Pressure sores, clinically referred to as pressure ulcers, decubitus ulcers, or bedsores, represent localized damage to the skin and underlying tissue. This injury arises as a consequence of sustained pressure, typically over bony prominences, which compromises blood flow and oxygen supply to the tissues. The resulting ischemia leads to tissue breakdown, ulceration, and necrosis, posing significant health challenges, especially for individuals with limited mobility.
Understanding Pressure Sores
Pressure ulcers are most commonly found over bony areas such as the sacrum, coccyx, greater trochanter, heels, and ankles, although they can develop in any area subjected to prolonged pressure.
The widely accepted staging system from the National Pressure Injury Advisory Panel (NPIAP) categorizes pressure ulcers based on tissue involvement:
- Stage 1: Characterized by intact skin with non-blanchable erythema, indicating altered microcirculation.
- Stage 2: Involves partial-thickness skin loss affecting the epidermis and/or dermis. It may present as an abrasion, blister, or shallow crater.
- Stage 3: Defined by full-thickness skin loss, where subcutaneous fat is visible, but bone, tendon, or muscle are not directly exposed.
- Stage 4: Represents 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 intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration, indicating damage to underlying soft tissue from pressure and/or shear.
Pressure ulcers are largely preventable with diligent assessment and intervention strategies. Prevention is paramount as these ulcers can be challenging to treat once established. Stage 3 and 4 pressure ulcers significantly elevate the risk of serious 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 in Pressure Ulcer Care
Effective pressure ulcer management relies heavily on a collaborative healthcare approach, emphasizing preventive measures like regular repositioning, meticulous hygiene, and optimal nutrition. Despite proactive care, high-risk patients may still develop ulcers, underscoring the critical role of vigilant nursing care in early detection and management to avert complications.
Comprehensive Nursing Assessment for Pressure Sores
The cornerstone of nursing care is a thorough assessment, encompassing physical, psychosocial, emotional, and diagnostic data. In the context of pressure ulcers, this assessment focuses on gathering both subjective and objective information pertinent to the patient’s condition and risk factors.
Reviewing Health History for Pressure Sore Risk
1. Detailed Inquiry About the Pressure Injury:
Elicit comprehensive details about any existing pressure injury, paying close attention to:
- Changes in skin color or discoloration
- Presence of any foul odor emanating from the area
- Characteristics and amount of any wound discharge
- Alterations in sensation, such as decreased feeling or pain
2. Identifying Potential Causative Factors:
Assess the patient’s skin integrity and mobility level. Document any medical devices or equipment, such as diapers, intravenous lines, and urinary catheters, that could exert pressure on the skin. Key contributing factors to pressure sore development include:
- Exposure to moisture from bodily fluids (sweat, urine, or feces)
- Friction caused by skin rubbing against surfaces, like bed linens
- Shear forces resulting from tissue layers moving against each other, damaging blood vessels
3. Determining Patient-Specific Risk Factors:
Identify patients at heightened risk for pressure ulcers, such as those who are:
- Elderly, due to age-related skin changes and comorbidities
- Bedridden or chair-bound with limited mobility
- Paralyzed, leading to immobility and sensory loss
- Incontinent, exposing skin to moisture and irritation
- Malnourished or obese, both conditions impairing skin integrity and healing
- Unable to communicate pain or discomfort, hindering early detection
4. Scrutinizing the Medical Record:
Review the patient’s medical history for conditions that predispose them to pressure ulcers. Note conditions such as:
- Immobility stemming from paraplegia, quadriplegia, or spina bifida
- Sensory perception deficits due to neuropathy or spinal cord injuries
- Conditions that compromise blood circulation, such as peripheral vascular disease
Note: Hospital stay duration is a significant factor, with prolonged 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, particularly linked to psychiatric medications in older adults.
6. Evaluating Living Situation and Support System:
A Stage 4 pressure ulcer may indicate potential neglect, especially in care facilities or home care settings. Assess the adequacy of care provided and offer education to families and caregivers on pressure ulcer prevention.
7. Surgical History Considerations:
Pressure ulcers can develop rapidly, sometimes within two hours of immobility, especially in perioperative settings. Factors such as prolonged anesthesia, extended surgical procedures, and post-operative immobility increase risk.
Physical Examination for Pressure Sore Assessment
1. Comprehensive Pressure Ulcer Assessment:
Thoroughly evaluate any existing pressure ulcer, documenting:
- Dimensions: length, width, and depth of the wound
- Wound characteristics:
- Presence and nature of exudate (drainage)
- Odor assessment
- Undermining (tissue destruction under intact skin at wound edges)
- Tunneling (narrow passageways extending from the wound)
- Presence of necrotic tissue (slough or eschar)
- Healing progress: presence of granulation tissue and epithelialization
- Condition of wound margins and periwound skin
2. Accurate Pressure Injury Staging:
Utilize the NPIAP staging system to classify the pressure ulcer accurately. Correct staging is crucial for monitoring ulcer progression or regression effectively.
3. Mental Status Evaluation:
Assess the patient’s cognitive ability to express needs and discomfort, ensuring the care team proactively addresses needs like repositioning, hygiene, and hydration to prevent pressure ulcers.
4. Neuromuscular and Mobility Status Assessment:
Patients with sensory impairments, like spinal cord injuries, may not perceive pressure or discomfort. Evaluate mobility limitations, contractures, or paralysis that increase pressure ulcer risk.
5. Utilizing the Braden Scale for Risk Assessment:
Employ the Braden Scale, a widely used tool, to evaluate pressure ulcer risk. This scale assesses sensory perception, moisture, activity, mobility, nutrition, friction, and shear, guiding the planning of appropriate preventive interventions.
Diagnostic Procedures for Pressure Sore Evaluation
1. Blood Workup:
Obtain blood samples to assess factors that may contribute to pressure ulcers or impede healing:
- Elevated white blood cell (WBC) count indicating inflammation or infection
- Low hemoglobin levels suggesting reduced oxygen-carrying capacity
- Low platelet counts potentially impairing wound healing processes
- Low albumin levels indicating protein deficiency, which hinders wound repair
- Elevated glucose levels that can negatively affect wound healing
2. Wound Culture:
Culture 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 osteomyelitis or malignancy.
4. Imaging Studies:
Employ MRI or CT scans if osteomyelitis is suspected to assess bone involvement.
Nursing Interventions for Pressure Sore Management
Nursing interventions are pivotal in managing and preventing pressure ulcers. These interventions are directed at relieving pressure, promoting healing, and preventing complications.
Pressure Ulcer Prevention Strategies
1. Regular Repositioning and Turning Schedules:
Implement a strict repositioning schedule, turning patients at least every two hours to alleviate pressure. Delegate turning schedules to assistive personnel as appropriate. Encourage mobility through active and passive range of motion exercises and ambulation as feasible.
2. Maintaining Skin Hygiene and Dryness:
Provide meticulous hygiene care to keep skin clean and dry. Use moisture barrier creams to protect skin from incontinence. Consider fecal and urinary diversion systems based on ulcer location and contamination risk.
3. Utilizing Support Surfaces and Offloading Devices:
Employ specialty mattresses, cushions, foam wedges, and heel protectors to minimize pressure on bony prominences.
4. Reducing Friction and Shear:
Minimize friction and shear forces by using transfer sheets when repositioning patients in bed. Keep the head of the bed as low as tolerated to prevent sliding.
5. Ensuring Adequate Hydration and Nutrition:
Promote adequate protein and nutrient intake to support skin health and healing. Ensure sufficient hydration for cell function, collagen production, and skin elasticity.
6. Keeping Lines and Devices Off the Skin:
Prevent pressure from medical devices like catheters and IV lines by ensuring they do not directly press against the skin. Check for and eliminate wrinkles in bed linens and clothing.
7. Educating Patients and Caregivers:
Educate patients, families, and caregivers about pressure ulcer prevention, emphasizing:
- Adherence to turning and repositioning schedules
- Maintaining clean and dry skin
- Use of pressure-offloading devices
- Recognizing early warning signs of skin breakdown
Treatment of Existing Pressure Ulcers
1. Pressure Relief and Protection:
For Stage 1 pressure ulcers, focus on pressure offloading through frequent repositioning and pressure-redistributing mattresses, pillows, and wedges. Apply protective dressings like Mepilex Border to vulnerable areas such as the sacrum, coccyx, or heels.
2. Wound Dressing Selection:
Dress wounds according to established protocols or healthcare provider orders, considering drainage and infection status:
- For infected wounds without drainage: silver dressings, topical medical-grade honey, or foam dressings.
- For infected wounds with drainage: alginate, silver, gauze, or foam dressings.
- For non-infected wounds without drainage: hydrogel dressings.
- For non-infected wounds with drainage: alginate, hydrocolloid, gauze, and foam dressings.
3. Debridement Preparation:
Prepare for debridement to remove necrotic or infected tissue, which may involve moist dressings, enzymatic ointments, or surgical debridement by a wound care specialist.
4. Wound Vac Therapy Consideration:
Consider vacuum-assisted closure (VAC) therapy for Stage 3 or 4 pressure ulcers to promote wound healing by removing exudate and reducing wound size.
5. Pain Management:
Administer pain medication as prescribed, especially before wound care procedures, to manage pain effectively.
6. Surgical Treatment Planning:
Prepare for potential surgical interventions like debridement, skin grafts, or flap reconstruction for complex wounds.
7. Hyperbaric Oxygen Therapy Exploration:
Consider hyperbaric oxygen therapy to enhance wound oxygenation and promote healing in recalcitrant ulcers.
8. Dietary Consultation:
Consult with a dietitian to optimize nutrition and hydration, crucial for skin and tissue viability and repair. Emphasize protein, macronutrients, and micronutrients like zinc, iron, and vitamins A, C, and E.
9. Referral to Wound Care Specialists:
Refer complex or chronic pressure ulcers to certified wound care nurses or specialists for advanced management and treatment planning.
Nursing Care Plans and Diagnoses for Pressure Sores
Nursing care plans are essential for structuring and prioritizing nursing care based on identified nursing diagnoses. For pressure ulcers, common nursing diagnoses address mobility, skin integrity, tissue integrity, perfusion, and infection risk.
1. Impaired Physical Mobility Related to Pressure Sores
Nursing Diagnosis: Impaired Physical Mobility
Related Factors:
- Paralysis
- Prescribed bed rest
- Decreased muscle strength
- Contractures
- Pain
- Neuromuscular conditions
- Cognitive or developmental impairment
- Obesity
As Evidenced By:
- Limited range of motion
- Inability to reposition independently
Expected Outcomes:
- Patient will use assistive devices to enhance repositioning.
- Patient will articulate two pressure ulcer prevention strategies.
- Patient will not develop new pressure ulcers.
Nursing Assessments:
- Assess Range of Motion and Mobility: Evaluate the patient’s ability to move and reposition themselves, considering individual variations regardless of age.
- Evaluate Caregiver Understanding: For patients in nursing homes or receiving home care, assess staff or family understanding of proper turning and skin care techniques.
Nursing Interventions:
- Implement Assistive Devices: Provide trapeze bars and side rails for patients with some mobility to aid in repositioning.
- Use Pressure-Relieving Devices: Utilize wedges, pillows, heel protectors, and air mattresses to protect bony prominences.
- Manage Pain: Pre-medicate for pain before repositioning, and manage chronic pain to facilitate movement.
- Educate on Skin Inspection: Instruct patients and caregivers on areas prone to breakdown, such as the back of the head, elbows, and ears.
- Promote Chair Transfers and Ambulation: Assist patients to chairs and with ambulation to improve circulation and relieve pressure.
- Implement Turning Schedules: Adhere to evidence-based turning schedules (every 2 hours for bed-bound patients, every 15 minutes for seated patients).
2. Impaired Skin Integrity Related to Pressure Sores
Nursing Diagnosis: Impaired Skin Integrity
Related Factors:
- Poor nutritional status
- Edema
- Impaired circulation
- Neuropathy
- Moisture/Incontinence
- Shearing or friction
- Surgical incisions
- Immobility
As Evidenced By:
- Patient reports of pain or altered sensation
- Changes in skin color (blanching, erythema)
- Skin disruption (breakdown, excoriation)
- Purulent or bloody drainage
Expected Outcomes:
- Pressure ulcer resolution within 30 days.
- Patient demonstrates three skin integrity maintenance methods.
- Pressure ulcer improvement (reduced size, absence of drainage).
Nursing Assessments:
- Regular Skin Assessments: Conduct skin assessments every shift, using the Braden Scale for risk stratification.
- Accurate Pressure Ulcer Staging: Precisely stage pressure ulcers to guide management and monitor progression.
- Identify Risk Factors: Consider age, chronic conditions, cognition, and nutritional status as factors influencing skin health.
Nursing Interventions:
- Consult Wound Care Experts: Involve wound care nurses early in skin breakdown management.
- Promote Nutrition and Hydration: Ensure adequate protein, vitamins (A, C, E), and zinc intake. Consider enteral or parenteral nutrition if needed.
- Maintain Clean and Dry Skin: Provide frequent perineal care and linen changes, especially for incontinent patients.
- Perform Wound Care: Implement prescribed wound care, including cleansing and application of appropriate dressings.
3. Impaired Tissue Integrity Related to Pressure Sores
Nursing Diagnosis: Impaired Tissue Integrity
Related Factors:
- Pressure injury
- Delayed wound healing
- Infection
- Poor circulation
- Impaired mobility
- Surgical procedures
- Poor nutrition
- Knowledge deficit regarding 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.
Nursing Assessments:
- Monitor Pressure Injury Staging: Regularly assess and document pressure injury stage to guide treatment.
- Assess Etiological Factors: Identify contributing factors such as comorbidities, mobility, and nutrition.
- Monitor Wound Size and Depth: Document wound dimensions according to facility protocols for tracking progress.
Nursing Interventions:
- Frequent Repositioning: Reposition patients frequently, avoiding pressure on the ulcer site.
- Prepare for Debridement: Prepare for debridement of Stage 3 or 4 ulcers to remove necrotic tissue.
- Utilize Pressure-Relieving Devices: Use specialized mattresses and cushions to redistribute pressure.
- Interdisciplinary Consultation: Consult with wound care nurses, dietitians, and PT/OT for comprehensive care.
4. Ineffective Peripheral Tissue Perfusion Related to Pressure Sores
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion
Related Factors:
- Diabetes mellitus
- Infection
- Circulatory compromise
- Smoking
- Lack of knowledge about comorbidities
As Evidenced By:
- Absent or diminished peripheral pulses
- Altered motor function
- Skin discoloration
- Pain
- Edema
- Paresthesia
- Delayed wound healing
Expected Outcomes:
- Adequate tissue perfusion (palpable pulses, normal skin color, wound healing).
- Patient understanding of factors affecting peripheral perfusion.
Nursing Assessments:
- Assess Peripheral Pulses: Monitor pulse quality as reduced pulses indicate perfusion issues.
- Monitor Perfusion Symptoms: Assess for pain, skin color changes, capillary refill, and altered sensation.
Nursing Interventions:
- Routine Skin Assessments: Perform frequent skin checks for patients at risk for perfusion issues.
- Encourage Movement/PT Consultation: Promote mobility and consult PT for exercise regimens to improve perfusion.
- Caution with Heat/Cold: Avoid direct heat or cold application to pressure ulcers due to sensory deficits.
- Patient Education: Educate patients about risk factors like smoking and conditions like diabetes that impair perfusion.
5. Risk for Infection Related to Pressure Sores
Nursing Diagnosis: Risk for Infection
Related Factors:
- Broken skin integrity
- Immunocompromised status
- Poor hygiene
- Incontinence
As Evidenced By:
(Risk diagnoses are not evidenced by signs and symptoms)
Expected Outcomes:
- Absence of wound infection signs (redness, drainage, odor, warmth).
- Absence of systemic infection (normal temperature and WBC count).
- Intact wound dressings to prevent bacterial entry.
Nursing Assessments:
- Monitor for Infection Signs: Observe for wound drainage, odor, swelling, redness, and systemic infection signs.
- Obtain Wound Cultures: Culture suspicious wounds to identify pathogens.
- Assess Lab Work: Monitor WBC count and other labs (protein, ESR, glucose) related to wound healing.
Nursing Interventions:
- Administer Antibiotics: Administer prophylactic or therapeutic antibiotics as ordered.
- Hand Hygiene: Practice strict hand hygiene before and during wound care.
- Ensure Dressing Integrity: Maintain clean, dry, and intact wound dressings.
- Educate on Infection Prevention: Educate patients and caregivers on home care infection prevention measures.
References
- National Pressure Injury Advisory Panel (NPIAP).
- European Pressure Ulcer Advisory Panel (EPUAP).
- Pan Pacific Pressure Injury Alliance (PPPIA).
- Clinical Practice Guideline for the Prevention and Treatment of Pressure Ulcers/Injuries.
