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.
Risk For Infection
- Poor nutritional status.
- Proximity of sacral wounds to perineum.
- Open pressure ulcer.
Possibly evidenced by
- [not applicable].
- 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.
|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.|
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 MUST READ!
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.
Other nursing care plans affecting the integumentary system:
- Burn Injury | 11 Care Plans
- Dermatitis | 4 Care Plans
- Herpes Zoster (Shingles) | 4 Care Plans
- Pressure Ulcer (Bedsores) | 3 Care Plans