3 Pressure Ulcer (Bedsores) Nursing Care Plans

Risk For Ineffective Health Maintenance

Patients with pressure ulcers are at risk for ineffective health maintenance due to several factors, including impaired functional status, lack of previous experience in managing pressure ulcers, and the need for long-term pressure management. Impaired functional status can make it difficult for the patient to perform self-care activities and follow a treatment plan, while a lack of previous experience may result in inadequate wound care. Additionally, long-term pressure management requires ongoing attention and monitoring, which can be challenging for patients and their caregivers.

Nursing Diagnosis

• Risk for Ineffective Health Maintenance

Risk factors

• Impaired functional status.
• Lack of previous similar experience.
• Need for long-term pressure management.
• Possible need for special equipment.

Possibly evidenced by

• Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

• The client and caregiver will verbalize understanding of the following aspects of home care: nutrition, pressure relief, wound care, and incontinence management.
• The client and caregiver will verbalize their ability to cope adequately with the existing situation, and provide support/monitoring as indicated.

Nursing Assessment and Rationales

1. Assess the client’s and caregiver’s knowledge of and ability to provide local wound care.
Clients are no longer kept hospitalized until pressure ulcers have healed, The need for local wound care may continue at home for weeks to months.

2. Assess the client’s and caregiver’s understanding of the prevention of further pressure ulcer development.
Clients who are immobile will need frequent repositioning to lessen the risk of a breakdown in those areas that are intact.

3. Assess the client’s and caregiver’s understanding of the long-term nature of wound healing
Pressure ulcers may take weeks to months to heal even under ideal circumstances. The wound heals from the base of the ulcer up, and from the edges of the ulcer toward the center. Palliative wound care may be appropriate for clean, chronic, non-healing wounds.

4. Assess the client’s and caregiver’s understanding of the relationship between incontinence and further skin breakdown or complication of healing.
Managing incontinence may be the most difficult aspect of home management and is often the reason nursing home placements are made.

5. Assess the client’s and caregiver’s understanding of and ability to provide a High-calorie, high-protein diet throughout the course of wound healing.
Clients may require enteral feeding (through gastronomy tube, nasogastric tube feedings, or the oral route), which requires knowledge of preparation and the use of special equipment.

6. Assess for the availability of a pressure reduction or pressure-relief surface.
Clients may take a thick, dense foam mattress home from the hospital to place on their own bed. Rental provisions of low-air-loss beds (e.g., KinAir, Flexicare) and air-fluidized therapy beds (FluidAir, Skytron, Clintron) may be arranged but often pose a financial difficulty because few payer sources will cover the cost of these beds in the home.

Nursing Interventions and Rationales

1. Educate the client and the caregiver to report the following signs indicating wound infection: Fever, malaise, chills, foul-smelling odor, and purulent drainage.
Early detection prompts immediate intervention.

2. Educate the client and the caregiver in managing incontinence (e.g., use of moisture barrier ointments, use of underpads, use of external catheters).
Teaching proper techniques can prevent leakage and skin problems. Reusable products such as underpads or linen protectors made of cloth with a waterproof lining are better for the client’s skin and are more economical but require laundering. Moisture barrier ointments protect intact skin from excoriation.

3. Educate the client and the caregiver regarding local wound care, and allow for a return demonstration.
This will allow the client to use new information immediately, thus enhancing retention. Immediate feedback allows the learner to make corrections, rather than practice the skill incorrectly.

4. Provide written instructions with listed resources.
Long-term management requires specific written plans to enhance adherence o treatment. Several internet resources provide lay education.

5. Involve a social worker or case manager.
Referral helps the client and family determine whether placement in an extended care facility is needed. Because many clients with pressures are older, it is often an older spouse who is available to provide care; as a result of the intensive nursing care needs of these clients, discharge to home is often unrealistic.

6. Consult a wound specialist to evaluate care in the home.
Besides evaluating the ability to deliver care, the specialist may be useful in securing specialty treatment.

7. Educate the client and the caregiver on the importance of pressure reduction and relief (e.g., turning schedule, use of specialty beds, use of relief surface where the client sits).
Information can nurture enhanced adherence to pressure ulcer treatment guidelines.

8. Discuss with the client and caregiver the possible need for respite care.
Long-term responsibility for client care in the home is burdening; those providing care may need help to understand that their needs for relaxation are important to the maintenance of health and should not be viewed as avoidance of the responsibility.

9. Discuss with the client and caregiver the need for in-home nursing care or homemaker services.
These provide all or part of the client’s care and can be economical to the client. Also, keeping the client in his or her own environment lessen the risk of hospital-acquired infection and keeps the client in a familiar surrounding.