Pressure Ulcers – are lesions caused by the primary barrier of the body against the outside environment – the skin. It is common in bony prominences in the body wherein friction usually occurs. The reduction of blood flow in the area leads to skin breakdown. Pressure ulcers can occur in patients with long-term stay on a wheelchair or stay in a bed. Most of the patients are elderly who have apparently the difficulty to change position, that is why assistance is needed in order to prevent further skin damage. Urinary and bowel incontinence can also precipitate pressure ulcers since fecal material and urine can corrode the skin. A reddened skin and sometimes with blisters can signal that the patient is developing pressure ulcers. The sites of pressure ulcers can be in the following areas: elbow, back of the head, shoulders, hips and heels.
There is a classification of pressure ulcers that is followed so that universally, caregivers can know what to give in order to prevent worsening conditions.
- Stage 1 – Reddened skin
- Stage 2 – Blisters are present
- Stage 3 – Crater can be observed, the skin eventually opens losing its ability to heal
- Stage 4 – The damage now reaches the bones and tendons
Nursing Diagnosis: Impaired Skin Integrity
Nursing Priorities:
1. To assess the contributing factors leading to lack of tissue perfusion.
2. To assess the extent of injury.
3. To promote compliance to medication and preventing future injury.
Nursing Care Plan of Pressure Ulcers- Impaired Skin Integrity
|
Nursing Diagnosis |
Patient Outcomes |
Nursing Interventions |
Rationale |
Evaluation |
| Nursing Diagnosis: Impaired Skin Integrity
Related Factors:
Evidenced by: |
1. The patient will be able to receive proper medical attention before it gets worse.
2. The patient will be able to manifest signs of healing and reduction of pressure ulcers. 3. The patient will be able to prevent future pressure ulcer |
1. Introduce yourself at the start of the nursing care.
2. Determine the risk factors leading to pressure ulcer formation: 3. Observe the skin integrity on the bony prominences. 4. Apply prescribed dressing such as hydrocolloid dressing. 5. Prevent over exposure to moisture such as from urine or perspiration. 6. Observe sterile technique in doing procedures. 7. Hydrate the patient and encourage intake of foods rich in Vitamin C and protein. |
1. This will establish trust in the working phase.
2. Elderly patient’s is less elastic and has less moisture making it more prone to skin impairment. 3. The areas were the skin is stretched are as follows: sacrum. Trochanters, scapulae, elbows. These are the areas were the highest skin breakdown are. There is a possibility of skin ischemia due compression of blood vessels. 4. This composition will prevent friction or shear. Another way is to provide emollient to skin to moisturize the skin. 5. This can prevent accumulation of bacteria thereby keeping away from infection. 6. Foreign body can also affect greatly the capability of the skin to regenerate. Keeping the area clean and free from excessive moisture can lead to faster healing process. 7. Collagen can come from Vitamin C, eating lots of food rich in Vitamin C can replace the lost collagen thereby leading to faster healing process. |
Please refer to the Patient Outcomes tab |
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2 Comments
I would just like to share what I know.
Dressings do not really prevent friction/shear but it protects the site. Dressings are chosen depending on your goal: protection, hydration, mechanical debridement, exudate absorption, cavity packing or all of these.
Presence of moisture would depend on where it is located because the main goal of any wound care is to keep the wound bed moist (to hasten healing) and keep the surrounding skin dry (to prevent maseration of the skin which would be a potential cause of skin breakdown).
Hope this helps
HI! thanks for the additional knowledge. It is actually case to case basis. The nursing care plan is designed to be flexible and goals can be changed in order to give better care.