Pressure Ulcer Nursing Diagnosis: A Comprehensive Guide for Nurses

Pressure ulcers, frequently referred to as bedsores, pressure injuries, or decubitus ulcers, represent localized damage to the skin and underlying tissue. This damage arises from sustained pressure, which disrupts blood flow and oxygen supply to the affected tissues. The resulting ischemia leads to tissue necrosis, ulceration, and potential complications. Effective nursing care is paramount in preventing and managing pressure ulcers, and accurate nursing diagnosis is the cornerstone of this care.

Understanding Pressure Ulcers

Pressure ulcers typically develop over bony prominences where external pressure is concentrated, such as the sacrum, coccyx, heels, hips, and ankles. The National Pressure Injury Advisory Panel (NPIAP) classification system is widely used to stage pressure ulcers based on the depth of tissue damage:

• 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. Clinically, this may present as an abrasion, blister, or shallow crater.
• Stage 3: Signifies 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. Undermining and tunneling are common in these ulcers.
• Unstageable: The extent of tissue damage cannot be determined due to the presence of slough or eschar obscuring the wound bed.
• Deep Tissue Pressure Injury (DTPI): Defined as persistent non-blanchable deep red, maroon, or purple discoloration, indicating damage to underlying soft tissue from pressure or shear.

Prevention is the most effective strategy for pressure ulcer management. Once developed, particularly Stage 3 and 4 ulcers, they pose significant risks of complications, including osteomyelitis and sepsis. While simple wound care may suffice for early stages, advanced ulcers often require debridement, negative pressure wound therapy, hyperbaric oxygen therapy, or surgical intervention.

The Nursing Process and Pressure Ulcer Nursing Diagnosis

The nursing process is fundamental to addressing pressure ulcers. It involves assessment, diagnosis, planning, implementation, and evaluation. Accurate Pressure Ulcer Nursing Diagnosis guides the selection of appropriate interventions and care plans.

Nursing Assessment for Pressure Ulcer Nursing Diagnosis

A comprehensive nursing assessment is crucial for identifying patients at risk and diagnosing existing pressure ulcers. This assessment encompasses subjective and objective data collection across physical, psychosocial, emotional, and diagnostic domains.

Review of Health History

1. Patient Interview Regarding the Pressure Injury: Elicit detailed information from the patient (if possible) or caregiver about any existing or suspected pressure injuries. Key signs and symptoms to inquire about include:

• Skin discoloration (redness, purple, black)
• Pain or discomfort at the site
• Presence of drainage or odor
• Changes in sensation (numbness, tingling)

2. Determining Potential Etiology: Thoroughly assess the patient’s skin and mobility status to identify factors contributing to pressure ulcer development. Consider:

• Pressure: Prolonged pressure on bony prominences is the primary cause.
• Moisture: Incontinence (urine, stool), excessive perspiration, and wound exudate can macerate the skin, increasing vulnerability.
• Friction: Skin rubbing against surfaces (bed linens, clothing) can cause superficial skin damage.
• Shear Force: Occurs when tissue layers slide over each other, damaging blood vessels. This is common when patients slide down in bed.

3. Identifying Risk Factors: Determine the patient’s individual risk profile for pressure ulcer development. High-risk populations include:

• Elderly individuals: Age-related skin changes and comorbidities increase susceptibility.
• Immobile patients: Bedridden or chair-bound individuals are at significantly higher risk.
• Patients with paralysis: Spinal cord injuries, stroke, or neuromuscular conditions impair mobility and sensation.
• Incontinent patients: Exposure to urine and feces increases skin moisture and irritation.
• Malnourished or obese individuals: Nutritional deficits compromise skin integrity, while obesity can increase pressure and friction.
• Patients with sensory deficits: Conditions like neuropathy prevent patients from feeling pressure and discomfort.

4. Medical Record Review: Examine the patient’s medical history for pre-existing conditions that elevate pressure ulcer risk:

• Conditions causing immobility: Paraplegia, quadriplegia, multiple sclerosis, advanced arthritis.
• Conditions affecting sensory perception: Diabetic neuropathy, spinal cord injury, stroke.
• Conditions impairing circulation: Peripheral vascular disease, diabetes, heart failure.

Note: Length of hospital stay is directly correlated with increased pressure ulcer incidence.

5. Medication Review: Certain medications can contribute to pressure ulcer development. Be aware of:

• Drug-induced pressure ulcers (DIPU): Emerging evidence links psychiatric medications, particularly in older adults, to increased pressure ulcer risk.

6. Socioeconomic and Support System Assessment: Consider the patient’s living situation and available support:

• Neglect and abuse: Stage 4 pressure ulcers can be indicators of neglect, especially in nursing homes or home care settings.
• Caregiver education: Assess the knowledge and ability of family or caregivers to provide pressure ulcer prevention and early intervention at home.

7. Surgical History: Prolonged surgical procedures and post-operative immobility are significant risk factors:

• Duration of anesthesia: Extended periods of anesthesia contribute to tissue ischemia.
• Post-operative mobility restrictions: Reduced movement after surgery increases pressure risk.

Image: Example of a Stage 2 Pressure Ulcer, illustrating partial-thickness skin loss. Alt text: Stage 2 pressure ulcer on sacrum showing partial thickness skin loss with blister-like appearance.

Physical Assessment

1. Comprehensive Pressure Ulcer Examination: If a pressure ulcer is present, meticulously document its characteristics:

• Size: Measure length, width, and depth in centimeters.
• Exudate: Note the amount, color, and consistency of drainage.
• Odor: Assess for any foul odor, which may indicate infection.
• Undermining and Tunneling: Probe the wound edges to detect any tissue destruction extending under intact skin (undermining) or channels within the wound (tunneling).
• Necrotic Tissue: Identify and describe any slough (yellow, stringy) or eschar (black, hard) present in the wound bed.
• Healing Status: Observe for signs of healing, such as granulation tissue (red, beefy) and epithelialization (new skin formation).
• Wound Margins and Periwound Skin: Assess the condition of the wound edges and surrounding skin for redness, warmth, maceration, or induration.

2. Pressure Injury Staging: Accurately stage the pressure ulcer using the NPIAP classification system. Correct staging is crucial for monitoring wound progression or regression and guiding treatment.

3. Mental Status Evaluation: Assess the patient’s cognitive function and ability to communicate needs and discomfort. Patients with altered mental status may be unable to report pain or reposition themselves.

4. Neuromuscular and Mobility Assessment: Evaluate the patient’s sensory perception and motor function. Neurological impairments and mobility limitations significantly increase pressure ulcer risk.

5. Braden Scale Assessment: Utilize the Braden Scale for Pressure Ulcer Risk Assessment. This validated tool evaluates six risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score indicates the patient’s risk level (high, moderate, low) and guides preventive interventions.

Image: The Braden Scale chart, showing the six subscales and scoring system used to assess pressure ulcer risk. Alt text: Braden Scale assessment tool for pressure ulcer risk prediction with sensory perception, moisture, activity, mobility, nutrition, friction and shear categories.

Diagnostic Procedures

1. Blood Workup: Blood tests can provide valuable information about factors influencing pressure ulcer development and healing:

• White Blood Cell Count (WBC): Elevated WBC indicates inflammation or infection.
• Hemoglobin: Low hemoglobin levels suggest reduced oxygen delivery to tissues.
• Platelet Count: Low platelets can impair wound healing processes.
• Albumin: Low albumin levels reflect protein deficiency, which hinders wound repair.
• Glucose: Elevated glucose levels (hyperglycemia) can impede wound healing, particularly in diabetic patients.

2. Wound Culture: Obtain wound cultures from pressure ulcers exhibiting signs of infection (drainage, odor, increased pain, cellulitis). Culture results guide antibiotic selection.

3. Tissue Biopsy: Consider tissue biopsy for non-healing pressure ulcers to rule out underlying conditions such as osteomyelitis or malignancy.

4. Imaging Studies: If osteomyelitis is suspected, imaging studies such as MRI or CT scans may be necessary to evaluate bone involvement.

Common Pressure Ulcer Nursing Diagnoses

Based on the comprehensive assessment, several nursing diagnoses may be relevant for patients with or at risk for pressure ulcers. These diagnoses provide a framework for developing individualized care plans. Common pressure ulcer nursing diagnoses include:

• Impaired Skin Integrity: This diagnosis is appropriate for Stage 1 and Stage 2 pressure ulcers, where there is damage to the epidermis and/or dermis.
• Impaired Tissue Integrity: Utilized for Stage 3 and Stage 4 pressure ulcers, indicating damage extending into subcutaneous tissue, muscle, or bone.
• Risk for Impaired Skin Integrity: For patients at high risk of developing pressure ulcers due to identified risk factors (immobility, incontinence, etc.).
• Impaired Physical Mobility: Relevant when immobility is a primary contributing factor to pressure ulcer development or a consequence of the ulcer.
• Ineffective Peripheral Tissue Perfusion: Considered when compromised circulation contributes to pressure ulcer formation or delayed healing.
• Risk for Infection: Appropriate for all pressure ulcers, as broken skin increases the risk of bacterial invasion.
• Pain: Pressure ulcers can be painful, especially during wound care or movement.

Nursing Interventions for Pressure Ulcers

Nursing interventions are crucial for both preventing and treating pressure ulcers. They are tailored to the individual patient’s needs and the specific nursing diagnoses identified.

Pressure Ulcer Prevention Strategies

1. Regular Repositioning and Turning: Implement a turning schedule, typically every two hours, to relieve pressure on bony prominences. Delegate turning schedules to assistive personnel as appropriate. Encourage activity as tolerated, including passive and active range of motion exercises and ambulation.

2. Skin Hygiene and Moisture Management: Maintain clean and dry skin. Provide regular hygiene care, especially after incontinence episodes. Use moisture barrier creams to protect skin from urine and stool. Consider fecal or urinary diversion devices if contamination is a significant concern.

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: Employ techniques to minimize friction and shear forces. Use transfer sheets when repositioning patients in bed. Keep the head of the bed as low as tolerated to prevent sliding down.

5. Nutritional and Hydration Optimization: Ensure adequate protein, calorie, and micronutrient intake to support skin health and wound healing. Promote hydration to maintain skin elasticity and cell function.

6. Device and Line Management: Regularly assess and adjust medical devices (catheters, IV lines, feeding tubes) to prevent pressure on the skin. Ensure linens and clothing are smooth and wrinkle-free.

7. Patient and Caregiver Education: Educate patients, families, and caregivers about pressure ulcer prevention strategies, including:

• Adherence to turning and repositioning schedules.
• Maintaining skin hygiene and dryness.
• Proper use of pressure-relieving devices.
• Early recognition of warning signs (skin redness, discoloration, pain).

Treatment of Existing Pressure Ulcers

1. Pressure Relief and Protection: For Stage 1 pressure ulcers, focus on eliminating pressure on the affected area through frequent repositioning and pressure-redistributing surfaces. Apply protective dressings like Mepilex Border to sacral or heel areas.

2. Wound Dressing Selection: Choose wound dressings based on wound characteristics (drainage, infection status) and established protocols or healthcare provider orders:

• Infected wounds without drainage: Silver dressings, topical medical-grade honey, foam dressings.
• Infected wounds with drainage: Alginate dressings, silver dressings, gauze, foam dressings.
• Non-infected wounds without drainage: Hydrogel dressings.
• Non-infected wounds with drainage: Alginate dressings, hydrocolloid dressings, gauze, foam dressings.

3. Debridement: Prepare for debridement to remove necrotic tissue, which impedes healing. Debridement methods include:

• Sharp debridement: Surgical removal by a trained professional.
• Autolytic debridement: Using moisture-retentive dressings to promote natural enzymatic breakdown of necrotic tissue.
• Enzymatic debridement: Topical application of enzymatic ointments.
• Mechanical debridement: Wet-to-dry dressings (less commonly used due to potential harm to healthy tissue).

4. Negative Pressure Wound Therapy (NPWT): Consider NPWT (wound vac) for Stage 3 and 4 pressure ulcers to promote wound healing by removing exudate, reducing edema, and stimulating granulation tissue formation.

5. Pain Management: Administer pain medications as prescribed, especially before wound care procedures.

6. Surgical Intervention: Prepare patients for potential surgical debridement, skin grafts, or flap reconstruction for complex or non-healing pressure ulcers.

7. Hyperbaric Oxygen Therapy: Consider hyperbaric oxygen therapy to enhance tissue oxygenation and promote healing in select cases.

8. Nutritional Support: Consult with a dietitian to optimize nutritional intake, focusing on protein, vitamins, and minerals essential for wound healing.

9. Wound Care Specialist Referral: Refer patients with complex or chronic pressure ulcers to a wound care certified nurse or specialist for advanced management and treatment planning.

Nursing Care Plans for Pressure Ulcer Nursing Diagnosis

Nursing care plans provide a structured approach to addressing pressure ulcer nursing diagnoses. Examples of care plans for common diagnoses are provided below:

Nursing Care Plan: Impaired Physical Mobility

Nursing Diagnosis: Impaired Physical Mobility

Related to: Paralysis, prescribed bed rest, decreased muscle strength, contractures, pain, neuromuscular conditions, cognitive impairment, morbid obesity.

As evidenced by: Limited range of motion, inability to turn or reposition self.

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.

Nursing Interventions:

1. Implement devices for independence in repositioning (trapeze bars, side rails).
2. Utilize pressure-redistributing support surfaces (wedges, pillows, specialty mattresses).
3. Manage pain effectively to facilitate movement.
4. Educate patient and caregivers on areas at risk for pressure ulcers and prevention strategies.
5. Promote mobility by assisting with transfers to chairs and ambulation as appropriate.
6. Implement and adhere to a regular turning schedule (every 2 hours).

Nursing Care Plan: 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 or numbness, alterations in skin color, skin disruption (breakdown, excoriation), drainage.

Expected Outcomes:

• Patient will demonstrate resolution of pressure ulcer within a specified timeframe (e.g., 30 days).
• Patient will demonstrate three ways to prevent impaired skin integrity.
• Pressure ulcer will improve as evidenced by reduced size and absence of drainage.

Nursing Interventions:

1. Perform regular and thorough skin assessments, utilizing the Braden Scale.
2. Correctly stage any pressure ulcers identified for accurate monitoring and management.
3. Identify and address individual risk factors contributing to impaired skin integrity.
4. Collaborate with wound care specialists for optimal management.
5. Encourage adequate nutrition and hydration to support skin health and healing.
6. Maintain clean and dry skin, especially in incontinent patients.
7. Implement prescribed wound care treatments and dressings.

Nursing Care Plan: Impaired Tissue Integrity

Nursing Diagnosis: Impaired Tissue Integrity

Related to: Pressure injury, delayed wound healing, infectious process, poor circulation, impaired mobility, surgical procedures, poor nutrition, insufficient knowledge.

As evidenced by: Pain, redness, bleeding, warmth, tissue damage (Stage 3 or 4 pressure ulcer).

Expected Outcomes:

• Patient will demonstrate interventions to protect and heal damaged tissue.
• Patient will experience a decrease in pressure ulcer size.

Nursing Interventions:

1. Accurately assess and monitor the stage of the pressure injury, including depth and presence of undermining or tunneling.
2. Assess and address etiological factors contributing to impaired tissue integrity.
3. Monitor and document wound size and depth regularly.
4. Encourage frequent patient repositioning, avoiding pressure on the ulcer site.
5. Perform or prepare for debridement as indicated.
6. Utilize pressure-relieving devices and support surfaces.
7. Consult with a multidisciplinary team including wound care nurses, dietitians, and physical/occupational therapists.

Nursing Care Plan: Ineffective Peripheral Tissue Perfusion

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion

Related to: Diabetes mellitus, infectious process, circulatory compromise, smoking, insufficient knowledge of risk factors.

As evidenced by: Absent or diminished peripheral pulses, altered motor function, skin discoloration, pain, edema, paresthesia, delayed wound healing.

Expected Outcomes:

• Patient will demonstrate adequate tissue perfusion as evidenced by palpable peripheral pulses, normal skin color, and wound healing.
• Patient will verbalize understanding of factors contributing to poor peripheral perfusion.

Nursing Interventions:

1. Assess and monitor peripheral pulses regularly.
2. Assess for signs and symptoms of decreased tissue perfusion (pain, discoloration, delayed capillary refill).
3. Perform routine skin assessments, especially in high-risk patients.
4. Encourage movement and consult with physical therapy to improve circulation.
5. Exercise caution when applying heat or cold to extremities due to potential sensory deficits.
6. Educate the patient about disease processes and lifestyle factors affecting peripheral perfusion.

Nursing Care Plan: Risk for Infection

Nursing Diagnosis: Risk for Infection

Related to: Broken skin/disrupted epidermis, immunocompromised status, poor hygiene, incontinence.

As evidenced by: (Risk diagnosis – no evidence by symptoms).

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).
• Wound dressings will remain intact to prevent bacterial entry.

Nursing Interventions:

1. Monitor for signs and symptoms of wound infection during wound care and assessments.
2. Obtain wound cultures if infection is suspected.
3. Assess laboratory values (WBC count) for indicators of infection.
4. Administer antibiotics as prescribed.
5. Practice strict hand hygiene before and after wound care.
6. Ensure wound dressings are intact and changed appropriately.
7. Educate patients and caregivers on infection prevention measures at home.

By employing a systematic nursing process, including thorough assessment and accurate pressure ulcer nursing diagnoses, nurses play a pivotal role in preventing pressure ulcers and providing effective, patient-centered care for those who develop these challenging wounds.

References

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