3 Pressure Ulcer (Bedsores) Nursing Care

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3 Pressure Ulcer (Bedsores) Nursing Care Plans

A pressure ulcer (also known as bedsores or decubitus ulcer) is a localized skin injury where tissues are compressed between bony prominences and hard surfaces such as a mattress. They are caused by pressure in combination with friction, shearing forces, and moisture. The pressure compresses small blood vessels and leads to impaired tissue perfusion. The reduction of blood flow causes tissue hypoxia leading to cellular death.

Nursing Care Plans

Pressure ulcers stage I through III can be managed with aggressive local wound treatment and proper nutritional support while stage IV pressure ulcers usually require surgical intervention.
Nursing care for clients experiencing pressure ulcer (bedsores) includes assessing the contributing factors leading to a lack of tissue perfusion, assessing the extent of the injury, promoting compliance to the medication regimen, preventing further injury.
Here are three (3) nursing care plans (NCP) for pressure ulcers (bedsores):

1. Impaired Skin Integrity

Impaired Skin Integrity: Altered epidermis and/or dermis.
May be related to
  • - Chronic disease state.
  • - Extreme of ages.
  • - Imbalanced nutritional state.
  • - Impaired cognition.
  • - Impaired sensation.
  • - Immobility.
  • - Immunological deficit.
  • - Incontinence.
  • - Mechanical factors (friction, pressure, shear).
  • - Moisture.
  • - Poor circulation.
  • - Pronounced body prominence.
  • - Radiation.
Possibly evidenced by
  • - Destruction of skin layers.
  • - Disruption of skin surfaces.
  • - Drainage of pus.
  • - Invasion of body structures.
  • - Pressure ulcer stages:
    • Deep tissue injury (new stage):
      • - Purple or maroon localized area of intact skin or blood-filled blister resulting from pressure damage of underlying soft tissue.
    • Stage I:
      • - Epidermis is intact.
      • - Non-branch able erythema of intact skin. Discolouration of the skin, warmth, edema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.
    • Stage II:
      • - Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.
    • Stage III:
      • - Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
      • - Slough may be present; may include undermining and tunneling.
    • Stage IV:
      • - Extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures, with or without full-thickness skin loss.
      • - Undermining and tunneling may develop.
    • Unstageable:
      • - Full-thickness tissue loss in which actual depth of ulcer is completely obstructed by slough or eschar in the wound bed.
Desired Outcomes
  • - Client will get stage-appropriate wound care and has controlled risk factors for prevention of additional ulcers.
  • - Client will experience healing of pressure ulcers and experiences pressure reduction.
Nursing InterventionsRationale
Assess the specific risk factors for pressure ulcer:Even clients with an existing pressure ulcer continue to be at risk for further injury, Nurses should consider all potential risk factors for pressure ulcers development.
  • - Determine the client’s age and general condition of the skin.
Elderly clients have less elastic skin, less moisture, less padding and have thinning of the epidermis, making it more prone to skin impairment.
  • - Assess the client’s nutritional status, including weight, weight loss, and serum albumin levels, if indicated.
A severe protein depletion has an albumin level of less than 2.5 g/dL. Clients with pressure ulcer lose big amounts of protein in wound exudates and may require 4000 kcal/day or more to remain anabolic.
  • - Assess for a history of preexisting chronic diseases (e.g., diabetes mellitus, acquired immune deficiency syndrome, guillain-barrĂ© syndrome, peripheral and/or cardiovascular disease).
Clients with chronic diseases typically exhibit multiple risk factors that predispose them to pressure ulceration. These include poor nutrition, poor hydration, incontinence, and immobility.
  • - Assess the skin on admission and daily for an increasing number of risk factors.
The incidence of skin breakdown is directly related to the number of risk factor present.
  • - Assess for a history of radiation therapy.
Irradiated skin becomes thin and brittle, may have less blood supply, and is at a higher risk for skin breakdown.
  • - Assess the client’s awareness of the sensation of pressure.
Usually, people shift their weight off pressure areas every few minutes; this occurs more or less automatically, even during sleep. Clients with decreased sensation are unaware of unpleasant stimuli and do not shift weight, thereby exposing the skin to excessive pressure.
  • - Assess for fecal and urinary incontinence.
The urea in urine turns into ammonia within minutes and is erosive to the skin. While the stool may contain enzymes that cause skin breakdown. Diapers and incontinence pads with plastic liners trap moisture and speed up breakdown.
  • - Assess client’s ability to move (shift weight while sitting, turn over in bed, move from the bed to a chair).
Immobility is a huge risk factor for pressure ulcer development among adult hospitalized clients.
  • - Assess for environmental moisture (excessive perspiration, high humidity, wound drainage).
Moisture may contribute to skin maceration.
  • - Assess the amount of shear (pressure exerted laterally) and friction (rubbing) on the client’s skin.
Shearing forces are most commonly noted on the sacrum, scapulae, heels, and elbows from skin-sheet friction, from semi-Fowler’s position and repositioning, and from lift sheets.
  • - Assess the surface that the clients spend a majority of time on (mattress for bedridden clients, cushion for clients in wheelchairs).
Clients who spend the majority of time on one surface need a pressure reduction or pressure relief device to reduce the risk of skin breakdown.
  • - Assess the skin over bony prominences (sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back of the head).
These areas at highest risk for breakdown resulting from tissue ischemia from compression against a hard surface.
Use an objective tool for pressure ulcer risk assessment:
  • - Braden scale.
  • - Norton scale.
The Braden scale is the most widely used risk assessment. It consists of six subscales namely: activity, mobility, moisture, nutrition, sensory perception, and friction.Acute care:Assessment should be carried out on all patients on admission and every 24 to 48 hours or sooner if the patient’s condition changes.Long-term care: Assess on admission, weekly for 4 weeks, then quarterly and whenever the resident’s condition changes.
Assess the client’s level of pain, especially related to dressing change and procedures.Prophylactic pain medication may be indicated.
Assess and stage the pressure ulcers.Staging is essential because it determines the treatment plan. Staging should be assessed at each dressing stage. It reflects whether the epidermis, dermis, fat, muscle, bone, or joint is exposed. If the ulcer is covered with necrotic tissue (eschar), it cannot be accurately staged. Stage I ulcers are difficult to detect in darkly pigmented skin. The use of mirrors or a penlight may be helpful.
Determine the condition of the wound or wound bed.
  • - Presence of necrotic tissue.
Necrotic tissue is tissue that is dead and eventually must be removed before healing can take place. Necrotic tissue exhibits a wide range of appearance: black, brown, leathery, hard, shiny, thin, tough, white.
  • - Color.
The color of tissue is an indication of tissue viability and oxygenation. White, gray, or yellow eschar may be present in stage II and III ulcers. Eschar may be black in stage IV ulcers.
  • - Odor.
Odor may arise from infection present in the wound; it may also arise from the necrotic tissue. Some local wound care products may create or intensify the odors and should be distinguished from wound or exudate odors.
  • - Viability of bone, joints, or muscle.
In stage IV pressure ulcers, these may be apparent at the base of the ulcer. Wounds may demonstrate multiple stages or characteristics in a single wound.
Measure the size of the ulcer, and note the presence of undermining.The ulcer dimensions include length, width, and depth. An ulcer begins in the deepest tissue layers before the skin breaks down. Hence the opening of the skin’s surface may not represent the true size of the ulcer.
Assess the condition of wound edges and surrounding tissue.Surronding tissue may be healthy or may have various degrees of impairment. Healthy tissue is necessary for the use of local wound care products requiring adhesion to the skin. The presence of healthy tissue demarcates the boundaries of the pressure ulcer.
Assess the wound exudate.Exudate is a normal part of wound physiology and must be differentiated from pus which is an indication of infection. Exudate may contain serum, blood, and white blood cells, and may appear clear, cloudy, or blood-tinged. The amount may vary from a few cubic centimeters, which are easily managed with dressings, to copious amounts not easily managed. Drainage is considered excessive when dressing changes are needed more often than every 6 hours.
Assess ulcer healing, using a pressure ulcer scale for healing (PUSH) tool.This tool provides standardization in the measurement of wound healing. It quantifies surface area, exudate, and the type of wound tissue.
Provide local wound care:
Stage I:
  • - Apply a topical vasodilator (e.g., Proderm)
It increases skin circulation.
  • - Apply a flexible hydrocolloid dressing (e.g., Duoderm) or a vapor-permeable membrane dressing (Tegaderm).
It prevents shear and friction.
  • - Apply a vitamin-enriched emollient to the skin every shift.
It moisturizes the skin.
Stage II:
  • - Apply a Alginates (Sorbsan, Kalginate, Kaltostat).
Alginate dressings are a type that is highly absorbent and so can absorb the fluid (exudate) that is produced by some ulcers. These are often used for ulcers with moderate-to-heavy exudate.
  • - Apply hydrocolloids or a vapor-permeable membrane dressing.
Hydrocolloids are used to promote healing and wound debridement. They are not advised to use for heavy-exudate-producing wounds.
  • - Apply gauze with sodium chloride solution.
This maintains a moist environment but requires multiple dressing changes. Dressings must be removed while still wet. Dressings absorb small amounts of drainage.
  • - Apply Hydrogels (Carrasyn V, Aqua Skin).
Hydrogels provide moisture to dry, sloughy or necrotic wounds and assists autolytic debridement. Can be used on wounds with low exudate. Usually use for shallow ulcers without exudates.
Stage III and IV:
  • - Foams.
Different foams have different levels of absorbency. They are best used on granulating wounds. Foams lessen odor and repel bacteria and water.
  • - Gauze with sodium chloride solution.
This maintains a moist environment but requires multiple dressing changes as describe for stage II.
  • - Wound fillers.
Wound fillers are used as a primary dressing and to pack wounds, maintain a moist environment.
  • - Autolytic debridement.
Using a hydrocolloid or hydrogel, these create a moist wound interface that enhances the activity of endogenous proteolytic enzymes within the wound, liquefying and separating necrotic tissue from healthy tissue.
  • - Sharp or surgical debridement.
This procedure removes the necrotic tissue and senescent cells that slow down the tissue repair process, converting a chronic wound into an acute one in the process.
  • - Mechanical debridement.
Involves allowing a traditional gauze-type dressing to dry out and adhere to the surface of the wound before manually removing the dressing, debriding any tissue attached to it.
  • - Electrical stimulation.
Stimulation of many cellular processes improves healing.
  • - Biosurgery.
Therapeutic use of live blow fly larvae (maggots) for a quick debridement.
  • - Topical growth factors.
Nerve-growth factors, colony-stimulating factors, and fibroblast growth factors are found to be effective in treating diabetic and venous ulcers.
  • - Negative pressure wound therapy.
A wound dressing systems that continuously or intermittently apply a subatmospheric pressure to the surface of a wound to assist healing.
  • - Enzymatic debridement (chlorophyll, collagenase, papain).
Enzymatic debridement uses proteolytic enzymes to remove necrotic tissue. These agents work by selectively digesting the collagen portion of the necrotic tissue. Care should be taken to prevent damage to surrounding healthy tissues.

2. Risk For Infection.

Risk for Infection: At increased risk for being invaded by pathogenic organisms.
Risk factors
  • - Poor nutritional status.
  • - Proximity of sacral wounds to perineum.
  • - Open pressure ulcer.
Possibly evidenced by
  • [not applicable].
Desired Outcomes
  • - Client will maintain normal body temperature.
  • - Client will remain free of local or systemic infections, as evidenced by the absence of copious, foul-smelling wound exudate.
Nursing InterventionsRationale
Assess the client’s nutritional status.Clients who seriously lack nutrition (serum albumin <2.5 mg/dl) are at risk of developing infection produced by a pressure ulcer. Also, clients with pressure ulcers lose tremendous amounts of protein in wound exudate and may require 4000 kcal/day or more to remain anabolic.
Assess the client for unexplained sepsis.When septic workup is done, the pressure ulcer must be considered a possible cause.
Assess for urinary and fecal incontinence.Sacral wounds, because of their proximity to the perineum, are at highest risk for infection caused by urine or fecal contamination. It is sometimes difficult to isolate the wound from the perineal area.
Assess pressure ulcer for odor, color of tissue, and drainage.Foul smelling pressure ulcer may indicate an infection; Infected tissue usually has a gray-yellow appearance without evidence of pink granulation tissue; The presence of exudate that is clear to straw-colored is normal. While purulent green or yellow drainage in large amounts indicates an infection.
Assess the client’s temperature.Fever is considered a temperature above 100.4 degrees F (38 degrees C) indicate a presence of infection unless the client is immunocompromised or diabetic.
Monitor the client’s white blood cell count (WBC).Elevated WBC counts indicate an infection, although, in very old individuals, the WBC count may rise only slightly during an infection, indicating a diminished marrow reserve.
Obtain wound cultures, if indicated.All pressure ulcers are colonized because skin normally has flora that will be found in an open skin lesion; however, all pressure ulcers are not infected. Infection is present when there is copious, foul-smelling, purulent drainage and the client has other signs of infection (fever, increased pain) and bacteria count greater than 105. Swab cultures are not recommended. Rather, tissue biopsy should be used to quantify and qualify the aerobic and anaerobic organisms present.
Consult with a dietitian for assistance with a high-protein, high-calorie diet.A High-calorie, high-protein diet may be recommended to help in healing and resist infection.
Provide thorough perineal hygiene after each episode of incontinence.This can lessen pathogens in the area of sacral pressure ulcers.
Provide hydrotherapy, if indicated.It is used to achieve wound cleansing and to promote good circulation.
Administer antibiotics as prescribed.Complicated wounds may develop cellulitis or sepsis, requiring antibiotic therapy. Oral antibiotics or topical silver sulfadiazine can be effective.
Provide local wound care as prescribed.The type and level of wound treatment depend on the staging of the ulcer and the type of infection present.

3. Risk For Ineffective Health Maintenance

Risk for Ineffective Health Maintenance: At risk for inability to identify, manage, and seek out help to maintain health.
Risk factors
  • - Impaired functional status.
  • - Lack of previous similar experience.
  • - Need for long-term pressure management.
  • - Possible need for special equipment.
Possibly evidenced by
  • [not applicable].
Desired Outcomes
  • - Client and caregiver will verbalize understanding of the following aspects of home care: nutrition, pressure relief, wound care, and incontinence management.
  • - Client and caregiver will verbalize ability to cope adequately with existing situation, provide support/monitoring as indicated.
Nursing InterventionsRationale
Assess the client’s and caregiver’s knowledge of and ability to provide local wound care.Client’s are no longer kept hospitalized until pressure ulcers have healed, The need for local wound care may continue at home for weeks to months.
Assess the client’s and caregiver’s understanding of the prevention of further pressure ulcer development.Clients who are immobile will need frequent repositioning to lessen the risk fro breakdown in those areas that are intact.
Assess the client’s and caregiver’s understanding of the long-term nature of wound healingPressure ulcer may take weeks to months to heal even under ideal circumstances. Wound heal from the base of the ulcer up, and from the edges of the ulcer toward the center. Palliative wound care may be appropriate for clean, chronic, non-healing wound.
Assess the client’s and caregiver’s understanding of the relationship between incontinence and further skin breakdown or complication of healing.Managing incontinence may be the most difficult aspect of home management and is often the reason for nursing home placement are made.
Assess the client’s and caregiver’s understanding of and ability to provide a High-calorie, high-protein diet throughout the course of wound healing.Clients may require enteral feeding (through gastronomy tube, nasogastric tube feedings, or the oral route), which requires knowledge of preparation and the use of special equipment.
Assess for the availability of a pressure reduction or pressure-relief surface.Client’s may take thick, dense foam mattress home from the hospital to place on their own bed. Rental provisions of low-air-loss beds (e.g., KinAir, Flexicare) and air-fluidized therapy beds (FluidAir, Skytron, Clintron) may be arranged but often pose a financial difficulty because few payer sources will cover the cost of these beds in the home.
Educate the client and the caregiver to report the following signs indicating wound infection: Fever, malaise, chills, foul-smelling odor, purulent drainage.Early detection prompts immediate intervention.
Educate the client and the caregiver in managing incontinence (e.g., use of moisture barrier ointments, use of underpads, use of external catheters).Teaching proper techniques can prevent leakage and skin problems. Reusable products such as underpads or linen protectors made of cloth with a waterproof lining are better for the client’s skin and are more economical but require laundering. Moisture barrier ointments protect intact skin from excoriation.
Educate the client and the caregiver regarding local wound care, and allow for a return demonstration.This will allow the client to use new information immediately, thus enhancing retention. Immediate feedback allows the learner to make corrections, rather than practice the skill incorrectly.
Provide written instructions with listed resources.Long-term management requires specific written plans to enhance adherence o treatment. Several internet resources provide lay education.
Involve a social worker or case manager.Referral helps the client and family determine whether placement in an extended care facility is needed. Because many clients with pressures are older, it is often an older spouse who is available to provide care; as a result of the intensive nursing care needs of these clients, discharge to home is often unrealistic.
Consult a wound specialist to evaluate care in the home.Besides evaluating the ability to deliver care, the specialist may be useful in securing specialty treatment.
Educate the client and the caregiver the importance of pressure reduction and relief (e.g., turning schedule, use of specialty beds, use of relief surface where the client sit).Information can nurture enhanced adherence to pressure ulcer treatment guidelines.
Discuss with the client and caregiver the possible need for respite care.Long-term responsibility for client care in the home is burdening; those providing care may need help to understand that their needs for relaxation are important to the maintenance of health and should not be viewed as avoidance of the responsibility.
Discuss with the client and caregiver the need for in-home nursing care or homemaker services.These provide all or part of the client’s care and can be economical to the client. Also, keeping the client in his or her own environment lessen the risk for hospital-acquired infection and keeps the client in a familiar surrounding.
References and Sources : 

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