Pressure Ulcers

Localized injury to the skin and/or underlying tissue (usually over a bony prominence) as a result of pressure or pressure in combination with shear
Located at tailbone, heels, hips, shoulder blades, ankles, elbows, ears, and the back of your head.

Risk factors for pressure ulcers

Advanced age	Immobility
Anemia	Impaired circulation
Contractures	Incontinence
Diabetes mellitus	Low diastolic blood pressure (<60 mm Hg)
Elevated body temperature	Mental deterioration
Friction (rubbing of surfaces together)	Neurologic disorders
Obesity	Prolonged surgery
Pain	Vascular disease

Nursing Assessment

Conduct a thorough head-to-toe assessment on admission to identify and document any pressure ulcers.
After admission, conduct periodic reassessment of the skin and wounds.
- Assessment tool such as the Braden Scale

Nursing Diagnosis

Impaired skin integrity related to mechanical factors and physical immobilization
Impaired tissue integrity related to impaired circulation and imbalanced nutritional state

Planning

Have no deterioration of the ulcer
Reduce or eliminate the factors that lead to pressure ulcers
No developing infection in the pressure ulcer
Have healing of pressure ulcers
Have no recurrence

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