Pressure Ulcer/Pressure Injury Nursing Care Plan

The oldest term for pressure ulcers is decubitus, which evolved into decubitus ulcers or ischemic ulcers in the 1950s. The term bedsores indicate the association of wounds with a stay in bed, which ignores the potential occurrence of these wounds on any other type of support surfaces.

In the 1980s, the term pressure sore became more popular, thus no longer relating the injury to just the bed. Since the early 1990s, the term pressure ulcer, referring to an open ulcer at the skin surface that is difficult to heal or fails to heal, has been in common usage. However, this term fails to capture both the deep tissue pressure injury form, which is internal soft tissue damage under intact skin, and the Category/Stage 1 in which the skin surface remains intact. Currently, in Europe, the term pressure ulcer is widely used. In the United States, Canada, Australia, New Zealand, and some countries in Southeast Asia, the term pressure injury was widely adopted.

Though preventable in most cases, pressure ulcers continue to pose a major burden to the individual and society, affecting more than 3 million adults annually in the United States alone. The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to medical or other devices as a result of intense and/or prolonged pressure or pressure in combination with shear. The damage can be present as intact skin or an open ulcer and may be painful.” The most common locations in adults are over bony prominences of the sacral and hip regions, and the lower extremities in <25% of cases.

Many factors are identified as contributing to pressure ulcers and injury formation.

• Immobility– Impaired immobility is probably the most common reason why clients are exposed to prolonged uninterrupted pressure that causes pressure injuries. This situation may be present in clients who are neurologically impaired, heavily sedated or anesthetized, restrained, demented, or recovering from atraumatic injury.
• Contractures and spasticity– Contractures and spasticity often contribute to ulcer formation by repeatedly exposing tissues to trauma through flexion of a joint. Contractures rigidly hold a joint in flexion, whereas spasticity subjects tissues to repeated friction and shear forces.
• Sensory deficits– Inability to perceive pain, whether from neurologic impairment or from medication, contributes to pressure injuries by removing one of the most important stimuli for repositioning and pressure relief.
• Skin quality– The quality of the skin also influences whether pressure leads to ulceration. Paralysis, insensibility, and aging lead to atrophy of the skin with thinning of this protective barrier.
• Friction and shear forces– The skin becomes more susceptible to minor traumatic forces, such as friction and shear forces typically exerted during the moving of a client. Trauma that causes deepithelialization or skin tears removes the barrier to bacterial contamination and leads to transdermal water loss, creating maceration.
• Incontinence– Incontinence or the presence of a fistula contributes to ulceration in several ways. These conditions cause the skin to be continually moist, thus leading to maceration.
• Poor nutritional status– Malnutrition, hypoproteinemia, and anemia reflect the overall status of the client and can contribute to tissue vulnerability to trauma as well as cause delayed wound healing.

In April 2016, the NPUAP (now known as the National Pressure Injury Advisory Panel [NPIAP] since November 2019) announced an updated version of its staging system, along with a change in preferred terminology from pressure ulcer to pressure injury. The NPIAP system consists of four main stages of pressure injury but it is not intended to imply that all pressure injuries follow a standard progression from stage 1 to stage 4 or that healing pressure injuries follow a standard regression from stage 4 to stage 1 to a healed wound

. The categories specified in the current NPIAP staging system are as follows:

• Stage 1: Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin; the presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.
• Stage 2: Partial-thickness skin loss with exposed dermis; the wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister; adipose and deeper tissues are not visible, and granulation tissue, slough, and eschar are not present.
• Stage 3: Full-thickness skin loss, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present; slough or eschar may be visible; the depth of tissue damage varies by anatomic location; areas of significant adiposity can develop deep wounds; undermining and tunneling may occur; fascia, muscle, tendon, ligament, cartilage, and bone are not exposed.
• Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer; slough or eschar may be visible; epibole, undermining, and tunneling often occurs; depth varies by anatomic location.
• Deep tissue pressure injury: Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister; pain and temperature change often precede skin color changes; discoloration may appear differently in darkly pigmented skin.

Pressure Ulcer/Pressure Injury

In individuals with normal sensation, mobility, and mental status, prolonged pressure elicits a feedback response that prompts a change in body position; however, when the feedback response is absent or impaired, sustained pressure ultimately leads to tissue ischemia, injury, and necrosis. Pressure ulcers typically begin when the individual’s body weight exerts a downward force on the skin and subcutaneous tissue that lie between a bony prominence and an external surface.

Nursing interventions for a client diagnosed with pressure injury include the early detection of initial tissue damage through regular skin assessment, nutritional interventions, appropriate use of skin care products, and decreasing continuous exposure time of tissues to sustained strain or stress. The following are nursing diagnoses associated with a pressure injury.

• Impaired Skin Integrity
• Risk for Infection
• Risk for Impaired Peripheral Tissue Perfusion

Pressure Ulcer/Pressure Injury Nursing Care Plan 

Below are sample nursing care plans for the problems identified above.

Impaired Skin Integrity

Pressure injuries are localized areas of soft tissue damage that typically occur in older adult populations, people with limited mobility or who are confined to the bed or chair, who underwent injury or surgery, and clients who have impaired nutrition. These factors mean that the tolerance of the individual’s skin and underlying tissues to forces that damage the skin and circulation is reduced. If pressure, friction, or shear are prolonged, they can result in impaired blood supply and damage to the skin and underlying tissues.

Nursing Diagnosis

• Impaired Skin Integrity

Related Factors

• Impaired immobility
• Friction or shear forces
• Poor nutrition
• Disruption of the skin surface
• Bowel or bladder incontinence

Evidenced by

• Skin lesions and ulcerations
• Erythema over bony prominences

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

• Be free of or display improvement in the wound or tissue healing.
• Identify individual risk factors.
• Demonstrate behaviors or techniques to prevent skin breakdown and promote healing.

Nursing Interventions

Assessment	Rationale
Inspect the client’s skin routinely.	Full skin assessment should be done as soon as possible after admission and thereafter at least daily, or more frequently if the client’s health deteriorates or healthcare interventions such as procedures or surgery increase the risk of pressure injury.
Focus on common pressure points during skin assessment.	Inspection should focus on common pressure points over bony prominences such as the sacrum, buttocks, heels, the back of the head, elbows, shoulders, hips, ischial tuberosities, and sides of the knees, and ankles.
Assess for the presence of medical devices that could cause pressure.	Assessment should also include taking note of any medical and other devices such as casts, urinary catheters, intravenous lines, oxygen masks, straps, and ties that can lead to additional pressure points.
Assess the skin for signs of possible tissue damage.	Skin inspection should note any broken, discolored, dry/flaking, papery/thin/fragile, clammy, edematous/puffy, or mottled skin, all of which increase the risk of, or indicate the existence of tissue injury. Any red or discolored skin over bony prominences indicates possible tissue damage and must be acted upon immediately to prevent deterioration.
Determine the stage of the pressure injury.	Once a pressure injury is identified, serial measuring, staging, and photography are essential in the ongoing assessment of the injury’s progression or healing. The NPIAP’s Pressure Ulcer Scale for Healing (PUSH) tool should be used to monitor clinical response. The tool measures injury dimensions, amount of exudate, and the presence of various types of tissue in the wound, and results can be graphed to show wound progress over time.
Assess for the presence of risk factors for pressure injury development.	A structured risk assessment should be carried out as soon as possible after admission to identify any risk of pressure injury development and the individual factors that require intervention. Client characteristics that indicate potential risk of pressure injury should be documented in the risk assessment including age, medical conditions impacting tissue health, and drug or other therapies.
Assess nutritional status and initiate corrective measures, as indicated.	A positive nitrogen balance and improved nutritional state can help prevent skin breakdown and promote ulcer healing.
Independent
Encourage adequate fluid intake.	Prevention of dehydration is necessary to maintain circulating volume and tissue perfusion, moist mucous membranes, and good skin turgor to reduce the risk of pressure injury formation.
Maintain strict skincare and hygiene.	Fundamental care that helps to maintain the skin’s protective purpose includes keeping the skin clean and dry using unscented skin cleansers that do not cause irritation. It is also helpful to protect the skin’s moisture barrier by regularly applying a light layer of simple, unscented moisturizers or emollients while avoiding the overuse of creams and lotions.
Avoid massaging and positioning the skin over bony prominences.	Positioning the client on areas of erythematous skin and massaging the skin should be avoided. Massage causes friction and shear that can damage the delicate microcirculation and lead to inflammation and tissue damage.
Change position frequently in the chair and bed.	Prolonged pressure   to bony prominences and other vulnerable areas, along with friction and shear, must be avoided by regular repositioning of the client, especially if they cannot do this for themselves or mobility is restricted. Pressure should be relieved and redistributed, and repositioning onto bony prominences should be avoided by using the 30-degree tilt options and profiling bed functions.
Keep sheets and bedclothes clean, dry, and free from wrinkles, crumbs, and other irritating materials.	This avoids friction or abrasion injury to the skin. Good manual handling practice is essential in avoiding friction and shear and heels should be lifted free of the bed surface using pillows.
Provide proper management to clients with incontinence.	Incontinence of urine and/or feces exposes the skin to excessive moisture which can damage the dermal and epidermal cells. Clients with incontinence should have an individual continence management plan that includes immediate cleansing of the skin following incontinent episodes and the light use of barrier creams to protect the skin. The absorbency of continence products such as pads can be affected by barrier creams transferred from the skin to the pad.
Provide a balanced diet with adequate protein, vitamins, and minerals.	It is essential to ensure that there is an adequate supply of nutrients- particularly protein, energy, water, and vitamins- to the skin. An individualized nutrition plan is needed for anyone with or at risk of malnutrition.
Collaborative
Provide support surfaces according to the client’s needs as indicated.	Support surfaces on both beds and chairs should meet individual client needs as well as operating tables during surgery. Support surface choice is based on the client’s level of mobility; those who are largely bedbound may benefit from the use of an alternating pressure mattress. Once the client can sit out of bed, it is essential that the risk of pressure injuries is still acknowledged and a pressure redistributing cushion is used until the client is fully mobile.
Assist with topical applications, as appropriate.	Topical applications such as hydrogel dressings, skin barrier dressings, collagenase therapy, absorbable gelatin sponges, and aerosol sprays may enhance healing.
Provide nutritional supplements, as indicated.	Previous study results in various settings suggest that the use of nutritional supplements may be useful in the prevention of pressure injuries. In a study, in addition to a standard diet, residents ate eight protein cookies with 11.5 g protein and 244 kcal daily. This innovative solid oral dietary supplement allowed for diversification and to enrich protein and calories in the diet of institutionalized older adults. There was a positive impact on weight and appetite, and a reduction of pressure injuries.

Risk for Infection

Insufficient treatment or complications such as infection can cause pressure injuries to heal poorly. The use of inappropriate therapy for the corresponding stage of ulcer can contribute to delay in treatment in a client with worsening tissue injury. Up to 32% of clients have underlying osteomyelitis; more rarely, the client may have a Marjolin ulcer, a squamous cell carcinoma within a pressure injury. Pressure injuries are a common finding but with interdisciplinary management and application of key preventive and therapeutic approaches, these injuries and their complications can be reduced.

Nursing Diagnosis

• Risk for Infection

Risk Factors

• Environmental exposure
• Inadequate acquired immunity
• Invasive procedures
• Trauma or tissue destruction
• Malnutrition
• Insufficient knowledge to avoid exposure to pathogens

Possibly Evidenced by

• Not applicable; the presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes

After the implementation of nursing interventions, the client is expected to:

• Be free of infection and maintain normothermia.
• Achieve timely wound healing.
• Verbalize understanding of individual exposure and risk factors.
• Identify interventions to prevent and reduce the risk of infection.

Nursing Interventions

Assessment	Rationale
Assess for signs and symptoms of systemic infection. Monitor temperature routinely.	Fever, chills, diaphoresis, altered level of consciousness, and positive blood cultures are some of the signs and symptoms of a systemic infection. This may indicate developing sepsis which may require further evaluation and intervention.
Observe the wound, noting the presence of drainage and inflammation.	The appearance and description of the pressure injury are the basis of the physical examination and are used to make the diagnosis. Tenderness, erythema of surrounding skin, swelling, warmth, exudate, or a foul odor suggests an underlying infection.
Note risk factors for the occurrence of infection.	Understanding the nature and properties of infectious agents and the individual’s exposure determines the choice of therapeutic intervention.
Independent
Practice and demonstrate proper hand hygiene.	Hand hygiene is the first-line defense to limit the spread of infections, especially when caring for an infected wound.
Review individual nutritional needs.	Optimal client nutrition is key to wound healing. A positive nitrogen balance and a total caloric intake of at least 30 kcal/kg (including 1.25 to 1.5 g/kg of protein daily) promote healing and can reduce the size of stage 3 and 4 pressure injuries.
Enforce stringent aseptic techniques during wound care.	A stringent aseptic technique is performed when caring for wounds and removing and handling wound drains.
Instruct the client or family members in techniques to prevent the spread of infection.	Educate the client and family members regarding techniques that protect skin integrity and wound care. These self-care activities may provide protection for the client and others.
Provide for infection precautions such as gloves and gowns.	Personal protective equipment reduces the risk of cross-contamination to staff, visitors, and other clients, especially during wound care and if the pressure injuries have exudates and drainages.
Emphasize the necessity of taking antibiotics as directed, especially the dosage and length of therapy.	Premature discontinuation of treatment when the client begins to feel well may result in the return of the infection. However, unnecessary use of antibiotics may result in the development of secondary infections or resistant organisms.
Dependent/Collaborative
Monitor diagnostic test results as appropriate.	Although the diagnosis of pressure injuries is made on visual inspection, several diagnostic tests are valuable in assessing these injuries. A complete blood cell count with differential may reveal leukocytosis, indicating inflammation or infection. Elevations of inflammatory markers such as erythrocyte sedimentation rate (ESR) or C-reactive protein also support inflammation.
Assist with debridement, as indicated.	Debridement methods include sharp, mechanical, autolytic, and biosurgical. Injuries with thick and extensive eschar or necrotic tissue require debridement to expose the granulation tissue, reduce infection risk, and facilitate healing.
Collect specimens for tissue cultures.	Deep tissue cultures taken in the operating room after debridement are preferable to wound swabs, which may represent necrotic tissue and contaminants. Laboratory analysis of wound samples such as swabs can be useful in providing information about which organisms may be colonizing the surface of the skin but is not helpful in diagnosing deep infection unless there is wound discharge.
Administer topical agents, as prescribed.	Numerous topical agents are used for decreasing bacterial burden and for wound healing. Mafenide, acetic acid, Dakin’s solution, and iodine preparations have been documented to kill fibroblasts and bacteria, potentially impeding wound healing with prolonged use, and should be reserved for instances of active infection or large amounts of necrotic tissue. Silver sulfadiazine and other silver agents have been demonstrated to be toxic to fibroblasts, but to a lesser degree.
Administer systemic antibiotics as indicated.	Systemic antibiotics are indicated for clients diagnosed with sepsis, osteomyelitis, cellulitis, fever, and leukocytosis, or to prevent bacterial endocarditis in clients who need debridement and who have prosthetic cardiac valves, congenital cyanotic cardiac malformations, or have had previous episodes of bacterial endocarditis.
Use appropriate wound cleaning solutions as prescribed.	Wounds should be cleaned initially and at each dressing change, preferably with a 0.9% sodium chloride solution. For clean wounds, avoid using cytotoxic antiseptic agents such as 5% mafenide acetate, 0.25% sodium hypochlorite solution, povidone-iodine, 3% hydrogen peroxide, and 0.25% acetic acid, which kill granulation tissue and can impair wound healing. Sodium hypochlorite is germicidal, and is appropriate for infected and malodorous wounds with large amounts of slough, and debrides necrotic tissue.
Apply wound dressings appropriate to the wound’s characteristics.	Appropriate dressing selection is based on the wound characteristics and includes transparent films (semiocclusive), hydrocolloids, hydrogels (occlusive or semiocclusive), alginates, and foams. Occlusive films and hydrocolloids are frequently used on dry, shallow pressure injuries, whereas alginates and other absorbent dressings are for deeper, heavily exudative wounds.
Assist with negative pressure therapy.	The use of negative-pressure wound therapy has had a significant impact on the treatment of pressure injuries. Negative-pressure wound therapy increases granulation tissue by applying microdeformational forces to the wound bed and can be used to manage exudate and bacterial burden and assist in wound contraction. However, it should be avoided in the presence of necrotic tissue and should be stopped if the wound deteriorates.

Risk for Impaired Peripheral Tissue Perfusion

Pressure applied to the soft tissue at a level higher than that found in the blood vessels supplying the area can cause ischemia and edema, and ultimately pressure injuries. Skin is more resistant to pressure than muscle, sometimes masking a deeper injury. Pressure, roughly double capillary closing pressure, applied for 2 hours results in irreversible ischemic damage to tissue (Ricci et al., 2017). Unrelieved direct pressure or force on an area causes microvascular circulatory occlusion, which in turn impairs cellular nutrition and the removal of waste products. Cells then use anaerobic metabolism, producing toxic byproducts that cause tissue acidosis, increased cell membrane permeability, edema, and cell death.

Nursing Diagnosis

• Risk for Impaired Peripheral Tissue Perfusion

Risk Factors

• Periods of low or high pressure on a specific area
• Impaired mobility
• Excessive sedation or anesthesia
• Advanced dementia
• Neurologic sequelae or impairment

Possibly Evidenced by

• Not applicable; the presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes

After the implementation of nursing interventions, the client is expected to:

• Demonstrate adequate tissue perfusion as evidenced by palpable pulses and timely wound healing.
• Be free of edema and signs of necrotic tissue formation.

Nursing Interventions

Assessment	Rationale
Assess for the presence of peripheral vascular/arterial diseases.	Consider vascular doppler studies in clients with pressure injuries of the extremities, especially if the client has manifestations of concomitant peripheral vascular disease. An ankle-brachial index (ABI) may be performed as a simple, non-invasive screening assessment for peripheral arterial disease.
Monitor the client’s blood glucose levels routinely. Assess for peripheral neuropathy.	A client diagnosed with diabetic neuropathy may have high hemoglobin A1C and plasma glucose levels and positive findings on nerve conduction velocity and electromyography testing, such as reduced or absent sensory nerve action potentials and denervation.
Monitor the client’s vital signs.	Palpate the client’s peripheral pulses and note capillary refill. These are indicators of adequacy of systemic perfusion or blood needs, and developing complications.
Independent
Reposition or turn the client every 2 hours.	If the client is unable to move on their own, reposition them every 2 hours. For clients who are mobile, advise them to shift their weight every 10 minutes.
Minimize sliding and shearing forces by elevating the head of the bed and raising the knees and heels.	Keep the client’s head of the bed at 30 degrees or less if not contraindicated to reduce pressure and shearing on the sacrum. Raise the client’s knees using footboards, and place pillows under the client’s lower legs. To prevent heel injuries, elevate the client’s heels or use pressure-reducing heel devices.
Assist with or instruct in foot and leg exercises and ambulate as soon as able.	Foot and leg exercises enhance circulation and prevent stasis complications.
Apply local cooling packs to areas under prolonged pressure.	Findings in a study recommended that local cooling on the skin could provide protection of the tissue under prolonged pressure in young, healthy subjects. However, further investigations on populations at risk are required to understand perfusion response toward local cooling and prolonged pressure for these populations.
Dependent
Utilize special support surfaces for pressure reduction such as foam, air, or gel-filled mattress overlays and low-air-loss devices, as indicated.	These may reduce the frequency of repositioning required in some clients and may be applied to beds and wheelchairs. Standard hospital mattresses are the least effective surfaces compared with static mattresses, mattress overlays, or low-air-loss mattresses.
Administer pharmacologic agents as appropriate.	Pharmacologically controlling spasticity can improve client positioning, weight distribution, and hygiene and can prevent tension on a healing wound. Sulfaphenazole, an off-patent sulfonamide antibiotic, functions to decrease post-ischemic vascular dysfunction and increase blood flow, leading to reduced overall severity, improved wound closure, and increased scar tensile strength.

References

1. Gefen, A., Brienza, D. M., Cuddigan, J., Haesler, E., & Kottner, J. (2021, August 11). Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries. International Wound Journal, 19(3), 692-704. https://doi.org/10.1111/iwj.13667
2. Hertz, K., & Santy-Tomlinson, J. (Eds.). (2018). Fragility Fracture Nursing: Holistic Care and Management of the Orthogeriatric Patient. Springer International Publishing.
3. Kirman, C. N., & Geibel, J. (2022, April 29). Pressure Injuries (Pressure Ulcers) and Wound Care: Practice Essentials, Background, Anatomy. Medscape Reference. Retrieved August 5, 2022, from https://emedicine.medscape.com/article/190115-overview#a5
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5. Mervis, J. S. (2019, October). Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. Journal of the American Academy of Dermatology, 81(4), 881-890. https://doi.org/10.1016/j.jaad.2018.12.069
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12. Tzen, Y.-T. (2008). EFFECTS OF LOCAL COOLING ON SKIN PERFUSION RESPONSE TO PRESSURE: IMPLICATIONS TO PRESSURE ULCER PREVENTION. Doctoral Dissertation, University of Pittsburgh.