Pressure ulcers, also known as decubitus ulcers, pressure injuries, or bedsores, are a type of skin breakdown that occurs due to continuous pressure disrupting blood flow and oxygenation to the tissues. This leads to poor tissue perfusion, tissue death, ulcerations, and necrosis.
In this article:
- Overview
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Skin Integrity
- Impaired Tissue Integrity
- Ineffective Peripheral Tissue Perfusion
- Risk For Infection
Overview
Pressure ulcers typically occur at the site of bony prominences, such as the sacrum, coccyx, greater trochanter, lateral malleolus, and heels, among other areas.
The National Pressure Injury Advisory Panel offers a widely recognized staging classification system for pressure ulcers based on the level of tissue involvement:
- Stage 1: Intact skin with non-blanchable redness
- Stage 2: Partial-thickness skin loss involving the epidermis or dermis (blister or abrasion).
- Stage 3: Full-thickness skin loss exposing subcutaneous tissue (fat) but not underlying muscle.
- Stage 4: Full-thickness skin loss that may expose muscle, tendon, or bones.
- Unstageable: Unknown tissue loss due to slough or eschar covering the wound.
A Deep Tissue Injury (DTI) is another pressure injury causing non-blanchable discoloration to intact or non-intact skin from damage to underlying tissues.
Pressure ulcers are preventable through thorough assessment and intervention. This is the priority goal, as they can be difficult to heal once they form. Stage 3 and 4 pressure ulcers increase the risk of complications like osteomyelitis or sepsis. Pressure ulcers that do not respond to simple wound care may require debridement, negative pressure therapy, hyperbaric oxygen therapy, or surgery.
Nursing Process
Preventing pressure ulcers requires the healthcare team to work together to implement turning schedules, hygiene care, nutrition, and more. 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.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to a pressure ulcers.
Review of Health History
1. Ask the patient about the pressure injury.
Gather information on the pressure injury, especially if the following is present:
- Skin discoloration
- Foul odor
- Discharge
- Decreased sensation
2. Determine the possible cause.
Assess the patient’s skin and mobility status. Note any devices or equipment such as diapers, IV lines, and urinary catheters that may place pressure on the skin. The following factors combined with pressure increase the risk of bedsores:
- Moisture from body fluids (sweat, urine, or stool)
- Friction (skin rubbing against surfaces, such as bed sheets)
- Shear force (tissue layers moving over each other, damaging blood vessels)
3. Determine the patient’s risk factors.
Patients most at risk for developing pressure ulcers are:
- Older
- Bedridden
- Paralyzed
- Incontinent
- Malnourished
- Obese or underweight
- Those who cannot verbalize pain or discomfort
4. Review the patient’s medical record.
Patients with certain conditions are more susceptible to pressure ulcers. Note the following conditions that may be related to pressure injury development:
- Immobility
- Paraplegia
- Quadriplegia
- Spina bifida
- Lack of sensory perception
- Spinal cord injuries
- Stroke
- Neurological disorders
- Multiple sclerosis
- Conditions affecting blood circulation
Note: Track the duration of the patient’s hospital stay, as this correlates with a higher incidence of pressure ulcers.
5. Review the patient’s medication list.
A recently recognized adverse drug reaction (ADR) is a drug-induced pressure ulcer (DIPU), which is linked to the use of psychiatric medications in elderly individuals.
6. Consider the patient’s housing situation and support system.
A stage 4 pressure ulcer is frequently indicative of negligence. Residents in nursing homes or patients living in their homes may acquire bed sores if caregivers neglect to address earlier signs of skin breakdown. Some facilities may require reporting of stage 4 pressure ulcers. The nurse can also offer teaching to families and caregivers if they are responsible for caring for a patient who cannot care for themselves.
7. Track the patient’s surgical history.
A decubitus ulcer can begin to form in a bedridden patient or a patient undergoing surgery after as little as two hours of immobility. Prolonged anesthesia, lengthy surgical procedures, and reduced mobility following surgery are factors the nurse should be aware of.
Physical Assessment
1. Assess the pressure ulcer thoroughly.
Note the following characteristics of the pressure ulcer:
- Size (length, width, depth)
- Presence of the following:
- Exudate
- Odor
- Undermining
- Tunneling
- Necrotic tissue
- Healing status (presence of granulation and epithelization)
- Wound margins and periwound
2. Stage the pressure injury.
The nurse should document the stage of the pressure injury using the classification system mentioned above. Staging the pressure ulcer accurately is vital to monitor progress or deterioration.
3. Assess the patient’s mental status.
Assess the patient’s ability to verbalize their needs or communicate discomfort. It is the nurse’s and care team’s responsibility to ensure the patient’s needs are met, such as toileting, repositioning, and hydration, to prevent pressure ulcers.
4. Determine the patient’s neuromuscular and mobility status.
Patients with conditions that affect sensory perception, such as spinal cord injuries, cannot recognize the presence of discomfort and pressure. Patients with reduced mobility, contractures, or paralysis will require assistance to prevent pressure ulcers.
5. Use the Braden scale.
The most widely used tool for assessing pressure injury risk is the Braden Scale. The patient is evaluated on six factors, including sensory perception, moisture, activity, mobility, nutrition, and friction/shear, to determine their risk for developing a pressure ulcer. The nurse can then plan appropriate interventions.
Diagnostic Procedures
1. Obtain blood for workup.
Certain lab values may offer insight into the causes of pressure ulcers or the risk for poor healing:
- Increased white blood cell (WBC) counts indicate inflammation or infection
- Low hemoglobin levels indicate less oxygen traveling to tissues
- Low platelet counts may complicate wound proliferation and angiogenesis
- Low albumin levels indicate decreased protein, which inhibits wound healing
- Elevated glucose levels may impact wound healing
2. Obtain a wound culture.
Pressure ulcers with drainage or signs of infection may require culturing to identify the pathogen and administer the appropriate antibiotic treatment.
3. Consider biopsy.
Tissue biopsy is recommended for non-healing pressure ulcers to monitor for osteomyelitis or malignancy.
4. Utilize imaging as needed.
An MRI or CT scan may be performed if osteomyelitis is suspected.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a pressure ulcer.
Pressure Ulcer Prevention
1. Reposition and turn the patient regularly.
Turn and reposition the patient every two hours to relieve pressure. The nurse can delegate turning schedules to unlicensed assistive personnel. Increase activity as applicable through passive and active range of motion and ambulation.
2. Keep the skin clean and dry.
Ensure hygiene care is performed to keep the skin clean and dry. Use moisture barrier creams to shield the skin from stool and urine. Consider the need for urine and fecal diversion systems based on the ulcer’s location and susceptibility to contamination.
3. Utilize specialty mattresses and offloading devices.
Alternating pressure mattresses, cushions, foam wedges, and heel protectors offer protection for bony prominences.
4. Reduce friction and shear.
Friction and shear force contribute to pressure ulcer development. The healthcare staff can reduce the risk by utilizing transfer sheets under the patient when pulling them up in bed. Keeping the head of the bed lowered when possible will also prevent sliding down.
5. Institute proper hydration and nutrition.
Adequate protein and nutrient intake is essential to support skin health. Hydration supports cell function, collagen production, and skin elasticity.
6. Keep lines and devices off the skin.
Urinary catheters, IV lines, feeding tubes, and more can press into the skin and cause breakdown. Ensure sheets and clothing are not wrinkled under the patient.
7. Ask the patient’s caregiver to enumerate pressure ulcer prevention measures.
Patients and their families/caregivers should understand the commitment and responsibility to prevent pressure ulcers. Educate on the following:
- Adhering to a turning/repositioning schedule
- Keeping the skin clean and dry
- Utilizing offloading devices
- Recognizing warning indicators such as skin darkening or decreased sensation
Treating an Existing Pressure Ulcer
1. Relieve further pressure and protect the area.
For a stage 1 pressure ulcer, the skin is non-blachable but still intact. The nurse can prevent further breakdown by offloading the area through frequent repositioning and using a pressure-relieving mattress, pillows, and wedges depending on the location of the ulcer. A Mepilex Border dressing can be applied to the sacral/coccyx area or heels to protect from pressure, friction, and shear force.
2. Dress the wound as per protocol or the healthcare provider’s order.
Pressure ulcer treatment varies depending on the amount of drainage and if infection is present.
- Infected wounds without drainage can be managed with silver dressings, topical medical-grade honey, or foam.
- Infected wounds with drainage require alginate, silver, gauze, or foam.
- Non-infected wounds without drainage are managed with hydrogel.
- Non-infected wounds with drainage can be treated with alginate, hydrocolloid, gauze, and foam.
3. Prepare for debridement.
Debridement may be necessary to remove dead, infected, or damaged tissue in order for the tissue to heal successfully. Debridement can be accomplished through moist dressings, enzymatic topical ointments, or surgical removal performed by a trained wound care nurse or specialist.
4. Consider a wound vac.
Vacuum-assisted closure (VAC), also known as negative pressure wound therapy (NPWT), is utilized for stage 3 or 4 pressure ulcers. It applies suction to remove exudate and dead tissue to promote healing and help draw the wound edges together.
5. Administer pain medications as ordered.
If the patient experiences pain with wound care, premedicate prior with prescribed analgesics.
6. Prepare for surgical treatment.
Surgical debridement, skin grafts, or flap reconstruction may be necessary, depending on the wound location and condition.
7. Consider hyperbaric oxygen therapy.
Hyperbaric oxygen therapy enhances oxygenation in the wound and surrounding tissues to promote healing.
8. Consult with a dietitian.
Maintaining skin and tissue viability and facilitating tissue repair are supported by proper nutrition and hydration strategies. Protein, other macronutrients, and micronutrients like zinc, iron, and vitamins C, E, and A are crucial for wound healing.
9. Refer to a wound care nurse or specialist.
A wound care certified nurse should assess complex or chronic pressure ulcers to recommend the appropriate wound care management and treatment plan. In the outpatient setting, other wound care specialists may be involved for non-healing ulcers or surgical follow-up.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for pressure ulcers, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for pressure ulcers.
Impaired Physical Mobility
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.
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.
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.
Impaired Skin Integrity
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.
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.
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.
Impaired Tissue Integrity
Severe pressure injuries indicate damage to the subcutaneous tissue (stage 3) or deeper damage exposing muscle, tendons, or bone (stage 4).
Nursing Diagnosis: Impaired Tissue Integrity
Related to:
- Pressure injury
- Delayed wound healing
- Infectious process
- Poor circulation
- Impaired mobility
- Surgical procedures
- Poor nutrition
- Insufficient knowledge about protecting or maintaining tissue integrity
As evidenced by:
- Pain
- Redness
- Bleeding
- Warmth
- Tissue damage
Expected outcomes:
- Patient will demonstrate interventions to protect and heal damaged tissue.
- Patient will experience a decrease in pressure ulcer size.
Assessment:
1. Assess and monitor the staging of the pressure injury.
Accurate staging of pressure injuries is vital in the patient’s treatment plan. Staging determines the severity of the injury and the level of tissue involvement. Stage 3 and 4 pressure ulcers may present with tunneling or undermining.
2. Assess etiological factors.
The nurse should assess potential causes or risk factors of impaired tissue integrity, such as comorbidities, current health status, mobility alterations, nutritional status, and more.
3. Monitor the size and depth of the wound.
The nurse should assess and document the length, width, and depth of the ulcer per facility guidelines for comparison over time.
Interventions:
1. Encourage frequent patient repositioning, avoiding positioning on the site of injury.
Frequent repositioning helps distribute pressure evenly across tissues, promote circulation, promote healing, and reduce the risk of further pressure ulcer development, especially over bony prominences. Repositioning must be performed every two hours, avoiding positioning on the site of impaired tissue integrity.
2. Perform or prepare for debridement.
Debridement may be indicated for stage 3 or 4 pressure ulcers to help remove necrotic tissue and promote improved tissue integrity and wound healing.
3. Utilize pressure-relieving devices.
Specialized mattresses and cushions can help redistribute pressure evenly across the body, significantly reducing the risk of developing pressure injuries and promoting improved tissue integrity and healing.
4. Consult with other disciplines.
Complex or non-healing pressure ulcers may require the expertise of a wound care certified nurse, dietician, wound care specialist, and PT/OT for holistic care of the patient.
Ineffective Peripheral Tissue Perfusion
Inadequate blood flow or oxygenation to the tissues increases the risk of pressure ulcers.
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion
Related to:
- Diabetes mellitus
- Infectious process
- Circulatory compromise
- Smoking
- Insufficient knowledge of comorbidities or risk factors
As evidenced by:
- Absent or diminished pulses
- Altered motor function
- Skin discoloration
- Pain
- Edema
- Paresthesia
- Delayed peripheral wound healing
Expected outcomes:
- Patient will demonstrate adequate tissue perfusion as evidenced by palpable peripheral pulses, skin color within normal limits, and adequate wound healing.
- Patient will verbalize understanding of disease processes or lifestyle factors that contribute to poor peripheral perfusion.
Assessment:
1. Assess and monitor peripheral pulses.
Decreased or absent peripheral pulses can indicate arterial insufficiency and contribute to impaired tissue perfusion, which can lead to the development or poor healing of pressure ulcers.
2. Assess and monitor symptoms of decreased tissue perfusion.
Poor tissue perfusion can present as pain, skin discoloration, delayed capillary refill, paresthesia, and weakness or loss of function in the affected site and the surrounding tissues.
Interventions:
1. Perform routine skin assessments.
Patients with a known history of vascular disorders, diabetes mellitus, poor mobility, or other conditions that affect peripheral perfusion should receive frequent skin assessments to monitor for changes in skin color, temperature, or sensation that indicate impaired perfusion and increase the risk for pressure ulcers.
2. Encourage movement or consult with physical therapy.
Patients should be assisted with movement within their capabilities to promote circulation. Expert advice from a physical therapist can help patients with pressure ulcers plan appropriate exercise regimens or mobility techniques to promote tissue perfusion.
3. Take caution when applying heat or cold.
Patients with impaired tissue perfusion may lack the sensory perception to recognize heat or cold and should take caution if applying heating pads or ice packs. Heat or cold should never be applied to pressure ulcers as this further damages compromised tissue.
4. Educate the patient about their risk factors.
Patients may lack knowledge surrounding their medical history that predisposes them to pressure ulcers, such as a stroke or other neurological condition that disrupts their sensory perception or causes unilateral neglect. The nurse can also educate on modifiable risk factors that disrupt perfusion, like smoking or obesity.
Risk For Infection
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
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- 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.
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.
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.
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