A pressure ulcer (also known as bedsores or decubitus ulcer) is a localized skin injury where tissues are compressed between bony prominences and hard surfaces such as a mattress. They are caused by pressure in combination with friction, shearing forces, and moisture. The pressure compresses small blood vessels and leads to impaired tissue perfusion. The reduction of blood flow causes tissue hypoxia leading to cellular death.
Nursing Care Plans
Pressure ulcers stage I through III can be managed with aggressive local wound treatment and proper nutritional support while stage IV pressure ulcers usually require surgical intervention.
Nursing care for clients experiencing pressure ulcer (bedsores) includes assessing the contributing factors leading to a lack of tissue perfusion, assessing the extent of the injury, promoting compliance to the medication regimen, preventing further injury.
Impaired Skin Integrity
May be related to
- Chronic disease state.
- Extreme of ages.
- Imbalanced nutritional state.
- Impaired cognition.
- Impaired sensation.
- Immunological deficit.
- Mechanical factors (friction, pressure, shear).
- Poor circulation.
- Pronounced body prominence.
Possibly evidenced by
- Destruction of skin layers.
- Disruption of skin surfaces.
- Drainage of pus.
- Invasion of body structures.
- Pressure ulcer stages:
- Deep tissue injury (new stage):
- Purple or maroon localized area of intact skin or blood-filled blister resulting from pressure damage of underlying soft tissue.
- Stage I:
- Epidermis is intact.
- Non-branch able erythema of intact skin. Discolouration of the skin, warmth, edema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.
- Stage II:
- Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.
- Stage III:
- Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
- Slough may be present; may include undermining and tunneling.
- Stage IV:
- Extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures, with or without full-thickness skin loss.
- Undermining and tunneling may develop.
- Full-thickness tissue loss in which actual depth of ulcer is completely obstructed by slough or eschar in the wound bed.
- Deep tissue injury (new stage):
- Client will get stage-appropriate wound care and has controlled risk factors for prevention of additional ulcers.
- Client will experience healing of pressure ulcers and experiences pressure reduction.
|Assess the specific risk factors for pressure ulcer:||Even clients with an existing pressure ulcer continue to be at risk for further injury, Nurses should consider all potential risk factors for pressure ulcers development.|
||Elderly clients have less elastic skin, less moisture, less padding and have thinning of the epidermis, making it more prone to skin impairment.|
||A severe protein depletion has an albumin level of less than 2.5 g/dL. Clients with pressure ulcer lose big amounts of protein in wound exudates and may require 4000 kcal/day or more to remain anabolic.|
|Clients with chronic diseases typically exhibit multiple risk factors that predispose them to pressure ulceration. These include poor nutrition, poor hydration, incontinence, and immobility.|
||The incidence of skin breakdown is directly related to the number of risk factor present.|
||Irradiated skin becomes thin and brittle, may have less blood supply, and is at a higher risk for skin breakdown.|
||Usually, people shift their weight off pressure areas every few minutes; this occurs more or less automatically, even during sleep. Clients with decreased sensation are unaware of unpleasant stimuli and do not shift weight, thereby exposing the skin to excessive pressure.|
||The urea in urine turns into ammonia within minutes and is erosive to the skin. While the stool may contain enzymes that cause skin breakdown. Diapers and incontinence pads with plastic liners trap moisture and speed up breakdown.|
||Immobility is a huge risk factor for pressure ulcer development among adult hospitalized clients.|
||Moisture may contribute to skin maceration.|
||Shearing forces are most commonly noted on the sacrum, scapulae, heels, and elbows from skin-sheet friction, from semi-Fowler’s position and repositioning, and from lift sheets.|
||Clients who spend the majority of time on one surface need a pressure reduction or pressure relief device to reduce the risk of skin breakdown.|
||These areas at highest risk for breakdown resulting from tissue ischemia from compression against a hard surface.|
|Use an objective tool for pressure ulcer risk assessment:
||The Braden scale is the most widely used risk assessment. It consists of six subscales namely: activity, mobility, moisture, nutrition, sensory perception, and friction.
Acute care: Assessment should be carried out on all patients on admission and every 24 to 48 hours or sooner if the patient’s condition changes.
Long-term care: Assess on admission, weekly for 4 weeks, then quarterly and whenever the resident’s condition changes.
|Assess the client’s level of pain, especially related to dressing change and procedures.||Prophylactic pain medication may be indicated.|
|Assess and stage the pressure ulcers.||Staging is essential because it determines the treatment plan. Staging should be assessed at each dressing stage. It reflects whether the epidermis, dermis, fat, muscle, bone, or joint is exposed. If the ulcer is covered with necrotic tissue (eschar), it cannot be accurately staged. Stage I ulcers are difficult to detect in darkly pigmented skin. The use of mirrors or a penlight may be helpful.|
|Determine the condition of the wound or wound bed.|
||Necrotic tissue is tissue that is dead and eventually must be removed before healing can take place. Necrotic tissue exhibits a wide range of appearance: black, brown, leathery, hard, shiny, thin, tough, white.|
||The color of tissue is an indication of tissue viability and oxygenation. White, gray, or yellow eschar may be present in stage II and III ulcers. Eschar may be black in stage IV ulcers.|
||Odor may arise from infection present in the wound; it may also arise from the necrotic tissue. Some local wound care products may create or intensify the odors and should be distinguished from wound or exudate odors.|
||In stage IV pressure ulcers, these may be apparent at the base of the ulcer. Wounds may demonstrate multiple stages or characteristics in a single wound.|
|Measure the size of the ulcer, and note the presence of undermining.||The ulcer dimensions include length, width, and depth. An ulcer begins in the deepest tissue layers before the skin breaks down. Hence the opening of the skin’s surface may not represent the true size of the ulcer.|
|Assess the condition of wound edges and surrounding tissue.||Surronding tissue may be healthy or may have various degrees of impairment. Healthy tissue is necessary for the use of local wound care products requiring adhesion to the skin. The presence of healthy tissue demarcates the boundaries of the pressure ulcer.|
|Assess the wound exudate.||Exudate is a normal part of wound physiology and must be differentiated from pus which is an indication of infection. Exudate may contain serum, blood, and white blood cells, and may appear clear, cloudy, or blood-tinged. The amount may vary from a few cubic centimeters, which are easily managed with dressings, to copious amounts not easily managed. Drainage is considered excessive when dressing changes are needed more often than every 6 hours.|
|Assess ulcer healing, using a pressure ulcer scale for healing (PUSH) tool.||This tool provides standardization in the measurement of wound healing. It quantifies surface area, exudate, and the type of wound tissue.|
|Provide local wound care:|
||It increases skin circulation.|
||It prevents shear and friction.|
||It moisturizes the skin.|
||Alginate dressings are a type that is highly absorbent and so can absorb the fluid (exudate) that is produced by some ulcers. These are often used for ulcers with moderate-to-heavy exudate.|
||Hydrocolloids are used to promote healing and wound debridement. They are not advised to use for heavy-exudate-producing wounds.|
||This maintains a moist environment but requires multiple dressing changes. Dressings must be removed while still wet. Dressings absorb small amounts of drainage.|
||Hydrogels provide moisture to dry, sloughy or necrotic wounds and assists autolytic debridement. Can be used on wounds with low exudate. Usually use for shallow ulcers without exudates.|
|Stage III and IV:|
||Different foams have different levels of absorbency. They are best used on granulating wounds. Foams lessen odor and repel bacteria and water.|
||This maintains a moist environment but requires multiple dressing changes as describe for stage II.|
||Wound fillers are used as a primary dressing and to pack wounds, maintain a moist environment.|
||Using a hydrocolloid or hydrogel, these create a moist wound interface that enhances the activity of endogenous proteolytic enzymes within the wound, liquefying and separating necrotic tissue from healthy tissue.|
||This procedure removes the necrotic tissue and senescent cells that slow down the tissue repair process, converting a chronic wound into an acute one in the process.|
||Involves allowing a traditional gauze-type dressing to dry out and adhere to the surface of the wound before manually removing the dressing, debriding any tissue attached to it.|
||Stimulation of many cellular processes improves healing.|
||Therapeutic use of live blow fly larvae (maggots) for a quick debridement.|
||Nerve-growth factors, colony-stimulating factors, and fibroblast growth factors are found to be effective in treating diabetic and venous ulcers.|
||A wound dressing systems that continuously or intermittently apply a subatmospheric pressure to the surface of a wound to assist healing.|
||Enzymatic debridement uses proteolytic enzymes to remove necrotic tissue. These agents work by selectively digesting the collagen portion of the necrotic tissue. Care should be taken to prevent damage to surrounding healthy tissues.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
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