A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx
Pressure ulcers, also known as decubitus ulcers, pressure injuries, or bedsores are a type of skin breakdown that occurs due to constant pressure causing a lack of blood flow and oxygen which leads to poor tissue perfusion and tissue death. Show
Patients most at risk for developing pressure ulcers are older, bedridden, immobile, and those who cannot verbalize pain or discomfort. Patients with chronic conditions such as diabetes or vascular diseases are also more susceptible. Pressure ulcers are preventable through thorough assessment and intervention. This is the priority goal as once a pressure ulcer occurs, it can be difficult to treat and heal. Pressure ulcers that do not respond to simple wound care may require debridement, negative pressure therapy, hyperbaric oxygen chambers, wound vacs, and surgery. The Nursing ProcessPreventing pressure ulcers requires a team of healthcare staff working together to implement turning schedules, hygiene care, and nutrition. Even with proper preventive care, ulcers can still develop in high-risk patients and nurses must remain vigilant in wound care to prevent further complications. Nursing Care Plans Related to Pressure UlcersImpaired Skin Integrity Care PlanCompromised skin through internal or external causes increases the risk of pressure ulcer injury. Nursing Diagnosis: Impaired Skin Integrity Related to:
As evidenced by:
Expected Outcomes:
Impaired Skin Integrity Assessment1. Perform skin assessments. 2. Stage pressure ulcers correctly. 3. Identify additional risk factors. Impaired Skin Integrity Interventions1. Collaborate with wound care experts. 2. Encourage nutrition and
hydration. 3. Keep skin clean and dry. 4. Perform necessary wound care. Risk For Infection Care PlanOpen areas to the skin allow pathogens to enter increasing the risk of infection. Nursing Diagnosis: Risk For Infection Related to:
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention. Expected Outcome:
Risk For Infection Assessment1. Monitor for signs of infection. 2. Obtain wound cultures. 3. Assess lab work. Risk For Infection Interventions1. Administer
antibiotics. 2. Proper hand hygiene. 3. Ensure dressings are intact. 4. Educate on infection prevention. Impaired Physical Mobility Care PlanPatients with impaired mobility who cannot turn or reposition themselves are at high risk of developing a pressure ulcer. Nursing Diagnosis: Impaired Physical Mobility Related to:
As evidenced by:
Expected Outcomes:
Impaired Physical Mobility Assessment1. Assess range of motion/mobility. 2. Assess staff and family understanding. Impaired Physical Mobility Interventions1. Implement devices for independence with repositioning. 2. Use wedges, pillows, and mattresses. 3. Treat pain. 4. Instruct on areas to inspect for breakdown. 5. Transfer to chairs and assist with
ambulation. 6. Implement a turning schedule. References and Sources
How is a Stage 1 pressure injury treated?If you believe that you have a stage 1 pressure ulcer, you should remove all pressure from the area. Keep the area as dry and clean as possible to prevent bacterial infections. To speed up the healing process, you should eat adequate calories and have a diet high in minerals, proteins, and vitamins.
What is a Stage 1 pressure ulcer?Pressure injuries are described in four stages: Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose colour briefly when you press your finger on it and then remove your finger).
What are three nursing interventions to prevent pressure ulcers?The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment. Standardized pressure ulcer risk assessment. Care planning and implementation to address areas of risk.
Which intervention should the nurse include in the plan to prevent the development of pressure injuries?Moisture control and skin care
Increased moisture on the skin or excessive dryness can exacerbate pressure injury development due to the risk of skin breakdown and altered skin integrity. Use a pH neutral or slightly acidic skin cleanser (pH 4-7) ~ Alkaline products (pH >7) should be avoided.
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