Pressure ulcers, commonly known as bed sores, decubitus ulcers, or pressure injuries, represent localized damage to the skin and underlying tissue. These injuries arise from sustained pressure, frequently over bony prominences, disrupting blood flow and oxygen supply to the tissues. This deprivation leads to tissue ischemia, cell death, ulceration, and necrosis if left unaddressed.
Understanding Pressure Ulcers
Pressure ulcers are a significant concern in healthcare, particularly for patients with limited mobility. They typically develop over bony areas such as the sacrum, coccyx, greater trochanter, heels, and ankles, though they can occur anywhere pressure persists.
The severity of pressure ulcers is classified using a staging system developed by the National Pressure Injury Advisory Panel (NPIAP):
- Stage 1: Identified by intact skin presenting non-blanchable erythema, indicating altered microcirculation.
- Stage 2: Characterized by partial-thickness skin loss involving the epidermis and/or dermis. May present as an abrasion, blister, or shallow crater.
- Stage 3: Involves full-thickness skin loss, where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed.
- Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present.
- Unstageable: The extent of tissue damage cannot be determined because the ulcer base is obscured by slough or eschar.
- Deep Tissue Pressure Injury (DTPI): Recognized as persistent non-blanchable deep red, maroon, or purple discoloration. Intact or non-intact skin.
Preventing pressure ulcers is paramount. They are often preventable with diligent assessment and intervention strategies. Once developed, especially Stage 3 and 4 ulcers, they can significantly increase the risk of severe complications, including osteomyelitis and sepsis. Treatment for pressure ulcers unresponsive to basic wound care might include debridement, negative pressure wound therapy, hyperbaric oxygen therapy, or surgical intervention.
The Nursing Process in Bed Sore Management
Effective prevention and management of bed sores necessitate a collaborative healthcare approach. Nursing plays a crucial role in implementing preventative measures and providing vigilant wound care when ulcers occur. This involves turning schedules, meticulous hygiene, nutritional support, and ongoing monitoring.
Comprehensive Nursing Assessment for Bed Sores
The initial step in addressing bed sores is a thorough nursing assessment. This involves gathering subjective and objective data encompassing physical, psychosocial, emotional, and diagnostic aspects relevant to the patient’s condition.
Reviewing Health History for Bed Sore Risk Factors
1. Inquire about the Pressure Injury: If a pressure injury is present, gather detailed information regarding its history:
- Observe and document any skin discoloration.
- Note any presence of foul odor emanating from the area.
- Assess for any discharge or exudate.
- Determine if the patient reports decreased sensation at the site.
2. Identify Potential Causative Factors: Evaluate the patient’s skin integrity and mobility status. Identify any medical devices or equipment (e.g., diapers, IV lines, catheters) that could exert pressure on the skin. Key factors contributing to bed sore development alongside pressure include:
- Exposure to moisture from bodily fluids like sweat, urine, or feces.
- Friction caused by skin rubbing against surfaces (e.g., bed linens).
- Shear forces occurring when tissue layers move against each other, damaging blood vessels.
3. Determine Patient-Specific Risk Factors: Certain patient populations are at heightened risk for developing pressure ulcers. Identify if the patient falls into any of these categories:
- Advanced age.
- Bedridden or chair-bound status.
- Paralysis or limited mobility.
- Incontinence (urinary or fecal).
- Malnutrition or nutritional deficiencies.
- Obesity or being underweight.
- Impaired ability to communicate pain or discomfort.
4. Analyze Medical History for Predisposing Conditions: Review the patient’s medical record for conditions that increase susceptibility to pressure ulcers:
- Conditions causing immobility:
- Paraplegia, Quadriplegia
- Spina bifida
- Sensory perception deficits.
- Diseases affecting blood circulation (e.g., peripheral vascular disease).
Note: Length of hospital stay is a significant factor, with longer stays correlating with increased pressure ulcer incidence.
5. Medication Review for Drug-Induced Pressure Ulcers: Be aware of drug-induced pressure ulcers (DIPU), a recognized adverse drug reaction. Certain medications, particularly psychiatric drugs in older adults, have been linked to DIPU development.
6. Assess Living Situation and Support System: Stage 4 pressure ulcers may indicate potential neglect. For patients in nursing homes or receiving home care, assess the adequacy of caregiver support and their understanding of pressure ulcer prevention. Nursing homes may have mandatory reporting for Stage 4 ulcers. Provide education to families and caregivers on pressure ulcer prevention strategies if they are responsible for patient care.
7. Surgical History and Perioperative Risks: Recognize that pressure ulcers can begin to form rapidly in immobile patients, even within two hours. Prolonged anesthesia, extended surgical procedures, and postoperative reduced mobility are crucial factors to consider.
Physical Examination for Bed Sore Identification
1. Comprehensive Pressure Ulcer Assessment: If a pressure ulcer is present, meticulously document its characteristics:
- Measure and record the size: length, width, and depth.
- Note the presence and characteristics of:
- Exudate (type, color, amount).
- Odor (presence and nature).
- Undermining (tissue destruction under intact skin at the wound edge).
- Tunneling (narrow passageway extending from the wound).
- Necrotic tissue (slough or eschar).
- Evaluate healing progress: presence of granulation tissue and epithelialization.
- Assess wound margins and the condition of the periwound skin.
2. Accurate Pressure Injury Staging: Utilize the NPIAP staging system to document the stage of the pressure injury. Accurate staging is essential for monitoring wound progression or deterioration and guiding treatment.
3. Mental Status Evaluation: Assess the patient’s cognitive ability to communicate needs and discomfort. Ensure the care team proactively addresses patient needs like toileting, repositioning, and hydration to prevent pressure ulcers.
4. Neuromuscular and Mobility Status: Evaluate neuromuscular function and mobility limitations. Patients with sensory impairments (e.g., spinal cord injuries) may not perceive pressure or discomfort. Patients with limited mobility, contractures, or paralysis require vigilant assistance for pressure ulcer prevention.
5. Utilize the Braden Scale for Risk Assessment: Employ the Braden Scale, a widely validated tool, to assess pressure injury risk. This scale evaluates six key factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The score helps determine the patient’s risk level and guides appropriate preventive interventions.
The Braden Scale is a vital tool in nursing to assess a patient’s risk for developing pressure sores, focusing on sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Diagnostic Procedures for Bed Sore Evaluation
1. Blood Workup: Certain laboratory values can provide insights into factors contributing to pressure ulcers or impaired healing:
- Elevated white blood cell (WBC) count may indicate infection.
- Low hemoglobin levels suggest reduced oxygen delivery to tissues.
- Low platelet counts can impair wound healing processes.
- Low albumin levels indicate protein deficiency, hindering wound repair.
- Elevated glucose levels can negatively impact wound healing.
2. Wound Culture: Obtain wound cultures from pressure ulcers exhibiting drainage or signs of infection to identify pathogens and guide targeted antibiotic therapy.
3. Tissue Biopsy: Consider tissue biopsy for non-healing pressure ulcers to rule out complications like osteomyelitis or malignancy.
4. Imaging Studies: If osteomyelitis is suspected, MRI or CT scans may be indicated for further evaluation.
Nursing Interventions for Bed Sore Management
Nursing interventions are critical for both preventing and treating pressure ulcers.
Pressure Ulcer Prevention Strategies
1. Regular Repositioning and Turning Schedules: Implement a strict turning and repositioning schedule, typically every two hours, to relieve pressure. Delegate turning schedules to assistive personnel as appropriate. Encourage increased activity as tolerated through passive and active range of motion exercises and ambulation.
2. Maintain Skin Hygiene and Dryness: Provide meticulous hygiene care to keep the skin clean and dry. Use moisture barrier creams to protect skin from incontinence. Consider fecal or urinary diversion devices if contamination is a significant risk based on ulcer location.
3. Utilize Pressure-Relieving Support Surfaces: Employ specialty mattresses, cushions, foam wedges, and heel protectors to offload pressure from bony prominences.
4. Minimize Friction and Shear Forces: Reduce friction and shear through proper patient handling techniques. Use transfer sheets when repositioning patients in bed. Keep the head of the bed as low as possible to minimize sliding.
5. Ensure Adequate Hydration and Nutrition: Promote adequate protein and nutrient intake to support skin health and wound healing. Hydration is crucial for cell function, collagen production, and skin elasticity.
6. Keep Medical Lines and Devices Off the Skin: Regularly check and adjust urinary catheters, IV lines, feeding tubes, and other devices to prevent them from pressing directly on the skin. Ensure linens and clothing are smooth and wrinkle-free.
7. Educate Patients and Caregivers on Prevention: Educate patients, families, and caregivers about their role in pressure ulcer prevention, emphasizing:
- Adherence to turning/repositioning schedules.
- Maintaining skin cleanliness and dryness.
- Proper use of offloading devices.
- Recognizing early warning signs of skin breakdown (e.g., discoloration, decreased sensation).
Treatment of Existing Pressure Ulcers
1. Pressure Relief and Protection: For Stage 1 pressure ulcers (non-blanchable intact skin), immediately offload pressure from the affected area. Utilize pressure-relieving mattresses, pillows, and wedges. Apply protective dressings like Mepilex Border to sacral, coccyx, or heel areas to minimize pressure, friction, and shear.
2. Wound Dressing Selection: Dressing choice depends on wound characteristics, including drainage and infection status. Follow established protocols or healthcare provider orders:
- For infected wounds without drainage: Silver dressings, topical medical-grade honey, or foam dressings.
- For infected wounds with drainage: Alginate, silver-impregnated dressings, gauze, or foam dressings.
- For non-infected wounds without drainage: Hydrogel dressings.
- For non-infected wounds with drainage: Alginate, hydrocolloid, gauze, or foam dressings.
3. Debridement Considerations: Debridement, the removal of necrotic tissue, may be necessary to promote healing. Methods include moist dressings, enzymatic ointments, or surgical debridement performed by trained wound care professionals.
4. Negative Pressure Wound Therapy (NPWT): Consider NPWT (wound vac) for Stage 3 or 4 pressure ulcers. NPWT uses suction to remove exudate and promote wound closure.
5. Pain Management: Administer pain medications as prescribed, especially prior to wound care procedures, if the patient experiences pain.
6. Surgical Intervention: Surgical debridement, skin grafts, or flap reconstruction may be required for complex or non-healing wounds.
7. Hyperbaric Oxygen Therapy: Hyperbaric oxygen therapy may be considered to enhance oxygenation to the wound and surrounding tissues, promoting healing.
8. Nutritional Consultation: Consult with a registered dietitian to optimize nutritional support. Adequate protein, macronutrients, and micronutrients (zinc, iron, vitamins C, E, A) are essential for wound healing.
9. Wound Care Specialist Referral: Refer patients with complex or chronic pressure ulcers to a certified wound care nurse or specialist for expert assessment and management.
Nursing Care Plans for Bed Sore Nursing Diagnosis
Nursing care plans are essential for organizing and prioritizing nursing care for patients with or at risk for pressure ulcers. They provide a framework for addressing identified nursing diagnoses and establishing patient-centered goals. Examples of common nursing diagnoses related to bed sores and associated care plan components are outlined below:
Impaired Physical Mobility related to Bed Sore Risk
Nursing Diagnosis: Impaired Physical Mobility
Related Factors:
- Paralysis
- Prescribed bed rest
- Decreased muscle strength
- Contractures
- Pain
- Neuromuscular conditions
- Cognitive impairment
- Obesity
Evidenced by:
- Limited range of motion
- Inability to reposition independently
Expected Outcomes:
- Patient will utilize assistive devices to improve mobility and repositioning.
- Patient will verbalize understanding of pressure ulcer prevention strategies.
- Patient will not develop new pressure ulcers.
Nursing Assessments:
- Assess Mobility and Range of Motion: Evaluate the patient’s ability to move and reposition themselves independently.
- Assess Caregiver Understanding: For patients receiving care at home or in nursing homes, assess the caregivers’ knowledge and ability to implement proper turning and skin care techniques.
Nursing Interventions:
- Implement Assistive Devices: Provide trapeze bars and side rails to enhance patient independence in repositioning.
- Utilize Pressure Redistribution Devices: Use wedges, pillows, heel protectors, and specialty mattresses to offload bony prominences.
- Pain Management: Pre-medicate for pain before repositioning and provide routine pain management to facilitate movement.
- Patient and Family Education: Instruct patients and families on areas at risk for breakdown (e.g., heels, sacrum, elbows, ears).
- Promote Activity: Assist with transfers to chairs and ambulation as appropriate to relieve pressure and improve circulation.
- Implement Turning Schedule: Adhere to a 2-hour turning schedule for bedridden patients and encourage repositioning every 15 minutes for seated patients.
Impaired Skin Integrity related to Bed Sore Development
Nursing Diagnosis: Impaired Skin Integrity
Related Factors:
- Poor nutritional status
- Edema
- Impaired circulation
- Neuropathy
- Moisture/Incontinence
- Shearing/Friction
- Immobility
Evidenced by:
- Reports of pain or numbness
- Skin color changes (erythema, blanching)
- Skin breakdown or disruption
- Drainage
Expected Outcomes:
- Patient will demonstrate pressure ulcer healing within a specified timeframe.
- Patient will describe methods to prevent skin integrity impairment.
- Pressure ulcer will show improvement (reduced size, absence of drainage).
Nursing Assessments:
- Regular Skin Assessments: Conduct skin assessments at least once per shift, using the Braden Scale to assess risk.
- Accurate Pressure Ulcer Staging: Stage any existing pressure ulcers accurately for proper management and monitoring.
- Identify Risk Factors: Consider patient age, chronic conditions, cognition, and nutritional status as contributing factors.
Nursing Interventions:
- Wound Care Consultation: Involve wound care specialists early in the management of skin breakdown.
- Nutritional Support: Encourage adequate nutrition and hydration, emphasizing protein, vitamins, and minerals crucial for skin health.
- Maintain Skin Cleanliness and Dryness: Provide meticulous perineal care and linen changes, especially for incontinent patients.
- Implement Wound Care Orders: Follow prescribed wound care orders, including cleansing and application of appropriate dressings.
Impaired Tissue Integrity related to Pressure Ulcer Severity
Nursing Diagnosis: Impaired Tissue Integrity
Related Factors:
- Pressure injury
- Delayed wound healing
- Infection
- Poor circulation
- Impaired mobility
- Poor nutrition
Evidenced by:
- Pain
- Redness
- Bleeding
- Warmth
- Tissue damage
Expected Outcomes:
- Patient will demonstrate protective measures to promote tissue healing.
- Patient will exhibit a reduction in pressure ulcer size.
Nursing Assessments:
- Pressure Injury Staging: Monitor and document the stage of the pressure injury accurately.
- Etiological Factor Assessment: Identify potential causes and risk factors contributing to impaired tissue integrity.
- Wound Measurement: Regularly measure and document wound size (length, width, depth) according to facility protocols.
Nursing Interventions:
- Frequent Repositioning: Reposition patients frequently, avoiding direct pressure on the ulcer site.
- Debridement Preparation: Prepare for and assist with debridement procedures as indicated.
- Pressure-Relieving Devices: Utilize specialized mattresses and cushions to redistribute pressure.
- Multidisciplinary Consultation: Consult with wound care nurses, dietitians, and physical/occupational therapists for comprehensive care.
Ineffective Peripheral Tissue Perfusion related to Bed Sore Risk
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion
Related Factors:
- Diabetes mellitus
- Circulatory compromise
- Smoking
- Insufficient knowledge of risk factors
Evidenced by:
- Diminished peripheral pulses
- Skin discoloration
- Pain
- Delayed wound healing
Expected Outcomes:
- Patient will demonstrate adequate tissue perfusion (palpable pulses, normal skin color, wound healing).
- Patient will verbalize understanding of factors affecting peripheral perfusion.
Nursing Assessments:
- Peripheral Pulse Assessment: Assess and monitor peripheral pulses for strength and presence.
- Signs of Decreased Perfusion: Monitor for signs of poor tissue perfusion (pain, discoloration, delayed capillary refill).
Nursing Interventions:
- Routine Skin Assessments: Perform frequent skin assessments, especially for patients with risk factors for impaired perfusion.
- Promote Movement and Physical Therapy: Encourage movement and consult with physical therapy to improve circulation.
- Caution with Heat and Cold: Use caution when applying heat or cold due to potential sensory deficits. Avoid direct application to pressure ulcers.
- Patient Education: Educate patients about risk factors for impaired perfusion and pressure ulcer development.
Risk for Infection related to Open Bed Sore
Nursing Diagnosis: Risk for Infection
Related Factors:
- Broken skin integrity
- Immunocompromised status
- Poor hygiene
- Incontinence
Evidenced by:
This is a risk diagnosis, therefore there are no current signs and symptoms.
Expected Outcomes:
- Patient will remain free from signs of wound infection (redness, drainage, odor, warmth).
- Patient will remain afebrile and maintain normal WBC count.
- Wound dressings will remain intact to prevent bacterial contamination.
Nursing Assessments:
- Monitor for Infection Signs: Assess for local signs of wound infection (drainage, odor, redness, swelling) and systemic signs (fever, elevated WBC).
- Wound Cultures: Obtain wound cultures if infection is suspected.
- Laboratory Data: Monitor WBC count and other relevant lab values (protein, glucose) to assess infection risk and healing potential.
Nursing Interventions:
- Antibiotic Administration: Administer antibiotics as prescribed for prophylaxis or treatment of infection.
- Hand Hygiene and Aseptic Technique: Practice strict hand hygiene and aseptic technique during wound care.
- Ensure Dressing Integrity: Maintain intact wound dressings and change them as needed to prevent contamination.
- Infection Prevention Education: Educate patients and caregivers on infection prevention measures at home.
References
National Pressure Injury Advisory Panel (NPIAP)
Wound, Ostomy and Continence Nurses Society (WOCN)
Agency for Healthcare Research and Quality (AHRQ)
UpToDate
MedlinePlus
