- Understand the definition and characteristics of a pressure ulcer, also known as a decubitus ulcer or pressure injury.
- Recognize the various stages of pressure ulcers based on tissue damage.
- Identify risk factors associated with the development of pressure ulcers, including immobility, poor nutrition, moisture, and compromised sensory perception.
- Recognize the importance of comprehensive risk assessments.
- Comprehend the pathophysiology of pressure ulcers, involving tissue ischemia, inflammation, and eventual tissue necrosis.
- Recognize the impact of pressure, shear, and friction on vulnerable skin areas.
- Learn preventive measures to reduce the risk of pressure ulcer development, including repositioning, use of support surfaces, and maintaining optimal skin hygiene.
- Understand the importance of education and collaboration in preventing pressure ulcers.
- Explore nursing interventions and treatment strategies for individuals with pressure ulcers, including wound care, infection prevention, and pain management.
- Recognize the multidisciplinary approach required for effective pressure ulcer management.
Pathophysiology of Pressure Ulcer / Decubitus Ulcer (Pressure Injury)
Pressure ulcers/Pressure injuries are also called decubitus ulcers or bedsores. These are injuries to the skin and underlying tissues that develop after prolonged pressure in a particular area. Bedsores are common on the heels, sacrum, and over bony prominences such as the elbows and shoulder blades. Pressure ulcers/Pressure injuries can develop and progress very quickly but are preventable and treatable.
- Ischemia and Tissue Hypoxia:
- Prolonged pressure on soft tissues compresses blood vessels, leading to reduced blood flow (ischemia) and oxygen supply to the affected area.
- Ischemia triggers an inflammatory response, causing cellular damage and impaired nutrient delivery.
- Inflammatory mediators contribute to tissue breakdown.
- Sustained ischemia and inflammation result in tissue necrosis, particularly in areas with minimal subcutaneous tissue, such as bony prominences.
- Shear forces occur when layers of tissue slide over each other, leading to damage to blood vessels and tissues beneath the skin surface.
- Friction, the rubbing of skin against surfaces, further exacerbates tissue damage.
- Pressure ulcers disrupt the normal healing process, impairing the formation of new blood vessels and collagen, and increasing the risk of infection.
Etiology of Pressure Ulcer / Decubitus Ulcer (Pressure Injury)
Pressure ulcers/Pressure injuries are caused by three main factors:
- Pressure: Constant or prolonged pressure that restricts blood flow to any part of the body. If blood is restricted to an area, nutrition, oxygenation, and tissue perfusion cannot take place. Without these essentials, the skin and nearby tissue is damaged and may eventually become necrotic.
- Friction: As skin rubs against clothing or bedding, it can weaken skin areas that are vulnerable to injury. This occurs often if the skin is consistently moist.
- Shear: When skin slides against a surface, such as sliding down in the bed when the head only is elevated or transferring or positioning a patient by allowing the skin to move across the bedding. Fragile skin is easily ripped or torn this way.
Desired Outcome for Pressure Ulcer / Decubitus Ulcer (Pressure Injury)
The patient will experience the healing of current pressure wounds, prevention of further skin injury, and maintain optimal skin integrity.
- Wound Healing:
- Facilitate timely wound healing, aiming for the closure of the pressure ulcer.
- Monitor the progression of healing stages, including tissue granulation and epithelialization.
- Prevent complications such as infection, cellulitis, or osteomyelitis associated with pressure ulcers.
- Monitor for signs of infection and intervene promptly.
- Alleviate pain associated with pressure ulcers through appropriate pain management strategies.
- Assess pain levels regularly and adjust interventions as needed.
- Achieve and maintain optimal nutritional status to support tissue repair and wound healing.
- Collaborate with a dietitian to address individual nutritional needs.
- Enhance the individual’s overall quality of life by promoting physical comfort, independence, and psychosocial well-being.
- Provide support and education to empower the individual and caregivers in pressure ulcer management.
Pressure Ulcer / Decubitus Ulcer Nursing Care Plan
Subjective Data:
- Tender areas of skin
- Pain, burning of the skin
- Itching
Objective Data:
- Changes in skin color or texture
- Swelling
- Drainage from wounds
- Stage 1 – non-blanchable redness
- Stage 2 – open skin, pink/red, blister
- Stage 3 – Exposed subcutaneous tissue
- Stage 4 – Exposed muscle/bone
Nursing Assessment for Pressure Ulcer / Decubitus Ulcer (Pressure Injury)
- Pressure Ulcer Characteristics:
- Assess the location, size, depth, and stage of the pressure ulcer.
- Document the presence of undermining, tunneling, or any signs of infection.
- Evaluate the individual’s pain levels associated with the pressure ulcer.
- Use a pain scale to quantify pain and determine the effectiveness of pain management interventions.
- Assess the characteristics of the wound bed, including tissue color, moisture, and the presence of necrotic tissue.
- Monitor for signs of granulation tissue and epithelialization.
- Monitor for signs of infection, such as redness, swelling, warmth, increased pain, or purulent drainage.
- Assess vital signs for systemic signs of infection.
- Conduct a nutritional assessment to identify deficiencies and support individualized nutritional interventions.
- Monitor serum albumin, pre-albumin, and other relevant nutritional markers.
- Assess the individual’s mobility and ability to reposition independently.
- Identify any barriers to mobility and collaborate with the healthcare team to implement repositioning schedules.
- Evaluate the overall skin integrity, assessing for other areas at risk of pressure ulcers.
- Identify any factors contributing to skin breakdown, such as moisture or friction.
- Assess the individual’s psychosocial well-being, including emotional responses to the pressure ulcer.
- Identify coping mechanisms and provide emotional support.
Implementation for Pressure Ulcer / Decubitus Ulcer (Pressure Injury):
- Wound Care:
- Implement a systematic wound care plan based on the pressure ulcer stage and characteristics.
- Use evidence-based practices for cleaning, debridement, and dressing changes.
- Utilize pressure-reducing support surfaces, such as specialized mattresses and cushions, to redistribute pressure.
- Establish a regular turning and repositioning schedule to relieve pressure on vulnerable areas.
- Adhere to strict infection prevention measures during wound care procedures.
- Administer antibiotics as prescribed for confirmed or suspected infections.
- Collaborate with a dietitian to optimize nutritional intake, focusing on protein, vitamins, and minerals.
- Administer nutritional supplements as needed to address deficiencies.
- Implement pain management strategies, such as analgesics or topical agents, to alleviate pain associated with the pressure ulcer.
- Monitor and reassess pain levels regularly to adjust interventions as needed.
Nursing Interventions and Rationales
- Assess skin for signs of hydration pressure injury, and note areas of increased risk
Get a baseline of skin status to compare changes; note areas that are at risk for developing pressure injuries such as heels, sacrum or shoulder blades
- Monitor for signs of infection
- Note odor and appearance of exudate
- Fever
- Warmth to touch
- Obtain wound cultures as needed
- Monitor white blood count (WBC)
- Administer antibiotics as required
Not all pressure ulcers/Pressure injuries are infected. Know and monitor for signs and symptoms of developing an infection. Treat current infections appropriately to avoid systemic complications.
- Reposition patient at least every 2 hours or more frequently as needed
- Use and reposition pillows under arms, between knees (if side-lying) and behind back to reduce pressure and friction
- Place rolled sheet or towel under ankles (not heels) to reduce the pressure of heels against bedding
- Provide cushions and padding on assistive devices such as wheelchairs, walkers, crutches, etc.
- Assess the patient’s level of sensation
Patients with pre-existing conditions, such as diabetes, will be at greater risk of developing pressure injuries but may have decreased sensation. Assess sensation to know if the patient will be able to feel pain or discomfort before a pressure injury occurs.
- Assess for incontinence of bowel or bladder
- Provide perineal care
- Assistance with toileting
- Apply barrier cream
Incontinence increases the risk of skin breakdown and risk of pressure injury. Protective devices such as diapers and incontinence pads/liners withhold moisture which can speed up breakdown.
- Assess patient’s mobility and assist as necessary
- Assess and manage pain
- Positioning
- Administer analgesics, opioids
- Provide appropriate wound care
- Cleaning
- Debridement
- Dressings
- Emollients
- Skin barriers
- Negative pressure wound therapy
- Promote nutrition and education
- Consult dietitian
- Offer high-protein, high-calorie diet
- Encourage hydration
Optimal nutrition helps aid in wound healing and strengthens tissues to prevent further injury; hydrated skin is at slightly less risk for injury than dry, dehydrated skin.
Evaluation of Nursing Care Plan (NCP) for Pressure Ulcer / Decubitus Ulcer (Pressure Injury)
- Wound Healing Progress:
- Evaluate the progress of wound healing, assessing changes in wound size, appearance, and the development of granulation tissue and epithelialization.
- Compare current assessments with baseline measurements.
- Monitor for signs of complications such as infection, cellulitis, or osteomyelitis.
- Assess the effectiveness of interventions in preventing and managing complications.
- Evaluate the effectiveness of pain management strategies in reducing pain associated with pressure ulcers.
- Adjust pain management interventions based on the individual’s pain levels.
- Monitor nutritional markers and assess for improvements in protein and caloric levels.
- Evaluate the impact of nutritional interventions on wound healing and overall nutritional status.
- Assess the individual’s psychosocial well-being, including emotional responses to the pressure ulcer and its impact on daily life.
- Evaluate the effectiveness of psychosocial support interventions.
References
- https://www.mayoclinic.org/diseases-conditions/bed-sores/symptoms-causes/syc-20355893
- https://www.webmd.com/skin-problems-and-treatments/pressure-sores-4-stages#1
- https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/skin-problems/skin-pressure-sores.html
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Transcript
All right. Let's work through an example Nursing Care Plan for a patient with a pressure ulcer or pressure ulcers, right? Let's look at the hypothetical patient. Let's think just about what we might see on this specific patient regarding the pressure ulcers. So subjective data, if I have a patient with a big wound, whether it's on their sacrum or their shoulder or their leg, they're probably going to be pretty uncomfortable, right? They might actually have some pain, right? Or they could potentially have some tenderness over the area, especially over those bony prominences. So that's something to think about for sure. Then you might actually see it, right? We're actually gonna see the pressure ulcer. So depending on the stage, stage one to stage four, make sure you check out the lesson on pressure ulcers inside of the med surg integumentary course to know how to stage these pressure ulcers.
But basically that's going to be what you see. You're either going to see the redness, that's non blanching. You're going to see all the way through that full thickness wound down to the muscle and bones. So you're gonna actually see the wound. They're probably going to have some redness, redness over the area or redness around the wound. They're possibly gonna have some drainage at the wound. And then of course, what's the possible risk here? If you've got a big open wound of any kind, you're probably at risk for infection, right? So any kind of signs of infection or something we could see as well. So maybe we actually see turbulent drain edge, so that pus, maybe we have a foul odor from the wound. Maybe you even have green, you know, gangrene looking drainage. So all bad signs, possibly warm to touch is also a bad sign.
It's a sign of infection, right? Elevated white blood cells. Again, that's going to tell us that that wound might be infected. Then the other thing to think about is think about this patient that has been so immobile that they have developed a pressure ulcer. So what else might we see in this patient? Well, first of all, of course we're going to see this decreased mobility. Something is happening that's causing them to not move enough that they end up with a pressure ulcer. So we have to remember this. When we're thinking about caring for a patient with pressure ulcers, we can't just say, oh, we're going to get 'em up and move them around, or we're going to turn them every two hours and we're going to do all these things and assume it's going to be fine because there's obviously something happened, right? To get them that pressure ulcer, it's also possible that they have decreased sensation.
We see pressure ulcers a lot in paraplegics because they're not feeling what's going on enough to tell you, hey, this, this hurts on my hip or it hurts my back. They can't feel it. They can't tell you. So remember these things too. When you have a patient with a pressure ulcer, there's other things that are going on that are associated with that, that we need to be considering when we start planning their care. So we've gathered all the information. Again, we're looking at just the relevant information related to pressure ulcers. As you're doing a real care plan for a real patient, you're looking holistically at the whole patient to really see what are all of their problems. Right? So what's a big problem here? Well, there's a huge problem with the fact that I have a pressure ulcer. I literally have an open wound, whether it's my sacred, I'm on my hips, my heels, I have a pressure ulcer and that is a huge, huge problem.
And then of course I'm probably in some pain. That's a problem. We definitely want to address that. What could be improved? Well, I definitely want to protect from infection, so that risk for infection, I could improve that. I could make that less. Right? And then I probably or possibly have decreased wound healing, possibly a really poor wound healing for bad circulation and things like that. Again, remember what gets a patient to a pressure ulcer in the first place. Right? There's definitely a problem going on there. Um, and so I've got some skin issues. I've got some pain issues, I've got some infection issues. So if I'm looking at all of these things, I really feel like kind of have a dual uh, problem here. But I think we can really classify and say the number one priority is going to be my skin.
Cause the reason why I'm at risk for infection is because my skin is broken. And so if I can address my skin issues and I can repair that and I can protect my skin, then I can also protect my barrier from infection. And I can protect that part too. So start asking your how questions, how'd you know it was a problem that's where we start linking your data. You go, Hey, well I saw this and that tells me this is a problem. So now we're going to talk about how we can address it. So what kinds of things are we going to do for this patient? Well, of course, of course, of course. We're going to assess, we're going to assess the skin, we're going to assess wounds, we're going to monitor for signs of infection. All of those things need to be done. If we see signs of infection, we'll probably culture the wound, right?
We might even start antibiotics if we see those signs of infection. And then what are we gonna do for the wound itself? We're actually going to do wound care, right? We've got to take care of that wound. We've got to keep it clean, keep it dry or moist based on what your orders are, right? And keep it from getting infected. And then what else do I want to assess? I actually want assess pain, pain or sensation, right? I want to know what can they feel? Does it hurt? Can they let me know if something feels different? So definitely assess that. We talked about wound care, changing dressings. What about nutrition? That's something we could pay attention to, right? Because we know that if you have poor nutrition, low protein levels, you also have poor wound healing. So that's something we could maybe educate or maybe just ensure that they have adequate nutrition.
And then the other thing we would want to do if it's applicable is incontinence care. So if you have a patient who's completely immobile, who can't turn themselves, there is also a relatively decent chance they might be in continent. And that moisture is going to cause a huge problem for pressure ulcers, especially if it gets on the wound. So making sure that you're doing incontinence care is super important. And then of course, anytime we have a pressure ulcer, we're going to turn that patient every two hours or more often. So at least every two hours, right? More often is always fine as long as there's not a friction and shear problem, right? So how do I know it's better? Well, the same way I knew it was a problem except reversed. So maybe I could longterm say my wound heals, or maybe I could say that my wound doesn't worsen.
Or I could say that I've no signs of infection, right? There's a lot of things I can say here to really address those initial pieces of data that I thought were a problem. So now that we've done that, we've kind of gotten an idea of the big things for this patient and we're going to translate, we're going to put it into concise terms so that we can communicate it really well. And you know, here at NRSNG, we love nursing concepts. So I'm just going to give you the top three, right? So number one we said straight up was tissue and skin integrity, right? It's like if we can't protect the barrier that we have against infection, then what good are we? Right? So let's fix the skin issue first. And then of course we did say infection is a high risk, right? So infection control is going to be our next priority.
And then the other one here comes from remembering that this patient is clearly in a state where they've developed pressure ulcers. They're possibly not healing well. And so what's happening is they're at high risk for new ulcers. They're at high risk for worsening of their existing ulcers, and they're at high risk for infection, which again is going to worsen their ulcers. And so I'm going to throw an extra concept in here and it's the concept of safety. So here we're worried about what's actually going on. This is our actual problem. This one is our potential. We're saying, listen, there's an actual tissue and skin integrity problem, but we also have a potential big problem of making it worse. And so I'm going to address the idea of safety with this patient to make sure that I'm not only taking care of the existing problem, but instituting precautions to make sure that the problem doesn't get worse or don't get a new one.
Okay? So let's transcribe. This is us getting it on paper, right? So our top three problems that we identified are tissues, skin integrity, infection control, and safety. So again, we're just going to link everything together here. What tells me it's a problem, what am I going to do about it and why? And what do I expect to find? So I might have a signs and symptoms of a stage one to four ulcer, right? Again, check out that pressure ulcers less than to know how to do that. I'm going to have some redness. Maybe I might actually literally just have some sort of open wounds. So obviously there's definitely a skin problem. So things I'm going to do, I'm going to assess that skin, I'm going to do wound care, however it's ordered to make sure I get those dressings changed appropriately. And then remember we talked about that adequate nutrition.
I think it's really important that we pay attention to their nutrition levels. So why are we doing these things? Well, obviously we need to evaluate the status of the wound. We need to know what's going on with it and how it's doing. Wound care itself helps promote healing and prevent infection. You got to make sure we keep that wound nice and clean, keep it dry if it needs to be dry. And then again, nutrition. It really helps to promote healing. And the big thing here is protein. We've got to make sure that they're getting enough protein in their diet. So my expected outcome long term, I just want my wounds to heal without complication. I want them to close up nicely, not get infected, not have any tunneling, not having any worsening, not getting the infections in the bones, right? I just want my wounds to heal without complication.
Remember, if you're thinking today, if you're thinking short term, you might think something of wounds will remain free of signs of infection, right? That's something that you can do. You can do wounds will not get larger today, right? So these are all things that you can do. Obviously you need measurements for that. But think short term, think long term, whatever's most appropriate for your patient and your plan. So infection. How do I know if that wound is infected? I might have some drainage, might have some foul odor, might have some elevated white blood cell count. So either way, there's a lot of things that we can look at. Even severe redness can possibly indicate infection, right? So what am I going to do? Well, I'm going to do a wound culture. I say prn. Remember you do still need an order for this.
So maybe ask the doctor for a wound culture if needed. Monitor for signs and symptoms of infection and possibly administer antibiotics if they get ordered. So why do we do cultures, obviously we need to identify whatever organism is actually infecting it so that we can treat it appropriately. The sooner we recognize those signs of infections, the sooner we can get those cultures and get that treatment started. And then of course the antibiotics are to actually treat the infection. So I know I set it up here because I was talking about worsening of my wounds, but down here, my expected outcome is also no signs and symptoms of infection in existing wounds or um, that infection signs would improve over a certain period of time, right? So our data [00:11:00] points to our outcomes. So safety again, remember that this patient, in order to get a pressure ulcer, had something else going on.
Either they had decreased sensation at the site and couldn't feel it, or they have a lot of decreased mobility or both, right? There's a reason why they developed this pressure ulcer, which means they are at risk for developing another one, right? So what are we going to do for this patient? We're going to reposition them. Q2 We're trying to prevent more pressure ulcers, assess that sensation, assess that pain, and of course, do incontinence care if appropriate. So again, we're preventing worsening or new ulcers, and we know that if they have no feeling, they can't communicate. If that pressure is getting worse or if something hurts. And then remember, moisture will always make a wound worse. Especially in continents. Your urine is sterile, but your feces are not. So again, our big goal here is that I don't get any new ulcers and that my wounds don't get worse.
So we don't want anything to get worse, get bigger. I will tell you, you can go from a stage two to a stage three in less than a day. I mean, in less than four hours, you can go from a stage two to a stage three if you're not repositioning, you have that consistent pressure. So that's where safety comes in here, is we're trying to prevent anything from getting worse. Okay? Let's really quickly review the five steps for care plan creation. So we're going to collect all of our information. That's our assessment data. We're gonna analyze that information so that we can determine what our major problems and priorities are. We're going to plan our interventions and then we're going to determine how we would evaluate them. Take all that information you just gathered and translate it. Figure out what terms you need to use, how to concisely communicate what the problems are, and then get it on paper.
That's your transcribed step. You can use whatever form you prefer. You can use a template. If your EMR requires you to document, you can do it there. Whatever works for you. Just get it on paper so that you have that plan in front of you to take the best care of your patient that you can. So that's it. For example, care plan for pressure ulcers. I hope that was helpful. Make sure you check out all the other examples in this course as well as our nursing care plan library. Now go out and be your best self today guys. As always, happy nursing.
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