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NCP : Patient With a Pressure Ulcer

Nursing Diagnosis Impaired skin Integrity related to pressure, shearing forces, impaired circulation, and skeletal prominence as evidenced
by presence of pressure ulcer
Patient Goals 1. Maintains intact skin with no further pressure ulcer
2. Experiences healing of pressure ulcer
Intervention Outcome
Pressure Ulcer Prevention Tissue Integrity: Skin and Mucous membranes
 Use an established risk assessment tool to monitor  Skin temperature………………..
individual’s risk factors (e.g., Braden Scale) to reduce  Sensation………………….
or eliminate factors that contribute to development or  Tissue Perfusion……………….
progression of the pressure ulcer.  Skin intactness…………..
 Remove excessive moisture on the skin resulting from
perspiration wound drainage and fecal or urinary Measurement Scale
incontinence to prevent maceration. 1= Severely compromised
 Avoid massaging over bony prominences to prevent 2= substantially compromised
further tissue damage. 3= Moderately compromised
 Turn every one to two hours to avoid prolonged 4= Mildly compromised
pressure in one area. 5= Not compromised
 Turn with care (e.g., avoid shearing) to prevent injury to
fragile skin.  Erythema……………….
 Position with pillows to elevate pressure points off the  Blanching……………..
bed.  Necrosis…………….
 Use specialty beds and mattresses as needed to provide
pressure relief and increase circulation to the site. Measurement Scale
 Use devices on the bed (e.g., Sheepskin) that protect the 1= Severe
individual from pressure. 2= Substantial
 Apply elbow and heel protectors as appropriate to avoid 3= Moderate
pressure. 4= Mild
 Assist individual in maintaining a healthy way as the 5= None
risk for pressure ulcer is increased in people who are
obese or very thin.

Pressure Ulcer Care Wound Healing: Secondary Intention

 Describe characteristic of the ulcer at regular intervals,  Purulent Discharge………………..
including size (length x width x depth), stage (I to IV),  Serous Drainage………………

NCP : Pressure Ulcer

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location, exudates, granulation, or necrotic tissue, and  Serousanguineous Drainage……………….

epitelialization to provide baseline and ongoing data for  Necrosis………………..
monitoring pressure ulcer.  Sloughing……………..
 Keep the ulcer moist to aid in healing.  Tunneling……………….
 Cleanse the ulcer with the appropriate non-toxic
solution, working in a circular motion from the center. Measurement Scale
 Debride ulcer, as needed, to promote new tissue growth. 1= Extensive
 Apply a permeable adhesive membrane, saline soaks, 2= Substantial
ointments, and/or dressing, as appropriate, to promote 3= Moderate
healing. 4= Limited
 Verify adequate caloric and high-quality protein intake 5= None
to provide nutrients necessary for tissue repair.
 Teach individual or family member(s) wound care
procedures to enhance self-care.
 Instruct family member/caregiver about science of skin
breakdown to prevent recurrent.
 Initiate consultation services of the enterostomal
therapy nurse, as needed, for specialized direction of
ulcer care.

NCP : Pressure Ulcer