Apressure ulcer is an irregularly shaped, depressed area that resulted from necrosis of the epidermis and/or dermis layers of the skin. Prolonged pressure causes inadequate circulation, ischemic ulceration, and tissue breakdown. Muscle tissue seems particularly susceptible to ischemia. Pressure ulcers may occur in any area of the body but occur mostly over bony prominences that can include the occiput, thoracic and lumbar vertebrae, scapula, coccyx, sacrum, greater trochanter, ischial tuberosity, lateral knee, medial and lateral malleolus, metatarsals, and calcaneus. Some 96% of pressure ulcers develop in the lower part of the body, with the hip and buttock region accounting for almost 70% of all pressure sores.
Pressure ulcers are the direct cause of death in 7% to 8% of all patients with paraplegia, and of those developing pressure ulcers in the hospital, more than half will die within a year. Pressure ulcers have been staged by the National Ulcer Advisory Panel, but the stages serve as a description only and do not necessarily provide an order for progression.
When external pressure exceeds normal capillary pressure of 25 mm Hg, blood flow in the capillary beds is decreased. When the external pressure surpasses arteriole pressure, blood flow to the area is impaired. Ischemia occurs when the pressure exceeds 50 mm Hg and blood flow is
completely blocked. Pressure from the bony prominence is transmitted from the surface of the body to the underlying bone, and all underlying tissues are compressed.
Pressure ulcers caused by shearing or friction result when one tissue layer slides over another. Shearing results in stretching and angulating of blood vessels, causing injury and thrombosis to the area. These injuries commonly occur when the head of the bed is elevated, causing the torso to slide downward.
Nursing care plan assessment and physical examination
Generally, patients have a history of a condition that causes decreased circulation and sensation leading to inadequate tissue perfusion. Associated diseases and conditions include diabetes mellitus, arterial insufficiency, peripheral vascular disease, and decreased activity and mobility or spinal cord injury. Patients with casts, braces, and splints are also predisposed to developing pressure ulcers.
The clinical manifestations of pressure ulcers are generally described in four stages that reflect the amount of tissue injury and the degree of underlying structural damage. Assess the wound to determine the precise location, along with size and depth. The color of the wound (whether pink, red, yellow, or black) indicates the stage of healing and the presence of epithelial tissue. A beefy red color signifies the presence of granulation tissue and denotes adequate healing. Black tissue indicates necrotic and devitalized tissue and signifies delayed healing. Observe for areas of sinus tracts and undermining, which indicate deeper involvement under intact wound margins. Determine the amount of drainage and the type, color, odor, consistency, and quantity. Assess the area around the wound for redness, edema, indurations, tenderness, and breakdown of healed tissues to identify signs and symptoms of infection.
The patient may exhibit signs of anxiety and depression because of the potential setback in an already long list of medical problems. The condition may slow the patient’s progress toward independence or necessitate a move from home to a nursing home for an elderly patient.
Nursing care plan primary nursing diagnosis: Impaired skin integrity related to pressure over bony prominences or shearing forces.
Nursing care plan intervention and treatment plan
In the early stages, pressure ulcers are best handled by nursing rather than medical interventions. Surgical intervention may be necessary to excise necrotic tissue in late stages of ulcer development. Skin grafts or musculocutaneous flaps may be indicated in very deep wounds in which healing is difficult or has been unsuccessful in completely covering the area. Drains may be inserted to prevent fluid buildup in the wound. The drains facilitate the removal of blood and bacteria from the wound that can increase the risk of infection. Mechanical débridement by an enzymatic agent (collagenase [Santyl]) may be ordered. Other types of wound care dressings include hydrocolloid, hydrogels, calcium alginates, film dressings, and topical agents and solutions. The type of dressing depends on the depth of the wound and the amount of débridement of necrotic tissue or support of granulation tissue required. In general, the following guidelines might be helpful in ulcer management, although management may depend on the particular ulcer and patient:
Stage I ulcers require no type of dressings.
Stage II pressure ulcers are treated with moist or occlusive dressings to maintain a moist, healing environment.
Stage III ulcers require débridement, usually with an enzymatic agent or wet-to-moist normal saline soak.
Stage IV ulcers are treated like stage III ulcers or by surgical excision and grafting.
All wounds are assessed before treatment because all wounds are different, and similar treatments may not be successful for dissimilar wounds. Other therapies include supplementing the patient’s nutrition, hyperbaric oxygen therapy for wounds that are deep and difficult to treat, and electrotherapy to deliver low-intensity direct current to wounds in attempts to assist the healing process.
The most important nursing intervention is prevention. Identify patients who are at risk by using assessment tools such as the Braden scale or the Norton scale, which determine the sensory and physiological factors that increase the incidence of pressure ulcers. The high-risk patient needs turning and proper positioning at least every 2 hours. Pressure-relieving devices, such as silicone- filled pads and foam mattresses, may be helpful. Dynamic devices include specialty beds (low-air-loss, air-fluidized, and air cushions). Airflow pressure mattresses are also useful preventive strategies.
Keep the patient’s skin dry. Patients who are incontinent of feces and urine should be cleaned as soon as possible to prevent skin irritation. When soiling of the skin cannot be controlled, use absorbent underpads and topical agents that act as moisture barriers. Avoid the use of hot water, and use a mild cleansing agent to minimize dryness and irritation in high-risk patients. Treat dry skin with moisturizers, but use care in massaging bony prominences as this may impede capillary blood flow and increase the risk of deep tissue injury. Lift high-risk patients up in bed instead of pulling them, which increases the risk of shearing and friction forces on the skin’s surfaces. To prevent the patient from sliding down in bed, do not elevate the patient’s head more than 20 degrees unless this angle is contraindicated because of other medical problems or treatment modalities. Keep linens dry and wrinkle-free. When skin breakdown occurs, apply appropriate dressings using clean technique or, in cases which infection is present, sterile technique.
Teach the caregiver preventive strategies, and determine if the patient’s situation is in jeopardy because of inadequate care. Note that the caregiver may have feelings of guilt because of the failure to prevent complications of immobility; the caregiver may need support rather than teaching, depending on the situation.
Nursing care plan discharge and home health care guidelines
Refer patients at increased risk for skin breakdown to a home healthcare agency to assist with monitoring skin and providing pressure-relieving devices in the home environment. Teach the patient or caregiver about frequent turning and positioning, how to keep the skin clean and dry, signs and symptoms of early breakdown and complications of existing ulcers, strategies to manage redness or skin breakdown, appropriate wound care and dressing techniques. Use a return demonstration before discharge to assess the understanding and ability to perform wound care.