NUSING DIAGNOSIS Subjective cues: Impaired skin mayda niya bed integrity related to reduced sore ha bobot as verbalized

d by activity/immobilit y the S.O. Objective cues: Bed sores (buttocks area) noted Poor skin turgor noted A 76 yr old patient Limited ROM noted

CUES

SCIENTIFIC OBJECTIVES RATIONALE Pressure ulcers are After 8 hours of nursing defined as any lesion intervention the client caused by will: unrelieved pressure that results in Demonstrate damage to behaviors/techniqu underlying tissue. es to prevent skin Prolonged pressure breakdown/injury occurs when tissue is such as: between a bony prominence and a Changing hard surface such as position at least mattress. The every 2 hours to pressure compresses relieve pressure small blood vessels Using items that and leads to can help reduce ineffective tissue pressure perfusion. Loss of pillows, perfusion causes sheepskin, foam tissue hypoxia and padding, and eventually cellular powders from death. In addition to medical supply prolonged pressure stores. friction and shearing Keeping the skin force contribute to clean and dry the development of pressure ulcers. This forces are present when a patient slide down in bed and is pulled up against the surface of the mattress. Reference:

NURSING INTERVENTIONS INDEPENDENT 1. Establish rapport 1.

RATIONALE

EVALUATION After 8 hours of nursing intervention the client had: Demonstrate behaviors/techniques to prevent skin breakdown/injury such as: Changing position at least every 2 hours to relieve pressure Using items that can help reduce pressure pillows, sheepskin, foam padding, and powders from medical supply stores. Keeping the skin clean and dry /

To gain trust and confidence to the client

2. Assess specific risk factors for pressure ulcers

2. Even patients who already have a pressure ulcer continue to be at risk for futher injury Skin of older patients is less elastic, has less pudding, and has less moisture making for higher risk of skin impairment This areas are at risk of breakdown due to tissue ischemia from compression against a hard surface.

Determine patients age, and general condition of the skin.

Specifically assess skin over bony prominences (sacrum, trochanters, scapulae, elbows, heels, inner and outer malleulus, inner and out knees, back of the head)

Normally individuals shift

Nursing Care Plane 6th ed by Gulanick and Mayers, page 1104

Assess the patients awareness in the sensation of the pressure.

their weight off pressure areas every few minutes; this occurs more or less automatically, even during sleep. Patients with decreased sensation or unaware of stimuli (pressure) and do not shift weight thereby exposing skin to excessive pressure. Immobility is the major risk factor in skin breakdown.

Assess the patients ability to move (turn over in bed, move from bed to chair)

Assess for fecal and/or urinary incontinence

Diapers and incontinence pads with plastic liners trap moisture and hasten breakdown

Assess the surface that the patient spends a majority of time on. ( mattress for bedridden patient, caution for persons in wheelchair)

Patient who spend the majority of time on one surface need a pressure reduction or pressure relief device to lessen the risk for breakdown. Staging is important because it determines the treatment plan The ulcer dimension include length width and depth and ulcer begins in the deepest before the skin breaks down. Therefore the opening of the skin surface may not represent the true size of the ulcer.

3. Assess on stage of pressure ulcers.

4. Measure the size of the ulcer and note the presence of undermining.

5. Describe the condition of the wound or wound bed: Color Color of tissue is an indication of tissue viability and oxygenation. White, gray or yellow, eschar may be present in stage 2 and 3 ulcers. Eschar may be black in stage 4 ulcers Odor may arise in infection present on the wound. It may also arise in necrotic tissue. Some local wound care products may create or

Odor

intensify odors and must be distinguished from wound or exudate odors Presence of necrotic tissue Necrotic tissue is tissue that is dead and eventually must be removed before healing can take place. Necrotic tissue exhibits a widerange appearances: thin, white, shiny, brown, tough, leathery, black, hard. Surrounding tissue may be healthy or may have various degrees of impairment. Healthy tissue is necessary for use of local wound care products requiring

6. Assess the condition of surrounding tissue.

adhesion to the skin. Presence of healthy tissue demarcates the boundaries of pressure ulcer. In stage 4 pressure ulcers, these may be apparent at the base of the ulcer. Wounds may demonstrate multiple stages or characteristics in a single wound.

Visibility of the bone muscle or joints..

7. Health Education: Change position at least every 2 hours to relieve pressure Use items that can help reduce pressure pillows, sheepskin, foam padding, and powders from

7. prevent further ulceration.

medical supply stores. Keep the skin clean and dry

COLLABORATIVE 1. Provide foam/ flotation mattres. 2. Provide local wound care as follows: STAGE 1 Apply a flexible hydrocolloid dressing or a vapor permeable membrane dressing. Apply vitaminenriched emollient to skin every shift. Apply topical vasodilator STAGE II Hydrogels Hydrocolloids or vapor permeable membrane dressing

Alginates Gauze with sodium chloride solution STAGE III & IV Consult a plastic surgeon to perform sharp debridement Gauze with sodium chloride solution