Nursing Assessment and Care Plan for Pressure Ulcers

Pressure ulcers are also called decubitus or pressure injuries. They occur when there is a constant lack of oxygen and blood, which causes poor tissue circulation, and tissue death.

Patients who are bedridden, immobile and unable to verbalize their pain or discomfort, and those older than 65, are at the highest risk of pressure injury development. Patients with chronic diseases such as diabetes and vascular disease are also at greater risk. To obtain a basic nursing skills, you can find licensed practical nursing programs near me for detailed nursing care plan for pressure ulcer prevention in long-term care facilities.

Through pressure ulcer risk assessment and early intervention, pressure ulcers can be prevented. Once a pressure wound occurs, it is difficult to heal and treat. If wound treatment does not work, ulcers may need debridement. Other options include hyperbaric oxygen, wound vacuums, wound and surgery in various health care settings.

The Nursing Process

To prevent ulcers, a team of healthcare professionals must work together to implement turning schedules and hygiene basic care. Even when ulcers are controlled, they can still occur in high-risk patients. Health care team must be vigilant to prevent further complications.

Nursing Care Plan for Pressure Ulcer Prevention

Impaired Skin Integrity Treatment Plan

Pressure ulcers can be caused by skin that is compromised, whether it’s internal or external.

 Nursing Diagnosis Impaired skin Integrity

Related to:

• Nutritional status
• Edema
• Circulation impaired
• Neuropathy
• Moisture/Incontinence
• Shearing forces or friction
• Incisions for surgical procedures
• Immobility

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As shown by:

• The affected area is verbalized as being in pain or feeling numb.
• Alterations of skin color (bruising, blanching, and erythema).
• Skin disruption (excoriation, breakdown)
• Bloody drainage or pus

Expected Outcomes:

• Within 30 days, the patient will show resolution of the pressure ulcer.
• The patient will demonstrate three ways to maintain skin integrity
• An ulcer will improve as evidenced by the reduction in size and absence of drainage.

Impaired Skin Integrity Evaluation

1. Patients should be assessed for skin conditions every shift. The Braden Skin Assessment Scale can be used to determine the patient’s potential for pressure injury, emphasize the importance of extensive wound care nursing education with prerequisite courses and competence. In nursing profession, this can be obtained through reputable LPN nursing programs with clinical courses in best nursing schools in Illinois.”
2. Pressure ulcers can be diagnosed correctly:- The correct staging of skin breakdown is vital for proper management and continual assessment. Stages of pressure ulcers range from 1 to 4, with stage 4 being an ulcer that has exposed bone and muscle. Deep tissue injuries and ulcers that are not stateable due to slough or eschar can also be caused by pressure.
3. Identify any additional risk factors:- Take into account the patient’s age, chronic conditions, cognition and nutritional status, which can affect the elasticity of the skin and its health, as well as their ability to verbalize feelings or prevent skin breakdown.

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Skin Integrity Interventions

1. Work with wound care specialists:- Wound care practical nurses or medical assistant must be involved as soon as possible to monitor and prevent any further skin breakdown. Chronic wound specialists may be required to follow up with patients who have severe pressure ulcers, or those whose healing is delayed.
2. Encourage nutrition and hydration:- Nutrition and hydration are essential for immune function, collagen production, and skin tensile strength. Zinc, vitamin A, C & E and protein intake support wound healing pressure ulcers. For adequate nutrition, enteral nutrition or IV fluids are often required.
3. Keep your skin dry and clean:- Perineal care is required for incontinent patients or cannot verbalize that they need to be cleaned in nursing home. Sweat, pee, and diarrhea can all cause skin irritation.
4. Apply the necessary wound care:- A pressure ulcer’s type, size and location will determine the wound care order. Applying foams, sprays and ointments will help heal the wound and prevent further breakdown.