Learning Center Articles

Pressure Ulcers

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