Pressure ulcers, clinically referred to as decubitus ulcers or pressure injuries, represent a significant concern in healthcare, characterized by localized damage to the skin and underlying tissue, typically over bony prominences. These injuries arise from sustained pressure, including pressure associated with shear and/or friction. Disruption of blood flow and oxygen supply to the tissues leads to ischemia, cellular death, ulceration, and necrosis.
Understanding Pressure Ulcers
Pressure ulcers are most frequently observed over bony prominences such as the sacrum, coccyx, greater trochanter, heels, and malleoli. The National Pressure Injury Advisory Panel (NPIAP) staging system categorizes pressure ulcers based on the depth of tissue involvement, providing a standardized approach to assessment and care planning:
- Stage 1: Non-blanchable erythema of intact skin.
- Stage 2: Partial-thickness skin loss with exposed dermis. Wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister.
- Stage 3: Full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible.
- Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.
- 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 temperature change and boggy feel may precede skin color changes.
Preventing pressure ulcers is paramount, as they can be challenging to treat once established. Stage 3 and 4 ulcers significantly elevate the risk of severe complications, including osteomyelitis and sepsis. While basic wound care is often effective for early-stage ulcers, more advanced stages may necessitate debridement, negative pressure wound therapy, hyperbaric oxygen therapy, or surgical intervention.
The Nursing Process and Decubitus Ulcers
Effective management of pressure ulcers relies on a collaborative healthcare approach, with nursing at its core. This includes implementing preventive measures such as regular repositioning, meticulous hygiene, and nutritional support. Despite proactive care, high-risk patients may still develop ulcers, underscoring the critical role of vigilant nursing assessment and intervention to mitigate complications and promote healing.
Comprehensive Nursing Assessment for Decubitus Ulcers
The initial step in nursing care is a thorough assessment encompassing physical, psychosocial, emotional, and diagnostic aspects. This section details the subjective and objective data collection pertinent to pressure ulcer management.
Health History Review
1. Inquire about the Pressure Injury: Gather detailed information from the patient regarding the pressure injury, particularly noting:
- Skin discoloration or changes in texture
- Presence of any foul odor
- Discharge characteristics (color, amount, consistency)
- Alterations in sensation (pain, numbness, tingling)
2. Determine Potential Etiology: Evaluate the patient’s skin condition and mobility status. Identify any medical devices or equipment (e.g., diapers, IV lines, catheters) that could exert pressure on the skin. Key contributing factors, beyond pressure itself, include:
- Moisture exposure from bodily fluids like sweat, urine, or stool, leading to skin maceration.
- Friction from skin rubbing against surfaces, such as bed linens or clothing.
- Shear forces resulting from tissue layers sliding over each other, causing damage to blood vessels and tissues.
3. Identify Risk Factors: Recognize patients at heightened risk for pressure ulcer development:
- Advanced age, due to decreased skin elasticity and subcutaneous fat.
- Immobility, whether due to bedridden status or limited mobility.
- Paralysis, leading to inability to reposition and relieve pressure.
- Incontinence, exposing skin to prolonged moisture and irritants.
- Malnutrition, impairing tissue repair and resilience.
- Obesity or underweight, both of which can compromise skin integrity and pressure distribution.
- Cognitive or sensory impairment, hindering the ability to perceive and communicate discomfort.
4. Review Medical History: Certain medical conditions predispose patients to pressure ulcers. Note conditions such as:
- Conditions causing immobility (paraplegia, quadriplegia, spina bifida).
- Sensory perception deficits (neuropathy, spinal cord injury).
- Conditions affecting circulation (peripheral vascular disease, diabetes).
Note: Duration of hospital stay is a significant factor, with prolonged stays increasing pressure ulcer incidence.
5. Medication Review: Be aware of drug-induced pressure ulcers (DIPUs), a recognized adverse drug reaction, especially associated with psychiatric medications in older adults.
6. Assess Housing and Support System: Stage 4 pressure ulcers can indicate potential neglect, especially in nursing home residents or home-care patients. Assess the adequacy of caregiver support and offer education to families and caregivers responsible for immobile patients.
7. Surgical History: Pressure ulcers can develop rapidly in immobile patients, even within two hours. Prolonged anesthesia, extended surgeries, and post-operative immobility are critical factors to consider.
Physical Examination
1. Comprehensive Pressure Ulcer Assessment: Document detailed characteristics of any existing pressure ulcer:
- Size measurements (length, width, depth in centimeters).
- Presence and characteristics of exudate (serous, serosanguinous, purulent).
- Odor assessment (foul, pungent, absent).
- Undermining (tissue destruction extending under intact skin at wound edges).
- Tunneling (narrow passageway extending from the wound).
- Necrotic tissue type and amount (slough, eschar).
- Healing indicators (granulation tissue, epithelialization).
- Condition of wound margins and periwound skin (erythema, induration, maceration).
2. Pressure Injury Staging: Accurately stage the pressure ulcer using the NPIAP classification system. Precise staging is crucial for monitoring wound progression or regression.
3. Mental Status Evaluation: Assess the patient’s cognitive ability to communicate needs and discomfort, as this impacts preventative care and timely intervention.
4. Neuromuscular and Mobility Assessment: Evaluate neuromuscular function and mobility level. Conditions affecting sensory perception (spinal cord injuries) or mobility (contractures, paralysis) increase pressure ulcer risk.
5. Braden Scale Application: Utilize the Braden Scale, a validated risk assessment tool, evaluating sensory perception, moisture, activity, mobility, nutrition, friction, and shear to determine pressure ulcer risk and guide preventive interventions.
Diagnostic Procedures
1. Blood Workup: Specific lab values can provide insights into pressure ulcer etiology and healing potential:
- Elevated White Blood Cell (WBC) count indicating infection or inflammation.
- Low Hemoglobin levels suggesting reduced oxygen-carrying capacity to tissues.
- Low Platelet count potentially impairing wound healing processes.
- Low Albumin levels reflecting protein deficiency, crucial for tissue repair.
- Elevated Glucose levels which can impede wound healing.
2. Wound Culture: Obtain wound cultures from ulcers exhibiting drainage or signs of infection to identify pathogens and guide antibiotic therapy.
3. Tissue Biopsy: Consider tissue biopsy for non-healing pressure ulcers to rule out osteomyelitis or malignancy.
4. Imaging Studies: MRI or CT scans may be indicated if osteomyelitis is suspected to assess bone involvement.
Nursing Interventions for Decubitus Ulcer Management
Nursing interventions are vital for both preventing and treating pressure ulcers.
Pressure Ulcer Prevention Strategies
1. Regular Repositioning: Implement a strict turning and repositioning schedule, ideally every two hours, to relieve pressure on vulnerable areas. Delegate turning schedules to assistive personnel as appropriate. Encourage increased activity through passive and active range-of-motion exercises and ambulation when feasible.
2. Skin Hygiene and Moisture Management: Maintain skin cleanliness and dryness. Use gentle cleansers and apply moisture barrier creams to protect skin from incontinence. Consider fecal and urinary diversion systems based on ulcer location and contamination risk.
3. Pressure-Relieving Support Surfaces: Utilize specialty mattresses, cushions, foam wedges, and heel protectors to redistribute pressure away from bony prominences.
4. Friction and Shear Reduction: Minimize friction and shear forces by using transfer sheets when repositioning patients in bed. Keep the head of the bed as low as medically possible to prevent sliding down.
5. Nutritional and Hydration Optimization: Ensure adequate protein, calorie, and micronutrient intake to support skin health and tissue repair. Maintain optimal hydration for cell function, collagen production, and skin elasticity.
6. Device and Line Management: Prevent pressure from medical devices (catheters, IV lines, feeding tubes) by ensuring they are positioned off the skin and are not causing pressure points. Keep bed linens smooth and wrinkle-free.
7. Patient and Caregiver Education: Educate patients, families, and caregivers on pressure ulcer prevention strategies, emphasizing:
- Adherence to repositioning schedules.
- Maintaining skin hygiene and dryness.
- Proper use of pressure-offloading devices.
- Early recognition of warning signs like skin discoloration or altered sensation.
Treatment of Existing Pressure Ulcers
1. Pressure Relief and Protection: For Stage 1 ulcers, focus on offloading pressure through frequent repositioning and pressure-redistributing support surfaces. Apply protective dressings like Mepilex Border to sacral/coccygeal areas or heels.
2. Wound Dressing Selection: Dressing choice depends on drainage level and presence of infection:
- Infected, non-draining wounds: Silver dressings, topical medical-grade honey, foam dressings.
- Infected, draining wounds: Alginate, silver-impregnated dressings, gauze, foam dressings.
- Non-infected, non-draining wounds: Hydrogel dressings.
- Non-infected, draining wounds: Alginate, hydrocolloid, gauze, foam dressings.
3. Debridement Preparation: Prepare for debridement as needed to remove necrotic, infected, or devitalized tissue, promoting healing. Methods include moist dressings, enzymatic ointments, or surgical debridement by a wound care specialist.
4. Negative Pressure Wound Therapy (NPWT): Consider NPWT (wound VAC) for Stage 3 or 4 ulcers to remove exudate, reduce edema, and promote granulation tissue formation.
5. Pain Management: Administer pain medications as prescribed, especially prior to wound care procedures, to enhance patient comfort.
6. Surgical Intervention: Prepare for surgical debridement, skin grafts, or flap reconstruction for complex or non-healing wounds.
7. Hyperbaric Oxygen Therapy: Consider hyperbaric oxygen therapy to increase tissue oxygenation and promote healing in recalcitrant wounds.
8. Dietitian Consultation: Consult a dietitian for nutritional optimization, ensuring adequate protein, macronutrients, and micronutrients (zinc, iron, vitamins C, E, A) crucial for wound healing.
9. Wound Care Specialist Referral: Refer to a certified wound care nurse or specialist for complex or chronic pressure ulcers to develop a comprehensive management plan.
Nursing Care Plans and Diagnoses for Decubitus Ulcers
Nursing care plans, guided by accurate nursing diagnoses, prioritize assessments and interventions for both short-term and long-term goals in pressure ulcer care. Common nursing diagnoses associated with decubitus ulcers include:
1. Impaired Physical Mobility
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Paralysis
- Activity restrictions/bed rest
- Decreased muscle strength
- Contractures
- Pain
- Neuromuscular conditions
- Cognitive/developmental impairment
- Morbid obesity
As evidenced by:
- Limited range of motion
- Inability to reposition self
Expected Outcomes:
- Patient will utilize assistive devices to improve repositioning.
- Patient will verbalize two pressure ulcer prevention strategies.
- Patient will not develop new pressure ulcers.
Assessments:
- Range of motion/mobility assessment: Evaluate patient’s ability to move and reposition independently.
- Staff/family understanding: Assess caregivers’ knowledge and ability to assist with turning and skin care.
Interventions:
- Assistive devices: Provide trapeze bars, side rails to enhance patient independence in repositioning.
- Pressure redistribution: Use wedges, pillows, specialty mattresses to protect bony prominences.
- Pain management: Pre-medicate for pain before repositioning and manage chronic pain to improve mobility.
- Education on inspection areas: Teach patients and caregivers to inspect areas prone to pressure and shear.
- Promote mobility: Assist with chair transfers and ambulation as tolerated to relieve pressure.
- Turning schedule: Implement and maintain a 2-hour turning schedule for bed-bound patients; 15-minute repositioning for chair-bound patients.
2. Impaired Skin Integrity
Nursing Diagnosis: Impaired Skin Integrity
Related to:
- Poor nutritional status
- Edema
- Impaired circulation
- Neuropathy
- Moisture/incontinence
- Shearing/friction
- Surgical incisions
- Immobility
As evidenced by:
- Verbalization of pain/numbness
- Skin color changes (blanching, erythema)
- Skin disruption (breakdown, excoriation)
- Drainage (pus, blood)
Expected Outcomes:
- Pressure ulcer resolution within 30 days.
- Patient will demonstrate three skin integrity maintenance methods.
- Pressure ulcer improvement (size reduction, absence of drainage).
Assessments:
- Regular skin assessments: Conduct skin checks every shift, using the Braden Scale for risk assessment.
- Accurate staging: Stage pressure ulcers correctly for proper management and monitoring.
- Risk factor identification: Consider age, comorbidities, cognition, nutrition as contributing factors.
Interventions:
- Wound care collaboration: Consult wound care specialists early for any skin breakdown.
- Nutrition and hydration: Encourage protein intake, vitamins, minerals, and adequate hydration.
- Skin hygiene: Maintain clean and dry skin, especially with incontinence.
- Wound care protocols: Follow prescribed wound care orders for cleansing, ointments, dressings.
3. Impaired Tissue Integrity
Nursing Diagnosis: Impaired Tissue Integrity
Related to:
- Pressure injury
- Delayed wound healing
- Infection
- Poor circulation
- Impaired mobility
- Surgical procedures
- Poor nutrition
- Knowledge deficit about tissue integrity protection
As evidenced by:
- Pain
- Redness
- Bleeding
- Warmth
- Tissue damage
Expected Outcomes:
- Patient will demonstrate tissue protection and healing interventions.
- Pressure ulcer size will decrease.
Assessments:
- Pressure injury staging: Monitor and document accurate staging, noting tunneling or undermining.
- Etiological factors: Identify and address risk factors (comorbidities, mobility, nutrition).
- Wound measurement: Document ulcer length, width, depth regularly.
Interventions:
- Frequent repositioning: Reposition patient every 2 hours, avoiding pressure on the ulcer site.
- Debridement: Prepare for and assist with debridement of necrotic tissue.
- Pressure-relieving devices: Utilize specialized mattresses and cushions.
- Multidisciplinary consultation: Consult wound care nurse, dietitian, PT/OT for holistic care.
4. Ineffective Peripheral Tissue Perfusion
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion
Related to:
- Diabetes mellitus
- Infection
- Circulatory compromise
- Smoking
- Insufficient knowledge of risk factors
As evidenced by:
- Absent/diminished pulses
- Altered motor function
- Skin discoloration
- Pain
- Edema
- Paresthesia
- 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 perfusion.
Assessments:
- Peripheral pulse assessment: Monitor for decreased or absent pulses.
- Perfusion symptom monitoring: Assess for pain, skin changes, delayed capillary refill, paresthesia.
Interventions:
- Routine skin assessments: Frequent skin checks for perfusion changes in at-risk patients.
- Promote movement/PT consult: Encourage mobility to improve circulation; consult physical therapy.
- Caution with heat/cold: Avoid direct heat or cold application to compromised tissues.
- Patient education: Educate on risk factors and lifestyle modifications affecting perfusion.
5. Risk for Infection
Nursing Diagnosis: Risk for Infection
Related to:
- Broken skin/disrupted epidermis
- Immunocompromised status
- Poor hygiene
- Incontinence
As evidenced by:
This is a risk diagnosis, therefore no “as evidenced by” factors are present.
Expected Outcomes:
- Patient will remain free of wound infection signs (redness, drainage, odor, warmth).
- Patient will remain afebrile and maintain normal WBC count.
- Dressings will remain intact to prevent bacterial entry.
Assessments:
- Monitor for infection signs: Observe for drainage, odor, swelling, redness during wound care. Monitor for systemic signs (fever, tachycardia).
- Wound cultures: Obtain cultures for suspected infections.
- Lab work: Assess WBC count and other markers of infection or delayed healing (protein, ESR, glucose).
Interventions:
- Antibiotic administration: Administer prophylactic or therapeutic antibiotics as ordered.
- Hand hygiene: Strict hand hygiene before and after wound care. Use clean or aseptic technique as indicated.
- Dressing integrity: Ensure dressings are clean, dry, and intact. Change if compromised.
- Infection prevention education: Educate patients on home care infection prevention measures.
By utilizing these nursing diagnoses and implementing targeted interventions, nurses play a crucial role in the prevention, management, and healing of decubitus ulcers, ultimately improving patient outcomes and quality of life.
