Risk for Pressure Ulcer Nursing Diagnosis: Comprehensive Guide for Nurses

Pressure ulcers, frequently referred to as pressure injuries, decubitus ulcers, or bedsores, represent a significant concern in healthcare settings. These localized injuries to the skin and underlying tissue arise due to prolonged pressure, often over bony prominences. The sustained pressure disrupts blood flow, leading to tissue ischemia, cell death, and subsequent ulceration. Recognizing and addressing the Risk For Pressure Ulcer Nursing Diagnosis is paramount for effective patient care and prevention of these debilitating conditions.

Understanding Pressure Ulcers: An Overview

Pressure ulcers predominantly develop over bony prominences such as the sacrum, coccyx, trochanters, heels, and malleoli. The National Pressure Injury Advisory Panel (NPIAP) provides a standardized staging system to classify pressure ulcers based on tissue involvement:

• Stage 1: Characterized by non-blanchable erythema of intact skin.
• Stage 2: Involves partial-thickness skin loss with exposed dermis, presenting as a blister or abrasion.
• Stage 3: Full-thickness skin loss where subcutaneous fat is visible, but muscle, tendon, or bone are not exposed.
• Stage 4: Full-thickness skin and tissue loss with exposed muscle, tendon, bone, cartilage, or subcutaneous adipose tissue.
• Unstageable: The extent of tissue damage cannot be determined because the ulcer base is obscured by slough or eschar.
• Deep Tissue Pressure Injury (DTPI): Intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration indicating damage to underlying soft tissue from intense or prolonged pressure and shear forces at the bone-muscle interface.

Prevention is the cornerstone of pressure ulcer management. Once pressure ulcers develop, they can be challenging to heal and may lead to severe complications such as osteomyelitis and sepsis. Advanced stages (Stage 3 and 4) often require complex interventions beyond basic wound care, including debridement, negative pressure wound therapy, hyperbaric oxygen therapy, and surgical procedures.

The Nursing Process and Pressure Ulcer Risk

The nursing process is crucial in addressing the risk for pressure ulcer nursing diagnosis. A collaborative approach involving the entire healthcare team is essential for implementing preventive strategies encompassing repositioning schedules, meticulous hygiene, and nutritional support. Nurses play a pivotal role in identifying at-risk patients and implementing timely interventions to mitigate pressure ulcer development and manage existing wounds effectively.

Comprehensive Nursing Assessment for Pressure Ulcer Risk

The initial step in nursing care is a thorough assessment to gather comprehensive patient data. This assessment includes subjective and objective data pertinent to pressure ulcer risk and existing ulcers.

Health History Review: Identifying Risk Factors

1. Detailed Inquiry about Existing Pressure Injuries:
If a pressure injury is present, the nurse should gather detailed information regarding its history, including:

• Onset and duration
• Changes in appearance (size, depth, stage)
• Presence of pain or discomfort
• Characteristics of wound exudate (color, odor, amount)
• Presence of odor
• Decreased or altered sensation around the affected area

2. Identification of Potential Causative Factors:
Assess the patient’s skin condition, mobility level, and exposure to extrinsic risk factors. Note the presence of medical devices or equipment that may exert pressure on the skin, such as:

• Diapers or briefs
• IV lines and dressings
• Urinary catheters
• Oxygen tubing
• Restraints

Furthermore, evaluate for factors that exacerbate pressure risk in conjunction with pressure:

• Moisture: Exposure to bodily fluids like sweat, urine, or stool can macerate the skin, increasing vulnerability.
• Friction: Skin rubbing against surfaces, such as bed linens or clothing, can cause superficial skin damage.
• Shear Force: Occurs when tissue layers slide over each other, leading to damage of blood vessels and underlying tissues. This is common when patients are repositioned in bed or slide down in a chair.

3. Determination of Patient-Specific Risk Factors:
Certain patient populations are inherently at higher risk for developing pressure ulcers. Identify these individuals through careful assessment:

• Advanced Age: Older adults often have thinner skin, reduced subcutaneous fat, and comorbidities that increase risk.
• Immobility: Patients who are bedridden, chair-bound, or have limited mobility are at significant risk.
• Paralysis: Spinal cord injuries, stroke, or other conditions causing paralysis impair mobility and sensation.
• Incontinence: Both urinary and fecal incontinence expose skin to moisture and irritants.
• Nutritional Deficiencies: Malnutrition, particularly protein deficiency, compromises skin integrity and wound healing.
• Obesity and Underweight: Both extremes of body weight can increase pressure ulcer risk. Obese patients may have increased pressure on weight-bearing areas and skin folds, while underweight patients have less tissue to protect bony prominences.
• Sensory Impairment: Conditions that impair sensation, such as neuropathy, reduce the ability to perceive pressure and pain, delaying protective repositioning.
• Cognitive Impairment: Patients with dementia or altered mental status may not be able to communicate discomfort or reposition themselves.

4. Review of Medical History and Comorbidities:
Certain medical conditions significantly increase the susceptibility to pressure ulcers. Scrutinize the patient’s medical record for conditions such as:

• Immobility-related Conditions:
  • Paraplegia and Quadriplegia
  • Spina Bifida
  • Multiple Sclerosis
  • Amyotrophic Lateral Sclerosis (ALS)
• Conditions Affecting Sensory Perception:
  • Diabetic neuropathy
  • Peripheral neuropathy
  • Spinal cord injury
• Conditions Affecting Blood Circulation:
  • Peripheral vascular disease (PVD)
  • Diabetes mellitus
  • Cardiovascular disease
  • Anemia

Note: Hospital length of stay is a notable factor; prolonged hospitalization is associated with a higher incidence of pressure ulcers.

5. Medication Review for Drug-Induced Pressure Ulcers (DIPU):
Be aware of the emerging concept of Drug-Induced Pressure Ulcers (DIPU). Certain medications, particularly psychiatric drugs in older adults, have been linked to increased pressure ulcer risk. A thorough medication review is essential, especially in geriatric patients.

6. Evaluation of Housing Situation and Support System:
Assess the patient’s living environment and the availability of support, especially for patients in nursing homes or receiving home care. Stage 4 pressure ulcers may raise concerns about potential neglect. Patient and caregiver education on pressure ulcer prevention is crucial, particularly for those managing care at home.

7. Surgical History and Prolonged Immobility:
Consider surgical history, as pressure ulcers can develop rapidly in immobile patients, even within a few hours. Prolonged anesthesia, extended surgical procedures, and post-operative immobility are significant risk factors.

Physical Assessment: Comprehensive Skin Examination

1. Thorough Pressure Ulcer Assessment (if present):
If a pressure ulcer is identified, meticulously document its characteristics:

• Size: Measure length, width, and depth in centimeters using a disposable measuring guide.
• Exudate: Note the amount, color, consistency, and odor of drainage.
• Wound Bed: Describe the tissue type in the wound bed (granulation, slough, eschar, necrotic tissue).
• Undermining and Tunneling: Assess for tissue destruction extending under intact skin at the wound edges (undermining) and channels extending from the wound into surrounding tissues (tunneling). Use the “clock method” to document location and depth.
• Necrotic Tissue: Describe the type and percentage of necrotic tissue (slough – yellow or white, stringy tissue; eschar – black or brown, hard, leathery tissue).
• Healing Status: Observe for signs of healing, such as granulation tissue (red, beefy, cobblestone appearance) and epithelialization (new pink or purple tissue growing in from the edges or as islands on the wound surface).
• Wound Margins and Periwound Skin: Assess the wound edges (defined, undefined, attached, unattached) and the skin surrounding the wound (color, temperature, moisture, edema, induration, signs of maceration or excoriation).

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

3. Mental Status Assessment:
Evaluate the patient’s cognitive status and ability to communicate needs, especially regarding discomfort or repositioning. Patients with cognitive impairments may be unable to express their needs, requiring vigilant attention from the nursing staff.

4. Neuromuscular and Mobility Status:
Assess the patient’s neuromuscular function, mobility, and sensory perception. Conditions affecting sensory perception, such as spinal cord injuries or neuropathy, increase risk. Reduced mobility, contractures, or paralysis necessitate proactive preventive measures.

5. Braden Scale Assessment:
Utilize the Braden Scale for Predicting Pressure Ulcer Risk. This widely recognized tool evaluates six subscales:

• Sensory Perception: Ability to respond meaningfully to pressure-related discomfort.
• Moisture: Degree to which skin is exposed to moisture.
• Activity: Degree of physical activity.
• Mobility: Ability to change and control body position.
• Nutrition: Usual food intake pattern.
• Friction and Shear: Assistance required to move and degree of sliding in bed or chair.

Each subscale is scored, and the total score indicates the level of risk:

• Very High Risk: ≤9
• High Risk: 10-12
• Moderate Risk: 13-14
• Low Risk: 15-18
• No Risk: 19-23

Based on the Braden Scale score, nurses can tailor preventive interventions.

Diagnostic Procedures: Laboratory and Imaging Studies

1. Blood Workup:
Certain laboratory values can provide insights into factors contributing to pressure ulcer development or impaired healing:

• White Blood Cell (WBC) Count: Elevated WBC indicates inflammation or infection.
• Hemoglobin Levels: Low hemoglobin suggests reduced oxygen-carrying capacity, impairing tissue oxygenation.
• Platelet Count: Low platelets can compromise wound healing processes like proliferation and angiogenesis.
• Albumin Levels: Low albumin indicates protein deficiency, which is crucial for wound repair.
• Glucose Levels: Elevated glucose levels in patients with diabetes can impair wound healing and increase infection risk.
• Prealbumin Levels: More sensitive indicator of nutritional status than albumin, reflecting recent protein intake.

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

3. Tissue Biopsy:
Consider tissue biopsy for chronic, non-healing pressure ulcers to rule out underlying complications such as osteomyelitis or malignancy (Marjolin’s ulcer).

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

Nursing Interventions for Pressure Ulcer Prevention and Treatment

Nursing interventions are critical for both preventing pressure ulcers and managing existing wounds.

Pressure Ulcer Prevention Strategies

1. Regular Repositioning and Turning Schedules:
Implement a strict turning and repositioning schedule, typically every two hours for bedridden patients, to relieve pressure. Delegate turning schedules to unlicensed assistive personnel while maintaining nursing oversight. Encourage patient activity as tolerated, including passive and active range of motion exercises and ambulation.

2. Skin Hygiene and Moisture Management:
Maintain clean and dry skin. Implement a hygiene regimen that includes gentle cleansing with mild soap and water and patting skin dry. Apply moisture barrier creams to protect skin from incontinence. Consider fecal and urinary diversion devices if indicated based on ulcer location and risk of contamination.

3. Pressure-Relieving Support Surfaces:
Utilize specialty mattresses (alternating pressure, low-air-loss), cushions, foam wedges, and heel protectors to redistribute pressure away from bony prominences.

4. Minimizing Friction and Shear:
Employ techniques to reduce friction and shear forces. Use transfer sheets when repositioning patients in bed. Keep the head of the bed as low as possible (≤30 degrees) unless contraindicated to minimize sliding down.

5. Nutritional and Hydration Optimization:
Ensure adequate nutrition and hydration. A diet rich in protein, vitamins, and minerals is essential for skin health and wound healing. Hydration supports cell function, collagen production, and skin elasticity. Consult with a dietitian for nutritional assessment and recommendations.

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 on pressure ulcer prevention strategies. Emphasize:

• Adherence to turning and repositioning schedules.
• Maintaining skin hygiene and dryness.
• Proper use of pressure-relieving devices.
• Recognition of early warning signs of skin breakdown (redness, discoloration, pain, altered sensation).

Treatment of Existing Pressure Ulcers

1. Pressure Relief and Protection:
For Stage 1 pressure ulcers, focus on pressure relief. Frequent repositioning and pressure-redistributing support surfaces are essential. Protective dressings like thin hydrocolloid dressings can protect the area from further friction and shear. For sacral or heel ulcers, consider prophylactic dressings such as silicone border dressings to protect from pressure, friction, and shear.

2. Wound Dressing Selection:
Wound dressing selection depends on ulcer characteristics, including drainage and infection status. Follow established protocols and healthcare provider orders.

• Infected wounds, no drainage: Silver dressings, topical medical-grade honey, foam dressings.
• Infected wounds, with drainage: Alginate dressings, silver dressings, gauze dressings, foam dressings.
• Non-infected wounds, no drainage: Hydrogel dressings.
• Non-infected wounds, with drainage: Alginate dressings, hydrocolloid dressings, gauze dressings, foam dressings.

3. Debridement:
Debridement, the removal of necrotic tissue, is often necessary for pressure ulcer healing. Methods include:

• Sharp Debridement: Surgical removal of devitalized tissue by a trained professional.
• Enzymatic Debridement: Topical application of enzymatic ointments to digest necrotic tissue.
• Autolytic Debridement: Using moisture-retentive dressings to promote the body’s own enzymes to break down necrotic tissue.
• Mechanical Debridement: Wet-to-dry dressings (generally not recommended for pressure ulcers due to potential damage to healthy tissue), wound irrigation, or hydrotherapy.

4. Negative Pressure Wound Therapy (NPWT):
Consider NPWT (wound VAC) for Stage 3 and 4 pressure ulcers. NPWT applies controlled negative pressure to remove exudate, promote granulation tissue formation, and approximate wound edges.

5. Pain Management:
Address pain associated with pressure ulcers and wound care. Premedicate with analgesics as prescribed prior to dressing changes if needed.

6. Surgical Interventions:
Surgical debridement, skin grafts, or flap reconstruction may be necessary for complex or non-healing pressure ulcers, especially Stage 4 ulcers or those with complications like osteomyelitis.

7. Hyperbaric Oxygen Therapy:
Hyperbaric oxygen therapy can enhance oxygen delivery to hypoxic wound tissues, promoting healing in select cases.

8. Nutritional Support:
Optimize nutritional status. Consult a dietitian to ensure adequate protein, calorie, vitamin, and mineral intake to support tissue repair.

9. Wound Care Specialist Consultation:
Refer complex or chronic pressure ulcers to a certified wound care nurse or specialist for comprehensive assessment and management. Outpatient wound care specialists can provide ongoing management for non-healing ulcers or post-surgical follow-up.

Nursing Care Plans for Pressure Ulcer Risk

Nursing care plans are essential for organizing and prioritizing care for patients at risk for pressure ulcer nursing diagnosis. Examples of relevant nursing diagnoses and associated care plan components are provided below.

Impaired Physical Mobility and Pressure Ulcer Risk

Nursing Diagnosis: Impaired Physical Mobility

Related to:

• Paralysis
• Prescribed bed rest
• Decreased muscle strength
• Contractures
• Pain
• Neuromuscular conditions
• Cognitive or developmental impairment
• Morbid obesity

As evidenced by:

• Limited range of motion
• Inability to turn or reposition self

Expected Outcomes:

• Patient will utilize assistive devices to improve repositioning.
• Patient will verbalize understanding of pressure ulcer prevention strategies.
• Patient will remain free from pressure ulcer development.

Assessments:

1. Range of Motion and Mobility: Assess patient’s ability to move, strength, and range of motion.
2. Caregiver Understanding: Evaluate staff or family caregiver’s ability to safely turn and reposition the patient.

Interventions:

1. Assistive Devices: Provide trapeze bars or side rails to enhance patient independence in repositioning.
2. Pressure-Relieving Devices: Use wedges, pillows, heel protectors, and specialty mattresses.
3. Pain Management: Premedicate for pain before repositioning; manage chronic pain to facilitate movement.
4. Education on Inspection Areas: Instruct patients and caregivers on areas prone to pressure and shear.
5. Chair and Ambulation Transfers: Facilitate transfers to chairs and ambulation as tolerated.
6. Turning Schedule: Implement and adhere to a 2-hour turning schedule for bedridden patients; 15-minute repositioning for chair-bound patients.

Impaired Skin Integrity and Pressure Ulcer Development

Nursing Diagnosis: Impaired Skin Integrity

Related to:

• Poor nutritional status
• Edema
• Impaired circulation
• Neuropathy
• Moisture/Incontinence
• Shearing/Friction
• Surgical incisions
• Immobility

As evidenced by:

• Pain or numbness
• Skin color changes (blanching, erythema)
• Skin disruption (breakdown, excoriation)
• Drainage

Expected Outcomes:

• Patient will demonstrate pressure ulcer resolution within a specified timeframe.
• Patient will describe methods to prevent skin integrity impairment.
• Pressure ulcer will show signs of improvement (size reduction, decreased drainage).

Assessments:

1. Regular Skin Assessments: Conduct skin assessments at least once per shift, using the Braden Scale.
2. Accurate Pressure Ulcer Staging: Stage pressure ulcers correctly to guide management and monitoring.
3. Risk Factor Identification: Identify patient-specific risk factors (age, comorbidities, cognition, nutrition).

Interventions:

1. Wound Care Collaboration: Consult wound care specialists early in the presence of skin breakdown.
2. Nutrition and Hydration: Optimize nutrition and hydration, considering enteral or parenteral support if needed.
3. Skin Hygiene and Dryness: Maintain clean, dry skin, especially with incontinence.
4. Wound Care Protocols: Implement appropriate wound care based on ulcer type, size, and location.

Impaired Tissue Integrity in Advanced Pressure Ulcers

Nursing Diagnosis: Impaired Tissue Integrity

Related to:

• Pressure injury
• Delayed wound healing
• Infection
• Poor circulation
• Impaired mobility
• Surgical procedures
• Poor nutrition
• Knowledge deficit regarding tissue integrity maintenance

As evidenced by:

• Pain
• Redness
• Bleeding
• Warmth
• Tissue damage

Expected Outcomes:

• Patient will demonstrate protective and healing interventions for damaged tissue.
• Patient will exhibit a reduction in pressure ulcer size.

Assessments:

1. Pressure Injury Staging: Accurately stage pressure injuries, noting depth and presence of tunneling or undermining.
2. Etiological Factors: Assess contributing factors (comorbidities, mobility, nutrition).
3. Wound Measurement: Monitor and document ulcer size (length, width, depth) regularly.

Interventions:

1. Frequent Repositioning: Reposition patient frequently, avoiding pressure on the ulcer site.
2. Debridement Preparation: Prepare for and assist with debridement as indicated.
3. Pressure-Relieving Devices: Utilize specialized mattresses and cushions.
4. Multidisciplinary Consultation: Consult wound care nurses, dietitians, and physical/occupational therapists.

Ineffective Peripheral Tissue Perfusion and Pressure Ulcer Risk

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion

Related to:

• Diabetes mellitus
• Infection
• Circulatory compromise
• Smoking
• Insufficient knowledge of risk factors

As evidenced by:

• 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 peripheral perfusion.

Assessments:

1. Peripheral Pulses: Assess and monitor peripheral pulses for strength and presence.
2. Tissue Perfusion Symptoms: Monitor for pain, skin discoloration, capillary refill, paresthesia, weakness.

Interventions:

1. Routine Skin Assessments: Frequent skin assessments for patients with perfusion risk factors.
2. Encourage Movement/Physical Therapy: Promote movement and consult physical therapy.
3. Caution with Heat/Cold: Exercise caution when applying heat or cold due to sensory deficits.
4. Risk Factor Education: Educate patients on modifiable risk factors like smoking and obesity.

Risk for Infection in Pressure Ulcers

Nursing Diagnosis: Risk for Infection

Related to:

• Broken skin
• Immunocompromised status
• Poor hygiene
• Incontinence

As evidenced by:
(Risk diagnoses are not evidenced by signs and symptoms)

Expected Outcomes:

• Patient will remain free from wound infection signs (redness, drainage, odor, warmth).
• Patient will remain afebrile with normal WBC count.
• Wound dressings will remain intact to prevent bacterial entry.

Assessments:

1. Infection Monitoring: Monitor for local (drainage, odor, redness) and systemic (fever, tachycardia) infection signs.
2. Wound Cultures: Obtain wound cultures for suspected infections.
3. Laboratory Assessment: Monitor WBC count and other relevant labs.

Interventions:

1. Antibiotic Administration: Administer antibiotics as prescribed.
2. Hand Hygiene: Strict hand hygiene before and after wound care.
3. Dressing Integrity: Ensure dressings are intact and changed as needed.
4. Infection Prevention Education: Educate patients on infection prevention measures at home.

By comprehensively addressing the risk for pressure ulcer nursing diagnosis through thorough assessment, targeted interventions, and meticulous nursing care, healthcare professionals can significantly reduce the incidence and severity of pressure ulcers, improving patient outcomes and quality of life.

References

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