The nurse is providing care to a patient with a pressure injury that is covered in eschar

Pressure ulcers, also known as decubitus ulcers, pressure injuries, or bedsores are a type of skin breakdown that occurs due to constant pressure causing a lack of blood flow and oxygen which leads to poor tissue perfusion and tissue death.

Inhaltsverzeichnis Show

The Nursing Process
Nursing Care Plans Related to Pressure Ulcers
Impaired Skin Integrity Care Plan
Risk For Infection Care Plan
Impaired Physical Mobility Care Plan
References and Sources
What stage 4 pressure injury does the nurse provide care for?
How to provide wound care to a client with a pressure injury?
How should a nurse position a patient to prevent pressure injuries?
What is the nurse’s priority when moving a client with neck injuries?
What is a eschar in nursing?
What guidelines should a nurse follow when caring for pressure sores?
Which dressing would the nurse use to protect and absorb moisture when providing care to a patient with a pressure injury?
What dressing is used for a stage 2 pressure injury?

Patients most at risk for developing pressure ulcers are older, bedridden, immobile, and those who cannot verbalize pain or discomfort. Patients with chronic conditions such as diabetes or vascular diseases are also more susceptible.

Pressure ulcers are preventable through thorough assessment and intervention. This is the priority goal as once a pressure ulcer occurs, it can be difficult to treat and heal. Pressure ulcers that do not respond to simple wound care may require debridement, negative pressure therapy, hyperbaric oxygen chambers, wound vacs, and surgery.

The Nursing Process

Preventing pressure ulcers requires a team of healthcare staff working together to implement turning schedules, hygiene care, and nutrition. Even with proper preventive care, ulcers can still develop in high-risk patients and nurses must remain vigilant in wound care to prevent further complications.

Impaired Skin Integrity Care Plan

Compromised skin through internal or external causes increases the risk of pressure ulcer injury.

Nursing Diagnosis: Impaired Skin Integrity

Related to:

Poor nutritional status
Edema
Impaired circulation
Neuropathy (impaired sensation)
Moisture/Incontinence
Shearing or friction
Surgical incisions
Immobility

As evidenced by:

Verbalization of pain or numbness to the affected area
Alterations in skin color (blanching, bruising, erythema)
Disruption of the skin (breakdown, excoriation)
Pus or bloody drainage

Expected Outcomes:

Patient will display resolution of pressure ulcer within 30 days
Patient will demonstrate three ways to prevent impaired skin integrity
Pressure ulcer will improve as evidenced by a reduction in size and absence of drainage

Impaired Skin Integrity Assessment

1. Perform skin assessments.
Patients should have their skin assessed every shift. Use of the Braden Skin Assessment Scale will assist in determining the patient’s risk for pressure injuries.

2. Stage pressure ulcers correctly.
Correct staging of skin breakdown assists in proper management and continuous assessment. Pressure ulcers are staged 1-4 with stage 1 being intact skin that is non-blanchable and stage 4 being a full-thickness ulcer with exposed bone or muscle. Other pressure injuries include deep tissue injuries or unstageable ulcers due to the presence of eschar or slough.

3. Identify additional risk factors.
Consider the patient’s age, chronic health conditions, cognition, and nutritional status which affect the elasticity and health of the skin as well as the patient’s ability to verbalize sensations or prevent skin breakdown.

Impaired Skin Integrity Interventions

1. Collaborate with wound care experts.
Wound care nurses should be involved at the beginning of any skin breakdown to prevent further deterioration and monitor closely. Severe pressure ulcers or those with delayed healing may require outpatient follow-up with a wound specialist.

2. Encourage nutrition and hydration.
Poor nutrition and hydration interfere with immune function as well as collagen production and tensile strength of the skin. Protein intake, vitamins A, C & E, and zinc support wound healing. Enteral nutrition and IV fluids may be necessary for adequate nutrition.

3. Keep skin clean and dry.
Patients who are incontinent or who cannot verbalize their need to be cleaned require frequent perineal care and linen changes. Sweat, urine, and feces create an environment that is irritating to the skin.

4. Perform necessary wound care.
Wound care orders will depend on the type, size, and location of the pressure ulcer. Proper cleansing and application of ointments, sprays, foams, and dressings will aid in healing and the prevention of further breakdown.

Risk For Infection Care Plan

Open areas to the skin allow pathogens to enter increasing the risk of infection.

Nursing Diagnosis: Risk For Infection

Related to:

Broken skin/disrupted epidermis
Immunocompromised status
Poor hygiene
Incontinence

Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

Expected Outcome:

Patient will remain free of signs of wound infection: redness, drainage, odor, warmth
Patient will remain free of systemic infection as evidenced by temperature and white blood count within normal limits
Wound care dressings will remain intact to prevent the entrance of bacteria

Risk For Infection Assessment

1. Monitor for signs of infection.
When providing wound care the nurse should monitor for signs of infection such as green or yellow drainage, odor, swelling, and redness. Signs of a systemic infection include fever, chills, tachycardia, and hypotension.

2. Obtain wound cultures.
Wounds that display possible signs of infection require culturing to test for bacteria and guide further treatment such as antibiotics.

3. Assess lab work.
The white blood count will likely be elevated in the event of infection. Additional lab tests that monitor for underlying causes of delayed wound healing include protein levels, ESR (erythrocyte sedimentation rate) glucose, iron, total lymphocyte count, and vitamin and mineral levels.

Risk For Infection Interventions

1. Administer antibiotics.
Prophylactic antibiotics may be given to prevent infection. When providing wound care, antibacterial/antimicrobial cleansers and ointments may be applied to treat or prevent infection.

2. Proper hand hygiene.
Strict hand hygiene must be followed before touching pressure ulcers or providing wound care. Most wound care instructs on clean or aseptic techniques though some situations such as debridement require sterile technique. Gloves must always be used with any wound treatment and should be discarded and changed when soiled or when going from a dirty to clean wound dressing.

3. Ensure dressings are intact.
Pressure ulcers are often covered with protective dressings to keep out bacteria. Dressings should be monitored regularly to ensure they are clean, dry, and intact and changed if not to prevent infection.

4. Educate on infection prevention.
Patients managing pressure ulcers at home should be educated on proper infection prevention measures such as keeping dressings dry and intact, always washing hands before changing dressings, and monitoring for signs of infection to know when to alert the nurse or provider.

Impaired Physical Mobility Care Plan

Patients with impaired mobility who cannot turn or reposition themselves are at high risk of developing a pressure ulcer.

Nursing Diagnosis: Impaired Physical Mobility

Related to:

Paralysis
Prescribed bed rest or activity restriction
Decreased muscle strength
Contractures
Pain
Neuromuscular condition that limits movement
Cognitive or developmental impairment
Morbid obesity

As evidenced by:

Limited range of motion
Inability to turn self or reposition

Expected Outcomes:

Patient will utilize assistive equipment to improve turning and repositioning
Patient will verbalize two strategies to prevent pressure ulcers
Patient will not develop a pressure ulcer

Impaired Physical Mobility Assessment

1. Assess range of motion/mobility.
The nurse should assess the patient’s range of motion, strength, and ability to reposition themselves. It should not be assumed that patients of younger age can turn themselves or that older patients can’t.

2. Assess staff and family understanding.
Bed or chair-bound patients in nursing homes or who receive care at home from family members should be assessed for proper turning and skincare. The nurse can observe staff and family members to ensure they are capable of turning the patient safely or if additional help or equipment is needed.

Impaired Physical Mobility Interventions

1. Implement devices for independence with repositioning.
Patients with some ability to move or reposition should be provided with trapeze bars and side rails to pull themselves up or turn over.

2. Use wedges, pillows, and mattresses.
Pressure ulcers often occur on boney prominences such as the sacrum, heels, and hips. Keep these areas protected with foam wedges, heel protectors, pillows, and air mattresses.

3. Treat pain.
Patients may be reluctant to move or reposition due to pain and discomfort. Medicate before turning and repositioning. For chronic pain, administer pain medications routinely to allow for ease of movement.

4. Instruct on areas to inspect for breakdown.
Educate patients and family members on additional areas subject to shearing and friction such as the back of the head, elbows, ears, and back.

5. Transfer to chairs and assist with ambulation.
Patients should be assisted out of bed to the chair and to ambulate if able to do so safely. This allows circulation to the tissues and relieves pressure.

6. Implement a turning schedule.
Evidence-based practice recommends turning bed-bound patients every 2 hours to prevent pressure ulcer development. Patients in wheelchairs or sitting up should be reminded to reposition themselves every 15 minutes to redistribute weight.

References and Sources

Bacterial Wound Culture. (n.d.). Labcorp. Retrieved April 14, 2022, from https://www.labcorp.com/help/patient-test-info/bacterial-wound-culture
Bhattacharya, S., & Mishra, R. K. (2015). Pressure ulcers: Current understanding and newer modalities of treatment. Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India, 48(1), 4–16. https://doi.org/10.4103/0970-0358.155260
Clean vs. Sterile Dressing Techniques for Management of Chronic Wounds, Journal of Wound, Ostomy and Continence Nursing: March/April 2012 – Volume 39 – Issue 2S – p S30-S34 doi: 10.1097/WON.0b013e3182478e06
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
Hess, Cathy Thomas BSN, RN, CWOCN Clinical Order Sets, Advances in Skin & Wound Care: March 2015 – Volume 28 – Issue 3 – p 144 doi: 10.1097/01.ASW.0000461295.42250.ec
Lyder CH, Ayello EA. Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Table 2, [National Pressure Ulcer Staging System]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2650/table/ch22.t2/
Saghaleini, S. H., Dehghan, K., Shadvar, K., Sanaie, S., Mahmoodpoor, A., & Ostadi, Z. (2018). Pressure Ulcer and Nutrition. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 22(4), 283–289. https://doi.org/10.4103/ijccm.IJCCM_277_17

What stage 4 pressure injury does the nurse provide care for?

The nurse is providing care for a patient who has a stage 4 pressure injury that is 2 cm in diameter and 2 cm deep. Bone is visible in the wound. Which patient assessment finding does the nurse communicate to the registered nurse (RN) immediately?

How to provide wound care to a client with a pressure injury?

Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options. 1)Put on clean gloves.

How should a nurse position a patient to prevent pressure injuries?

Position patients at a 45-degree angle when on their side. The nurse is participating in a unit program aimed at preventing pressure injuries to residents in a long-term care facility. Which intervention does the nurse anticipate will be least effective? The wound has a grainy, spongy texture.

What is the nurse’s priority when moving a client with neck injuries?

The priority when moving a client who presents with a neck and a spinal cord injury is to logroll the client whenever a transfer must occur. The nurse would not remove the cervical spine collar because this can exacerbate the original injury. The nurse would not monitor for autonomic dysreflexia during the acute phase of the injury.

What is a eschar in nursing?

Eschar is dead tissue that falls off (sheds) from healthy skin. It is caused by a burn or cauterization (destroying tissue with heat or cold, or another method).

What guidelines should a nurse follow when caring for pressure sores?

Position patient every 2 hours. Keep the pressure areas clean and dry. Always look for redness and numbness. Provide air mattress.

Which dressing would the nurse use to protect and absorb moisture when providing care to a patient with a pressure injury?

Hydrocolloids / Hydrogels: Hydrocolloid dressings have gel-like properties and absorb fluids from the wound. Because hydrocolloid dressings form a moisture-proof barrier they frequently used with incontinent patients as they can keep urine and feces out of the healing wounds.