Pressure ulcers, commonly known as bed sores, decubitus ulcers, or pressure injuries, represent a significant concern in healthcare. These localized injuries to the skin and underlying tissue arise due to prolonged pressure, often over bony prominences, disrupting blood flow and oxygen supply to the tissues. This sustained pressure leads to tissue ischemia, cell death, and subsequent ulceration and necrosis if left unaddressed.
Overview of Pressure Ulcers
Pressure ulcers predominantly develop over bony prominences such as the sacrum, coccyx, greater trochanter, heels, and lateral malleoli, though they can occur in any area subjected to unrelieved pressure.
The National Pressure Injury Advisory Panel (NPIAP) provides a standardized staging system to classify pressure ulcers based on the depth of tissue damage:
- Stage 1: Characterized by intact skin with non-blanchable erythema of localized area, usually over a bony prominence.
- Stage 2: Involves partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister.
- Stage 3: Presents with full-thickness skin loss, where adipose (fat) is visible, but bone, tendon, muscle are not exposed. Slough and/or eschar may be present.
- Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable bone, tendon, or muscle. Slough or eschar may be present.
- Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
- Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration. Intact or non-intact skin. Painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Prevention is paramount in managing pressure ulcers, as they can be challenging to treat once established. Untreated Stage 3 and 4 pressure ulcers significantly elevate the risk of severe complications including osteomyelitis and sepsis. While minor pressure ulcers may respond to basic wound care, more severe cases often necessitate interventions such as debridement, negative pressure wound therapy, hyperbaric oxygen therapy, or surgical procedures.
The Nursing Process for Pressure Ulcer Management
Effective pressure ulcer prevention and management require a collaborative healthcare team approach, focusing on consistent turning schedules, meticulous hygiene, and adequate nutritional support. Despite proactive preventive measures, high-risk patients can still develop pressure ulcers, emphasizing the crucial role of vigilant nursing assessment and wound care to avert complications.
Comprehensive Nursing Assessment for Pressure Ulcers
The initial phase of nursing care involves a thorough nursing assessment to gather comprehensive patient data – physical, psychosocial, emotional, and diagnostic. This section details both subjective and objective data collection pertinent to pressure ulcers, guiding effective Nursing Diagnosis For Bed Sores.
Review of Health History: Subjective Data Collection
1. Detailed Inquiry about the Pressure Injury:
Initiate a conversation with the patient (or their caregiver) to gather detailed information about any existing or suspected pressure injury. Key symptoms to explore include:
- Skin discoloration or changes in skin integrity
- Presence of any unusual or foul odor emanating from the area
- Discharge or exudate – noting the color, consistency, and amount
- Alterations in sensation, such as pain, numbness, or tingling at the site
2. Identifying Potential Causative Factors:
Conduct a comprehensive assessment of the patient’s skin condition and mobility status. Document any medical devices or equipment that may exert pressure on the skin, such as diapers, intravenous (IV) lines, urinary catheters, or orthopedic appliances. Recognize that the following factors, when combined with pressure, significantly increase the risk of pressure sore development:
- Moisture: Excessive skin moisture from perspiration, urinary incontinence, or fecal incontinence.
- Friction: Skin rubbing against external surfaces like bed linens, clothing, or medical devices.
- Shear Force: Forces exerted when tissue layers slide over each other, leading to damage to blood vessels and underlying tissues.
3. Assessing Patient-Specific Risk Factors:
Identify patients at heightened risk for developing pressure ulcers. High-risk populations include:
- Elderly individuals with fragile skin and reduced mobility
- Patients who are bedridden or chair-bound for extended periods
- Individuals with paralysis or limited mobility due to neurological conditions
- Patients experiencing incontinence (urinary or fecal)
- Those with compromised nutritional status, including malnutrition, obesity, or being underweight
- Patients with impaired sensory perception who may not readily perceive pain or discomfort
4. Medical Record Review for Predisposing Conditions:
Scrutinize the patient’s medical history for pre-existing conditions that increase susceptibility to pressure ulcers. Relevant conditions include:
- Conditions causing immobility:
- Paraplegia or quadriplegia
- Spina bifida
- Neurological disorders leading to lack of sensory perception
- Conditions that compromise blood circulation, such as peripheral vascular disease or diabetes
Note: Document the duration of the patient’s hospitalization, as prolonged hospital stays are correlated with an increased incidence of hospital-acquired pressure ulcers.
5. Medication Review for Drug-Induced Pressure Ulcers (DIPU):
Review the patient’s current medication list for any drugs known to increase pressure ulcer risk. Drug-induced pressure ulcers (DIPU) are a recognized adverse drug reaction, particularly associated with psychiatric medications in older adults.
6. Socioeconomic and Support System Assessment:
Evaluate the patient’s living situation and available support system. Stage 4 pressure ulcers, in particular, may raise concerns about neglect, especially in vulnerable populations like nursing home residents or home-bound patients. Assess the competence and resources of caregivers (family or professional) to provide adequate skin care and pressure ulcer prevention. Provide education and training to families and caregivers responsible for patients unable to care for themselves.
7. Surgical History and Anesthesia Considerations:
Inquire about the patient’s surgical history. Pressure ulcers can develop rapidly, sometimes within two hours of sustained immobility, particularly in perioperative settings. Prolonged anesthesia, lengthy surgical procedures, and post-operative reduced mobility are critical factors to consider.
Physical Assessment: Objective Data Collection
1. Comprehensive Pressure Ulcer Assessment:
If a pressure ulcer is present, conduct a detailed physical examination, documenting the following characteristics:
- Size: Measure and record the length, width, and depth of the ulcer in centimeters or millimeters.
- Exudate: Note the presence, color, type (serous, serosanguinous, sanguineous, purulent), and amount of any wound drainage.
- Odor: Assess for any malodor, which may indicate infection.
- Undermining: Probe the wound edges to identify any tissue destruction extending under intact skin at the wound periphery.
- Tunneling: Assess for sinus tracts or channels extending from the wound bed into surrounding tissues.
- Necrotic Tissue: Identify and describe any necrotic tissue present in the wound bed, including slough (yellow or tan stringy tissue) and eschar (black or brown leathery tissue).
- Healing Status: Observe for signs of healing, such as granulation tissue (red, beefy, cobblestone appearance) and epithelialization (new skin migrating from the wound edges).
- Wound Margins and Periwound Skin: Describe the appearance of the wound edges (defined, undefined, rolled) and the condition of the skin surrounding the wound (erythema, induration, maceration).
2. Accurate Pressure Injury Staging:
Utilize the NPIAP staging system to accurately stage the pressure injury. Proper staging is essential for monitoring wound progression, guiding treatment decisions, and for documentation purposes.
3. Mental Status Evaluation:
Assess the patient’s cognitive status and ability to communicate needs or express discomfort. Patients with cognitive impairments may not be able to report pain or the need for repositioning, making proactive nursing care even more critical.
4. Neuromuscular and Mobility Status Assessment:
Evaluate the patient’s neuromuscular function and mobility level. Conditions affecting sensory perception, such as spinal cord injuries or neuropathy, impede the patient’s ability to sense pressure and discomfort. Limited mobility, contractures, or paralysis necessitate vigilant preventive measures and assistance with repositioning.
5. Braden Scale Assessment for Risk Prediction:
Employ the Braden Scale for Pressure Ulcer Risk Assessment. This widely used tool evaluates six key factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total Braden Scale score categorizes the patient’s risk level (high, moderate, mild, or low risk) and guides the implementation of appropriate preventive interventions.
Diagnostic Procedures for Pressure Ulcer Evaluation
1. Blood Workup:
Obtain blood samples for laboratory analysis. Certain blood values can provide insights into factors contributing to pressure ulcer development or impaired healing:
- Elevated White Blood Cell (WBC) Count: May indicate infection or inflammation.
- Low Hemoglobin Levels: Suggest reduced oxygen-carrying capacity, potentially impairing tissue oxygenation.
- Low Platelet Count: Can compromise wound healing processes, including proliferation and angiogenesis.
- Low Albumin Levels: May indicate protein deficiency, which is essential for wound repair.
- Elevated Glucose Levels: Hyperglycemia can negatively impact wound healing.
2. Wound Culture:
For pressure ulcers exhibiting drainage or clinical signs of infection (increased pain, warmth, erythema, purulent exudate), obtain a wound culture. Culture results identify the causative pathogen(s) and guide appropriate antibiotic therapy.
3. Tissue Biopsy:
Consider tissue biopsy for chronic, non-healing pressure ulcers. Biopsy can rule out underlying complications such as osteomyelitis or malignancy (Marjolin’s ulcer).
4. Imaging Studies:
Utilize imaging modalities as clinically indicated. Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans may be necessary if osteomyelitis is suspected to assess bone involvement.
Nursing Interventions for Pressure Ulcer Management
Nursing interventions are crucial for both pressure ulcer prevention and the effective treatment of existing ulcers. These interventions form the cornerstone of nursing care plans and aim to promote healing, prevent complications, and improve patient outcomes.
Pressure Ulcer Prevention Strategies
1. Regular Repositioning and Turning Schedules:
Implement a strict turning and repositioning schedule, typically every two hours, to relieve pressure on vulnerable areas. Delegate turning schedules to unlicensed assistive personnel as appropriate, ensuring proper technique and documentation. Encourage and facilitate patient activity as tolerated, including passive and active range of motion exercises and ambulation.
2. Skin Hygiene and Moisture Management:
Maintain meticulous skin hygiene to keep the skin clean and dry. Use gentle cleansers and avoid harsh soaps that can dry or irritate the skin. Apply moisture barrier creams to protect skin from excessive moisture due to incontinence or perspiration. Consider fecal and urinary diversion devices (e.g., external catheters, rectal pouches) based on ulcer location and contamination risk.
3. Pressure-Relieving Support Surfaces and Offloading Devices:
Utilize specialized support surfaces, such as alternating pressure mattresses, overlays, and cushions, to redistribute pressure. Employ offloading devices like foam wedges, pillows, and heel protectors to elevate and protect bony prominences.
4. Friction and Shear Reduction:
Minimize friction and shear forces, which contribute significantly to pressure ulcer development. Use draw sheets or transfer aids when repositioning or transferring patients in bed to avoid dragging or sliding. Keep the head of the bed as low as medically feasible to reduce shear forces from sliding down in bed.
5. Optimize Hydration and Nutrition:
Ensure adequate hydration and nutritional intake, particularly protein, to support skin health and wound healing. Collaborate with dietitians to optimize nutritional plans, addressing any deficiencies.
6. Device and Line Management:
Prevent pressure from medical devices and lines (urinary catheters, IV lines, feeding tubes) by ensuring they are properly positioned and secured, and do not directly compress the skin. Regularly inspect skin under and around devices. Ensure bed linens and clothing are smooth and wrinkle-free.
7. Patient and Caregiver Education:
Educate patients, families, and caregivers on pressure ulcer prevention strategies. Emphasize:
- Adherence to turning and repositioning schedules.
- Maintaining skin cleanliness and dryness.
- Proper use of pressure-offloading devices.
- Early recognition of warning signs of skin breakdown, such as persistent redness or decreased sensation.
Treatment of Existing Pressure Ulcers
1. Pressure Relief and Protection of the Ulcer Site:
For Stage 1 pressure ulcers, focus on immediate pressure relief. Implement frequent repositioning, utilize pressure-redistributing mattresses, pillows, and wedges as needed. Consider applying a protective dressing, such as a Mepilex Border dressing on sacral/coccygeal areas or heels, to shield from pressure, friction, and shear.
2. Wound Dressing Selection and Application:
Select appropriate wound dressings based on wound characteristics, including drainage level and presence of infection, following established protocols or healthcare provider orders.
- Infected wounds without significant drainage: Silver dressings, topical medical-grade honey, or foam dressings may be used for antimicrobial action.
- Infected wounds with drainage: Alginate, silver-impregnated dressings, gauze dressings, or foam dressings can manage exudate and infection.
- Non-infected wounds without drainage: Hydrogel dressings can maintain a moist wound environment.
- Non-infected wounds with drainage: Alginate, hydrocolloid, gauze, or foam dressings can absorb exudate while promoting healing.
3. Debridement Considerations:
Prepare for debridement if necrotic tissue is present. Debridement removes dead, devitalized, or infected tissue to promote wound healing. Methods include:
- Sharp debridement (surgical removal by a trained professional)
- Mechanical debridement (e.g., wet-to-dry dressings – generally not recommended for pressure ulcers due to potential harm to healthy tissue)
- Autolytic debridement (using moisture-retentive dressings to facilitate the body’s natural enzymatic debridement)
- Enzymatic debridement (using topical enzymatic ointments)
- Biological debridement (using sterile maggots – less common but can be effective in specific cases)
4. Negative Pressure Wound Therapy (NPWT):
Consider NPWT (wound vac) for Stage 3 or 4 pressure ulcers. NPWT applies controlled negative pressure to the wound bed, removing exudate, promoting granulation tissue formation, and drawing wound edges together.
5. Pain Management:
Administer pain medications as prescribed, especially prior to wound care procedures if the patient reports pain. Assess pain levels regularly and adjust pain management strategies as needed.
6. Surgical Intervention:
Prepare for potential surgical treatment, which may include surgical debridement, skin grafts, or flap reconstruction, particularly for large, deep, or non-healing pressure ulcers.
7. Hyperbaric Oxygen Therapy (HBOT):
Consider HBOT as an adjunct therapy in select cases. HBOT increases oxygen concentration in the wound and surrounding tissues, potentially promoting healing in chronic, non-responsive pressure ulcers.
8. Nutritional Support and Dietitian Consultation:
Consult with a registered dietitian to optimize nutritional support. Adequate protein, macronutrients, and micronutrients (zinc, iron, vitamins C, E, A) are vital for tissue repair and wound healing.
9. Wound Care Specialist Referral:
Refer patients with complex or chronic pressure ulcers to a certified wound care nurse or wound care specialist for expert assessment, management recommendations, and treatment plan development.
Nursing Care Plans for Pressure Ulcers: Addressing Nursing Diagnoses
Once nursing diagnoses for bed sores are identified, nursing care plans provide a structured framework for prioritizing assessments and interventions, establishing both short-term and long-term goals of care. The following sections outline nursing care plan examples for common nursing diagnoses associated with pressure ulcers.
Nursing Diagnosis: Impaired Physical Mobility
Patients with impaired physical mobility, unable to independently change position, are at high risk for pressure ulcer development.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Paralysis
- Prescribed bed rest or activity restriction
- Decreased muscle strength
- Contractures
- Pain
- Neuromuscular conditions limiting 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 during hospitalization/care period.
Nursing Assessments:
- Assess Range of Motion and Mobility: Evaluate the patient’s current range of motion, muscle strength, and ability to reposition independently. Avoid assumptions based on age or general appearance.
- Assess Staff and Family Understanding: For patients in nursing homes or receiving home care, assess the competency of staff or family members in proper turning techniques and skin care practices. Observe their ability to safely turn the patient and identify any need for additional assistance or specialized equipment.
Nursing Interventions:
- Implement Assistive Devices for Repositioning: Provide patients with some mobility with assistive devices such as trapeze bars or bed rails to facilitate self-repositioning.
- Utilize Pressure-Relieving Devices: Employ wedges, pillows, heel protectors, and specialized mattresses to protect bony prominences (sacrum, heels, hips).
- Pain Management: Address pain effectively. Pre-medicate before repositioning if the patient experiences pain. For chronic pain, administer analgesics routinely to facilitate easier movement.
- Educate on Skin Inspection Areas: Instruct patients and family members on areas vulnerable to shearing and friction, such as the back of the head, elbows, ears, and back, for regular skin checks.
- Promote Chair Transfers and Ambulation: Assist patients to transfer to a chair and ambulate (if safe and feasible) to relieve pressure and improve circulation.
- Implement a Turning Schedule: Adhere to evidence-based turning schedules (e.g., every 2 hours for bed-bound patients). Remind wheelchair-bound or sitting patients to shift weight every 15 minutes.
Nursing Diagnosis: Impaired Skin Integrity
Compromised skin integrity, whether due to internal or external factors, increases vulnerability to pressure ulcers.
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 in the affected area
- Alterations in skin color (blanching, bruising, erythema)
- Disruption of skin surface (breakdown, excoriation)
- Purulent or bloody drainage
Expected Outcomes:
- Patient will demonstrate resolution of pressure ulcer within a specified timeframe (e.g., 30 days).
- Patient will demonstrate three methods to prevent impaired skin integrity.
- Pressure ulcer will show improvement (reduction in size, absence of drainage).
Nursing Assessments:
- Routine Skin Assessments: Conduct comprehensive skin assessments at least once per shift, utilizing the Braden Scale to assess pressure ulcer risk.
- Accurate Pressure Ulcer Staging: Correctly stage any existing pressure ulcers using the NPIAP staging system for proper management and ongoing assessment.
- Identify Additional Risk Factors: Consider patient-specific factors like age, chronic conditions, cognitive status, and nutritional status, which influence skin elasticity, overall skin health, and the patient’s ability to perceive and prevent skin breakdown.
Nursing Interventions:
- Wound Care Expert Collaboration: Consult with wound care nurses or specialists early in the presence of skin breakdown to prevent further deterioration and ensure close monitoring. For severe or slow-healing ulcers, arrange for outpatient wound specialist follow-up.
- Nutritional and Hydration Support: Promote optimal nutrition and hydration, recognizing that deficiencies impair immune function, collagen production, and skin tensile strength. Ensure adequate protein intake and provide vitamins A, C, and E, and zinc. Consider enteral or parenteral nutrition if necessary.
- Maintain Skin Cleanliness and Dryness: Provide frequent perineal care and linen changes for incontinent patients or those unable to verbalize hygiene needs. Address perspiration promptly.
- Implement Prescribed Wound Care: Execute wound care orders meticulously, considering ulcer type, size, and location. This includes cleansing, application of topical agents (ointments, sprays, foams), and appropriate dressing selection.
Nursing Diagnosis: Impaired Tissue Integrity
Severe pressure injuries indicate damage extending into subcutaneous tissue (Stage 3) or deeper, involving 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 tissue integrity protection
As evidenced by:
- Pain
- Redness
- Bleeding
- Warmth
- Tissue damage
Expected Outcomes:
- Patient will demonstrate interventions to protect and promote healing of damaged tissue.
- Patient will experience a measurable decrease in pressure ulcer size over time.
Nursing Assessments:
- Pressure Injury Staging and Monitoring: Accurately stage and consistently monitor the pressure injury. Staging determines injury severity and tissue involvement. Note presence of tunneling or undermining in Stage 3 and 4 ulcers.
- Etiological Factor Assessment: Identify potential causes and risk factors contributing to impaired tissue integrity, including comorbidities, health status, mobility limitations, and nutritional status.
- Wound Size and Depth Monitoring: Measure and document ulcer length, width, and depth according to facility policy for comparative tracking of wound progression.
Nursing Interventions:
- Frequent Repositioning and Pressure Avoidance: Reposition patients frequently, avoiding direct pressure on the ulcer site. Repositioning redistributes pressure, enhances circulation, and promotes healing. Maintain a 2-hour turning schedule, avoiding positioning directly on the impaired tissue.
- Debridement Procedures: Perform or prepare for debridement for Stage 3 or 4 ulcers to remove necrotic tissue and facilitate tissue regeneration and wound healing.
- Pressure-Relieving Devices: Utilize specialized mattresses and cushions to redistribute pressure and minimize the risk of further tissue damage and promote healing.
- Multidisciplinary Consultation: For complex or non-healing ulcers, consult with a wound care certified nurse, dietitian, wound care specialist, and physical/occupational therapists for holistic patient care.
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion
Inadequate peripheral blood flow and oxygenation increase the risk of pressure ulcers and impede healing.
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 peripheral pulses
- Altered motor function
- Skin discoloration (pallor, cyanosis)
- Pain (ischemic pain)
- Edema
- Paresthesia
- Delayed peripheral wound healing
Expected Outcomes:
- Patient will demonstrate adequate tissue perfusion (palpable peripheral pulses, normal skin color, adequate wound healing).
- Patient will verbalize understanding of disease processes and lifestyle factors contributing to poor peripheral perfusion.
Nursing Assessments:
- Peripheral Pulse Assessment: Regularly assess and monitor peripheral pulses. Diminished or absent pulses may indicate arterial insufficiency and compromised tissue perfusion, increasing pressure ulcer risk and hindering healing.
- Assess Symptoms of Decreased Tissue Perfusion: Monitor for signs and symptoms of poor tissue perfusion: pain, skin discoloration, delayed capillary refill, paresthesia, weakness, or loss of function in affected areas.
Nursing Interventions:
- Routine Skin Assessments: Patients with vascular disorders, diabetes, mobility limitations, or other perfusion-compromising conditions require frequent skin assessments to monitor for changes in skin color, temperature, or sensation indicative of impaired perfusion and pressure ulcer risk.
- Promote Movement and Physical Therapy Consultation: Encourage patient movement within their capabilities to improve circulation. Consult physical therapy for tailored exercise regimens and mobility techniques to enhance tissue perfusion.
- Caution with Heat and Cold Application: Exercise caution when applying heat or cold, as patients with impaired perfusion may have reduced sensation. Avoid direct application of heat or cold to pressure ulcers as it can further damage compromised tissue.
- Patient Education on Risk Factors: Educate patients about medical conditions (stroke, neurological conditions) and modifiable risk factors (smoking, obesity) that contribute to poor peripheral perfusion and pressure ulcer risk.
Nursing Diagnosis: Risk for Infection
Breaks in skin integrity create portals of entry for pathogens, increasing infection risk in pressure ulcers.
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. Interventions are 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 (normal temperature and WBC count).
- Wound care dressings will remain intact to prevent bacterial contamination.
Nursing Assessments:
- Monitor for Signs of Infection: During wound care, monitor for local infection signs: purulent drainage (green/yellow), malodor, swelling, increased redness, warmth, and increased pain. Assess for systemic infection signs: fever, chills, tachycardia, hypotension.
- Wound Cultures: Obtain wound cultures for wounds showing signs of infection to identify pathogens and guide antibiotic treatment.
- Laboratory Assessment: Monitor WBC count for elevation, indicating infection. Assess other lab values (protein levels, ESR, glucose, iron, total lymphocyte count, vitamin/mineral levels) to identify factors that may impair wound healing.
Nursing Interventions:
- Administer Antibiotics: Administer prophylactic or therapeutic antibiotics as prescribed. Use antibacterial/antimicrobial cleansers and ointments during wound care to prevent or treat infection.
- Strict Hand Hygiene: Enforce rigorous hand hygiene before and after touching pressure ulcers or performing wound care. Use clean or aseptic techniques for routine wound care; sterile technique may be required for debridement. Always wear gloves during wound care and change gloves between dirty and clean procedures.
- Maintain Dressing Integrity: Ensure pressure ulcer dressings remain intact and secure to prevent bacterial contamination. Monitor dressings regularly, changing them if soiled, wet, or non-intact.
- Educate on Infection Prevention: Educate patients and caregivers on infection prevention at home: keeping dressings dry and intact, handwashing before dressing changes, and recognizing and reporting signs of infection to healthcare providers.
References
National Pressure Injury Advisory Panel (NPIAP) resources and guidelines.
Wound, Ostomy and Continence Nurses Society (WOCN) guidelines.
Evidence-based nursing journals and textbooks on wound care and pressure ulcer management.
Clinical practice guidelines from reputable healthcare organizations.
