NURSING CARE PLAN FOR PRESSURE ULCER

ASSESSMEN NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

T DIAGNOSIS INTERVENTION
SUBJECTIVE: Impaired skin Pressure on Short Term: Independent: After 8 hours of
integrity soft tissues After 6-8 hours  Assess between  Pressure ulcers nursing
“meron na related to between bony of nursing folds of skin, under medical interventions
syang sugat sa pressure ulcer prominences interventions of remove anti devices are patient:
bandang pwet, secondary to ↓ nursing embolic stockings commonly reduced risk
dahil sa prolonged Compresses interventions, or devices & use a overlooked. of further
pagkakahiga immobility capillaries & the client will: mirror to see the impairment of
niya ng and occludes blood heels. Also assess skin integrity
matagal..” as unrelieved flow  Have reduced under oxygen as evidenced
verbalized by pressure as ↓ risk of further tubing especially by no actual
the patient’s evidenced by: Pressure not impairment of on the ears & the additional
granddaughter. relieved skin integrity cheek, beneath tissue
 Stage II ↓ splints and under breakdown &
OBJECTIVES: pressure Microthrombi  Patient’s medical devices. no persistent
ulcer @ L formation caregivers will reddened areas
 Stage II &R ↓ demonstrate  Note objective data  Reassessment of
pressure ulcer buttocks + occlusion in understanding of pressure ulcer ulcer is Patient’s
@L&R  Localized capillaries & & skill in care (stage, length, completed each caregivers’
buttocks injury blood flow of wound width, depth, time dressing are demonstrated
 Localized over bony ↓ wound bed changed or understanding
injury over prominen Formation of appearance, sooner if ulcer & skill in care
bony ce blister Long Term: drainage & shows of wound as
prominence  Dry & ↓ After 3-4 days condition of manifestations of evidenced by
 Dry & shallow shallow Rupture of of nursing periulcer tissue) deterioration. checking
wound wound blister interventions, Analyses of the pressure ulcer
 Reddish-pink  Reddish- ↓ the client will: trends in healing sites
open/rupture pink + open wound are important step frequently &
blister open/rupt ↓  Experience in assessment. cleansing the
ure blister Stage II healing of wound
 manifestations: ulcer/regain  Increase the  To disperse aseptically.
 Stage II skin integrity frequency of turning pressure over
pressure (reduce size of (turning q2). time or PARTIALLY
ulcer @ L & ulcer) Position the client to decreasing the MET
R buttocks  Reduce risk stay off the ulcer. If tissue load
 Localized for infection there is no turning After 4 days of
injury over surface without a nursing
bony pressure ulcer, use a interventions the
prominence pressure client:
 Dry & redistribution bed &  Experienced
shallow continue turning the healing of
wound client tissue as
 Reddish-pink evidenced by
open/rupture  Elevate heels off the  Heel covers do development
blister bed by using pillows not relieve of
or heel elevation pressure, but they granulation
botts. can reduce tissue &
friction. decrease in
ulcer size.
 Maintain head of  To prevent
bed @ the lowest further  Reduce risk
elevation, if client occurrence of of infection
must have the head pressure ulcer. as evidenced
elevated to prevent by observing
aspiration, proper hand
reposition to 30 washing
degree lateral technique
position. Use seat before &
cushions & assess after wound
sacral ulcers daily. care.
 Follow body  To reduce risk of PARTIALLY
substance isolation infection MET
precautions; use
 clean gloves &
clean dressing for
wound care.
Practicing proper
hand washing
before & after
wound care.

Dependent/Collaborati
ve:

 Ensure adequate  To prevent

dietary intake. malnutrition &
Review dietician’s delayed healing
recommendations.

 Prevent the ulcer  To prevent

from being contamination or
exposed to urine & spread of
feces. Use infection
indwelling
catheters, bowel
containment
systems, & topical
creams or
dressings.

 Supplement the diet  To promote

with vitamins & wound healing on
minerals. Vitamins clients who do
C and zinc are not have adequate
commonly calories.
 prescribed.

 Provide oral  Pressure ulcers

supplementations, cannot heal in
tube-feedings or clients with
hyperalimentation to severe
achieve positive malnutrition.
nitrogen balance.

 Remove devitalized  To promote faster

tissue from the healing & reduce
wound bed, except infection
in the avascular
tissue or on the
heels. Began by
cleansing the ulcer
bed with normal
saline, then use
appropriate
technique for
debridement. Once
the ulcer is free of
devitalized tissue,
apply dressing the
keep the wound bed
moist & the
surrounding skin
dry. Do not use
occlusive dressings
on ulcer.