3 Pressure Ulcer (Bedsores) Nursing Care Plans

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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.

Here are three (3) nursing care plans (NCP) and nursing diagnosis for pressure ulcers (bedsores):

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  1. Impaired Skin Integrity
  2. Risk For Infection
  3. Risk For Ineffective Health Maintenance
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Risk For Infection

Nursing Diagnosis

Risk factors

  • Poor nutritional status.
  • Proximity of sacral wounds to perineum.
  • Open pressure ulcer.

Possibly evidenced by

  • [not applicable].

Desired Outcomes

  • Client will maintain normal body temperature.
  • Client will remain free of local or systemic infections, as evidenced by the absence of copious, foul-smelling wound exudate.
Nursing InterventionsRationale
Assess the client’s nutritional status.Clients who seriously lack nutrition (serum albumin <2.5 mg/dl) are at risk of developing infection produced by a pressure ulcer. Also, clients with pressure ulcers lose tremendous amounts of protein in wound exudate and may require 4000 kcal/day or more to remain anabolic.
Assess the client for unexplained sepsis.When septic workup is done, the pressure ulcer must be considered a possible cause.
Assess for urinary and fecal incontinence.Sacral wounds, because of their proximity to the perineum, are at highest risk for infection caused by urine or fecal contamination. It is sometimes difficult to isolate the wound from the perineal area.
Assess pressure ulcer for odor, color of tissue, and drainage.Foul smelling pressure ulcer may indicate an infection; Infected tissue usually has a gray-yellow appearance without evidence of pink granulation tissue; The presence of exudate that is clear to straw-colored is normal. While purulent green or yellow drainage in large amounts indicates an infection.
Assess the client’s temperature.Fever is considered a temperature above 100.4 degrees F (38 degrees C) indicate a presence of infection unless the client is immunocompromised or diabetic.
Monitor the client’s white blood cell count (WBC).Elevated WBC counts indicate an infection, although, in very old individuals, the WBC count may rise only slightly during an infection, indicating a diminished marrow reserve.
Obtain wound cultures, if indicated.All pressure ulcers are colonized because skin normally has flora that will be found in an open skin lesion; however, all pressure ulcers are not infected. Infection is present when there is copious, foul-smelling, purulent drainage and the client has other signs of infection (fever, increased pain) and bacteria count greater than 105. Swab cultures are not recommended. Rather, tissue biopsy should be used to quantify and qualify the aerobic and anaerobic organisms present.
Consult with a dietitian for assistance with a high-protein, high-calorie diet.A High-calorie, high-protein diet may be recommended to help in healing and resist infection.
Provide thorough perineal hygiene after each episode of incontinence.This can lessen pathogens in the area of sacral pressure ulcers.
Provide hydrotherapy, if indicated.It is used to achieve wound cleansing and to promote good circulation.
Administer antibiotics as prescribed.Complicated wounds may develop cellulitis or sepsis, requiring antibiotic therapy. Oral antibiotics or topical silver sulfadiazine can be effective.
Provide local wound care as prescribed.The type and level of wound treatment depend on the staging of the ulcer and the type of infection present.
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Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

Other recommended site resources for this nursing care plan:

Other nursing care plans affecting the integumentary system:

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Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-surgical nurse for five years, he handled different kinds of patients and learned how to provide individualized care to them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals. He is currently working as a nursing instructor and have a particular interest in nursing management, emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his clinical knowledge and skills to students and nurses helping them become the best version of themselves and ultimately make an impact in uplifting the nursing profession.
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