skin pressure ulcers nursing care plan

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 a long-term stay in a wheelchair or stay in a bed. Most of the patients are elderly who have apparently difficulty changing 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. Reddened skin and sometimes 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 the injury.
3. To promote compliance with medication and preventing future injury.

Nursing Care Plan of Pressure Ulcers

Gone are the days when doctors become nurses. Now the table is turned, nurses may turn to medical doctors, and I'm one of them. I can say I've been in both sides now, but still I see writing as a means of venting things out and touching lives, helping each struggling individual decipher the ever growing body of health care education.


  1. 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.

  2. 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


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