THE PREVENTION AND TREATMENT OF PRESSURE ULCERS

Source: NICE 2005, RCN

PRESSURE ULCERS (IMPAIRED SKIN INTEGRITY) 

CARE PLAN

The National Pressure Ulcer Advisory Panel defines pressure ulcer as "a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear and/or friction".

Common related factors:
-Extremes of age.
-Inmobility.
-Imbalanced nutritional state.
-Mechanical factors (friction, shear and pressure)
-Pronounced bony prominences.
-Impaired circulation.
-Impaired sensation.
-Incontinence.
-Moisture.
-Radiation.
-Chronic disease state.
-Inmunological deficit.
-Impaired cognition.

Defining characteristics:
-Destruction of skin layers.
-Disruption of skin surfaces.
-Invasion of body structures.
-Pressure ulcer stages:

• Deep tissue injury (new stage): purple or maroon localized area of intact skin or blood-filled blister resulting from pressure damage or underlying soft tissue.
• Stage I

• Stage II

• Stage III

• Stage IV

• Unstageable: Full thickness tissue loss in which actual depth of ulcer is completely obstructed by slough or eschar in the wound bed.

Common expected outcomes:
-Patient receives stage-appropiate wound care, experiences pressure reduction and has controlled risk factors for prevention of additional ulcers.
-Patient experiences healing of pressure ulcers.

Source: Nursing Care Plans Diagnoses, Interventions and Outcomes. Meg Gulanick, 8th Edition.