The development of pressure ulcers is an example of such skin damage. The most common sites of injuries are the bony prominences of the body, such as the heels, knees, elbows, and sacrum. There are different stages of pressure ulcers in terms of severity. Not all stages of pressure ulcers present with open sores. The National Pressure Injury Advisory Panel (NPIAP) has coined that the most appropriate term should be “pressure injuries”. Problems on mobility, poor nutrition, among others, predispose patients in having this condition. Signs and Symptoms of Pressure UlcerThe general clinical manifestations of pressure ulcers include:
Causes and Risk Factors of Pressure UlcerPressure ulcers are caused by relentless pressure against the skin, thereby limiting blood flow to the skin and its surrounding tissues. Inactivity and limited movement, particularly on bed-ridden patients, makes the skin vulnerable for the development of pressure ulcers. There are three contributing factors for its development, and they are:
The risk factors of pressure ulcers are the following:
Complications of Pressure UlcerComplications of pressure ulcers are debilitating, some even life-threatening:
Diagnosis of Pressure Ulcer
Treatment for Pressure Ulcer
Nursing Diagnosis for Pressure UlcerNursing Care Plan for Pressure Ulcer 1Nursing Diagnosis: Impaired Skin Integrity related to skin breakdown secondary to pressure ulcer, as evidenced by pressure sore on the sacrum, discharge from the sores for a couple of days, pain and soreness Desired Outcome: The patient will have optimal skin integrity by following treatment regimen for decubitus ulcers. Nursing Interventions for Pressure UlcersRationaleAssess the patient’s skin on his/her whole body. Create a wound care chart.To determine the severity and extent of decubitus ulcers and any affected areas that require special attention or wound care.Commence wound care that is appropriate to the stage of the decubitus ulcer. Application of the prescribed antibiotic cream or ointment directly to the affected area may be required.Performing the correct wound care in accordance to the stage of the decubitus ulcer maximizes the healing potential of the pressure injury.Educate the carer about proper wound hygiene through washing the sores with the prescribed cleanser. Advise the patient to prevent scratching the affected areas.It is important to maintain the cleanliness of the affected areas by washing with the prescribed cleanser. The sores may cause mild itching, but it is advisable to prevent the child from scratching the affected areas to prevent worsening of the infection.Perform frequent bed turning for bed-ridden patients at least every 2 hours. Use appropriate equipment such as pressure-relieving or “air” mattress and trochanter rolls on bony prominences. To reduce the pressure from the affected area and other bony prominences.Encourage getting out of bed to sit on the chair and performing tolerable exercises. Refer to physical therapy team as needed. Encouraging the patient to move from bed to chair and to perform appropriate exercises through physical therapyIf the patient is to be discharged, teach the carer the proper wound care over the affected areas.Proper wound care and application of bandages over the affected areas can help prevent the worsening of pressure injury and promote wound healing at home.Nursing Care Plan for Pressure Ulcer 2Nursing Diagnosis: Acute Pain related to pressure ulcers as evidenced by pain score of 10 out of 10, guarding sign on the affected limb, restlessness, and irritability especially during wound care Desired Outcome: The patient will report a pain score of 0 out of 10. Nursing Interventions for Pressure UlcersRationalesAssess the patient’s vital signs. Ask the patient to rate the pain from 0 to 10, and describe the pain he/she is experiencing.To create a baseline set of observations for the patient. The 10-point pain scale is a globally recognized pain rating tool that is both accurate and effective.Administer analgesics/ pain medications as prescribed, at least 30 minutes before wound care.To provide pain relief to the patient.Ask the patient to re-rate his/her acute pain 30 minutes to an hour after administering the analgesic.To assess the effectiveness of treatment.Provide more analgesics at recommended/prescribed intervals.To promote pain relief and patient comfort without the risk of overdose.Reposition the patient in his/her comfortable/preferred position. Encourage pursed lip breathing and deep breathing exercises.To promote optimal patient comfort and reduce anxiety/ restlessness.More Nursing Diagnosis for Pressure Ulcer
Nursing ReferencesAckley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon Disclaimer:Please follow your facilities guidelines and policies and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. What nursing interventions are used to prevent pressure injuries?The review identified four broad categories of interventions that are the most effective for preventing pressure injuries: (a) PI prevention bundles, (b) repositioning and the use of surface support, (c) prevention of medical device-related pressure injuries and (d) access to expertise.
What are three nursing interventions to prevent pressure ulcers?The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers:. Comprehensive skin assessment.. Standardized pressure ulcer risk assessment.. Care planning and implementation to address areas of risk.. What are some examples of pressure injury prevention?Tips to prevent pressure injuries include:. Keeping the skin clean and clear of bodily fluids.. Moving and repositioning the body frequently to avoid constant pressure on bony parts of the body.. Using foam wedges and pillows to help relieve pressure on bony parts of the body when turned in bed.. What nursing interventions prevent skin breakdown?Turning every 2 hours is the key to prevent breakdown. Head of bed should be kept at 30 degrees or less to avoid sliding down on bed. Use pillows or foam wedges to keep bony prominences from direct contact with each other. Keep pillows under the heels to raise off bed.
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