Nursing Diagnosis and Care Plan for Pressure Ulcers- A Student’s Guide
Introduction
A pressure ulcer is a type of wound that occurs when an individual’s skin and tissue are exposed to prolonged pressure. The ulcers are often found on bony prominences (such as elbows, coccyx, and heels) with less padding between bone and skin. They can also occur in other areas of the body.
Sometimes these breaks will not heal on their own because they become infected from bacteria present on the person’s skin or clothing, which colonizes deep into the wet wound bed. This blog post discusses the nursing diagnosis and care plan for pressure ulcers, including assessment/diagnosis, risk factors, complications, and interventions.
We hope that this article is to help medical practitioners better understand what causes these wounds, signs of them developing, and ways to treat them, so they don’t worsen. As you read, keep in mind that our top nursing writers are ready to help with your nursing assignment in case you get stuck. All you need to do is place an order with us!
Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
What is a Pressure Ulcer?
A pressure ulcer is a break in the skin caused by unrelieved pressure. It can also be described as an area of tissue damaged or killed due to prolonged and intense contact with a hard surface, such as when someone lies down for too long without changing position.
Types of Pressure Ulcers
The most common types of pressure ulcers are bedsores, decubitus ulcers, and trochanteric bursitis. Not all of them cause deep tissue damage. They can be further categorized as:
Dry ulcers
The skin is dry and does not bleed when scratched. Blood supply to the tissue may be damaged or destroyed. The area feels firm to the touch.
Wet/Moist ulcers
This type of pressure ulcer often has a wet or moist feel to it. The skin may bleed when the injured area is scratched, and inflammation is visible in the form of redness, swelling, and warmth.
Cold ulcers
This type of ulcer does not cause pain or bleeding when touched. Instead, the tissue will be cold due to poor blood flow (also known as poor perfusion). The skin may appear pale and even frosty.
Sterile ulcers
This type of ulcer is red, swollen, and warm to the touch. Blood supply to the tissue has been cut off or reduced, but there are no bacteria present in the area.
Will Not Heal Pressure ulcers
This type of pressure sore has not responded to treatment and will not heal without surgical intervention.
Risk Factors for Pressure Ulcers
Pressure ulcers typically develop in people who are bedridden, paralyzed, or have recently had surgery.
The risk factors for developing pressure ulcers include prolonged immobility, inadequate nutrition intake, peripheral vascular disease (PVD), diabetes mellitus (DM), poor hygiene practices, or incontinence.
Other Risk Factors include:
- Low muscle tone
- Poor tissue perfusion
- Dehydrated Skin condition (dry skin or tight skin)
- Increased age Immobility
- Decreased mobility due to illness or disease (cancer, HIV/AIDS and diabetes)
To prevent infection in a pressure ulcer:
- Keep the area clean and dry
- Keep the site free from bacteria (clean before dressing changes, use sterile gloves)
- Avoid overusing skin creams or ointments
- Put protective barriers between injured tissue and external sources of friction (including clothing).
- Take care when bathing to avoid damaging the pressure ulcer.
To keep tissue healthy:
- Prevent moist wound bed (change position frequently)
- Provide oxygen to the pressure ulcer by keeping it exposed to air
- Treat underlying medical or surgical condition that caused the pressure ulcer
- Prevent excessive weight bearing on wounds
- Take good care of skin surrounding injured area (keep it clean and moisturized)
- Modify environment around the patient to prevent skin breakdown (elevate feet 8 inches)
Classification of Pressure Ulcers
Pressure ulcers can be classified as superficial or deep, depending on the depth of the injury. Medical professionals need to understand how to identify these wounds to provide appropriate care to not worsen over time and become more difficult to heal.
What Causes Pressure Ulcers?
-Pressure ulcers often develop with prolonged pressure on the skin. This may be due to sitting in a chair or lying down for long periods without repositioning. It can also occur if someone is seated or lying in one position and their weight shifts to one side, applying pressure on just one area of the body.
–Poor nutrition, dehydration, and lack of mobility are common factors in developing pressure ulcers.
-Pressure ulcers are also more likely to develop in people who wear restrictive clothing, including tight-fitting pants, belts, or collars. The pressure from these garments can cause injury even without weight being applied directly to the affected area.
Preventing Pressure Ulcers
Many factors contribute to pressure ulcers developing. One of the best ways to prevent them is by ensuring that patients are positioned not to place pressure on their skin or the structures underneath. Moisture and friction can also increase the risk of developing wounds, so avoiding this type of situation is very important for healing.
These types of injuries aren’t just found in hospitals, nursing homes, or rehabilitation centers. Older people and those who have conditions such as diabetes can suffer from these wounds at home without the help of a medical professional. Any significant changes in a person’s healthcare plan should be discussed with a doctor before implementation.
Heavy people are at high risk of developing pressure ulcers on the skin. Proper body alignment is critical to prevent this type of injury from occurring. If the patient must be positioned in a certain way and there is no other option, an air mattress or body support system can help manage their weight not to be left in a position that will cause pressure on their skin.
One of the best ways to prevent wounds and sores from forming is to reposition a patient every two hours. The nurse can do this by lifting the bed slightly and repositioning the patient’s body so they are not laying in one position for too long and putting pressure on just one area.
Signs and Symptoms of Pressure Ulcers
The most common signs and symptoms are;
-Redness,
-Swelling or pain in the area that is touching a hard surface for prolonged periods.
-Blisters may develop from the pressure of being in one position for too long.
-Bleeding may occur, and usually, it comes from the lower layers of the skin.
–Infection can become apparent as a wound swells, turns red, or smells bad.
-Patients may show signs of lethargy, fever, or chills.
Nursing Diagnosis for Pressure Ulcers
Diagnosis involves;
-Physical examination to assess for symptoms like erythema and the presence of fluid exuding from the lesion.
-Impaired circulation- what may cause this? Is it a vascular condition or due to positioning?
-To assess for signs of infection that include looking for symptoms like redness, swelling, pain, and elevated temperature.
-Lab tests to determine if the patient has an infection or is suffering from any other condition. These tests can include urine analysis, cultures, and blood counts.
Nursing Diagnosis Impaired Skin Integrity, Related to Pressure Ulcer
Ineffective peripheral Tissue Perfusion Pressure Ulcers occur when skin is in prolonged contact with an underlying bony prominence or other fixed objects. This can be due to improper positioning or activity restrictions. They are usually more severe than stage I and II pressure ulcers and can be dangerous if not treated properly. Pressure Ulcers are open wounds and should be cleaned regularly with mild soap, rinsed with clean water, and dried thoroughly.
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Nursing Care Plans for Pressure Ulcers
The nursing care plan should include a summary of the following factors:
-Patient Assessment: This part of the plan includes reviewing the patient’s history, medications, and other pertinent information. This allows the nurse to establish goals related to their needs, assess for potential complications, and determine expected outcomes and whether or not they are appropriate for that particular patient.
-Diagnoses: Is the wound created by pressure and friction, or is it a puncture, burn, abrasion, etc.? Each wound responds differently to treatment and will require different treatments depending on its location and severity.
-Goal: This part of the plan states what we hope to achieve to help the patient return to their baseline state. It also includes an objective to evaluate the patient’s progress and individualized goals that align with overall treatment plans.
Objective: This part aims to list any nursing interventions that will lead to meeting the established goal for that patient. If there are patient-specific care objectives, then those should be included in this part of the plan.
-Evidence: This section is based on current evidence and best practice. It explains how the treatment will achieve specific outcomes that are important to patient care.
Skin Integrity Nursing Care Plans
-Provide the patient with a scheduled play, pain management, and device change.
-Upon noticing the presence of redness or changes in skin temperature, notify the charge nurse immediately. This is to prevent further breakdown and eliminate serious complications such as infection.
-Adjust bed height or reposition the patient to prevent further pressure on the area.
-Assess precautions/contraindications: Review updated physician orders, laboratory and diagnostic studies, and current medication.
-Identify and eliminate/minimize the risk of exposure: Use standard precautions as appropriate for all patients, including transmission-based precautions when indicated.
Protect exposed areas from further damage: Use protective devices such as skin barriers or glove powder to reduce friction during patient repositioning and transfers.
-Instruct patient/family of home care to include:
Daily inspection for proper wound dressing and possible signs or symptoms of infection.
Change bandages as needed to maintain the integrity of the skin edges.
Keep wound area clean and dry. Use hydrogel dressings as ordered and according to the manufacturer’s recommendation.
Educate on the need to provide adequate nutrition and enough fluids for hydration to the patient.
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Nursing Intervention for Pressure Ulcers
-Assess the patient’s skin for any wounds or lesions that might be a sign pressure ulcers are forming.
– Monitor the patient’s skin daily to ensure proper hygiene.
-Assess the patient’s mobility, if it is limited or there is the risk for falls, assess their need for nursing fall precautions, and implement measures necessary to prevent further injury.
-Encourage the patient to move every two hours to relieve pressure.
-Assessment of the patient’s fluid intake and output level frequently and notify a doctor if either of them is too high or low. Fluids levels are essential because they will affect overall blood circulation in the body.
-Skin integrity will need to be monitored regularly by the nurse. This involves assessing for redness, pain, and lesions as well as providing appropriate care when necessary.
-Ensure the patient has a proper diet that includes essential vitamins and minerals
-The frequency of turning, hygiene measures, and nutrition are all based on the medical condition as directed by staff members like doctors or nurses.
It will be essential to keep it clean and free from infection if you have an open wound.
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How to Heal Pressure Ulcers
When it comes to healing pressure ulcers, there are two main goals: 1) prevent infection; 2) keep tissue healthy (through blood flow).
Complications of Pressure Ulcers
If not appropriately treated, the ulcers can become infected. This is called a “Stage 3” ulcer. It will appear redder in color, feel hot and tender to the touch. Additionally, some patients may experience nausea, vomiting, fever, chills, increased pain, and diminished or smaller amounts of urine output. Stage 3 pressure ulcers are potentially life-threatening because they can cause sepsis and gangrene.
Treatment for Pressure Ulcers
The ulcers are treated with methods that promote wound healing and prevent further damage, such as;
-Preventing deep or prolonged contact with a hard surface. This is done by using a unique cushion called an air body or air mattress. This helps maintain position, prevent shearing and improve circulation to the wound site.
-Removing or repositioning any objects in contact with the ulcer, such as clothing or sheets.
-Lifting extremities for bedridden patients. A unique tool called the McRoberts’ maneuver can raise a leg while the patient is lying on their back. This will help prevent pressure from being placed on that area and allow it to heal.
-Turning/repositioning bed-bound patients every two hours if possible. If not, reposition as often as possible for the patient.
-Prompt treatment of any skin breakdown with a topical or local wound-care product that will protect the skin from further damage.
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Summary
Pressure ulcers can affect patients of all ages and are especially prevalent among individuals inflicted with diabetes. The leading causes include prolonged bed rest (at least 8 hours at a time), malnutrition, dehydration, poor circulation, edema, and lack of movement. There are three stages to pressure ulcer severity: ulcer stage 1, ulcer stage 2, and ulcer stage 3.
The best way to prevent ulcer formation is through proper wound care products like topical negative pressure dressings, support surfaces, padding, and bandages. Giving patients a balanced diet and keeping them hydrated and mobile will help promote healing.
There are many methods of treating these ulcers, including surgical revision with grafts or flap surgery, removal of dead tissue (debridement and wound irrigation with saline or another cleansing agent), application of chemical or acid solutions to the wound, and closure with sutures or staples.
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