Nursing Care Plan for Decubitus Ulcer / Pressure Sores
Assessment and Nursing Diagnosis for Decubitus Ulcer / Pressure Sores
Definition
Decubitus is local tissue necrosis that tends to occur when the stress on the soft tissue between the bony external surface for a prolonged period (National Pressure Ulcer Advisory Panel [NPUAP], 1989a, 1989b).
A new definition has been filed in the National Conference NPUAP 4th (1995a). Margolis (1995) mentions " the best definition of decubitus is damage to anatomical structure and function of normal skin as a result of external pressures associated with herniated discs and not cured by the order and the usual time. Furthermore, this disorder occurs in individuals who are in a chair or on a bed, often on incontinence and malnutrition or individuals who have difficulty eating alone, and impaired level of consciousness."
Body parts are often experienced decubitus ulcers is the part where there is a protrusion of bone, namely the elbows, heels, hips, ankles, shoulders, back and back of the head.
Although all parts of the body at risk for pressure sores, the lower part of the body are especially at high risk and need special attention.
Common areas of decubitus is a bony ridge above and not covered by sub-cutaneous fat enough, for example; the sacrum, the greater trochanter and the anterior superior spine ischiadica, heel and elbow area.
Decubitus is a serious matter, with morbidity and mortality in elderly clients.
Pressure sores can occur at any stage of life , but this is a particular problem in the elderly. Particularly in clients with immobility. Old age has a great potential for pressure sores occur because the skin changes associated with aging include:
Etiology
1. Extrinsic factors
The other factors are :
Clinical Manifestations and Complications
Assessment for Decubitus Ulcer / Pressure Sores
1. Activity / rest
Signs : decreased strength, endurance, range of motion limitations on the area of pain , eg disturbances ; muscle buds change.
2. Circulation
Signs : hypoxia, decreased peripheral pulse distal extremity injuries, general peripheral vasoconstriction with loss of pulse, white and cold, tissue edema formation.
3. Elimination
Signs : decreased urine output is the absence of the emergency phase, color ; maybe reddish black, in the event, identify muscle damage.
4. Food / fluid
Signs : general tissue edema, anorexia, nausea and vomiting.
5. Neuro sensory
Symptoms : area numb / tingling.
6. Breathing
Symptoms : decreased function of the spinal cord, cord edema, neurological damage, paralysis of abdominal and respiratory muscles.
7. Ego integrity
Symptoms : family problems, work, finances, disability.
Signs : anxiety, crying, dependence, withdrawal, anger.
8. Security
Signs : a fracture due to the location (falls, accidents, tetanic muscle contraction, up to an electric shock).
Nursing Diagnosis for Decubitus Ulcer / Pressure Sores
Definition
Decubitus is local tissue necrosis that tends to occur when the stress on the soft tissue between the bony external surface for a prolonged period (National Pressure Ulcer Advisory Panel [NPUAP], 1989a, 1989b).
A new definition has been filed in the National Conference NPUAP 4th (1995a). Margolis (1995) mentions " the best definition of decubitus is damage to anatomical structure and function of normal skin as a result of external pressures associated with herniated discs and not cured by the order and the usual time. Furthermore, this disorder occurs in individuals who are in a chair or on a bed, often on incontinence and malnutrition or individuals who have difficulty eating alone, and impaired level of consciousness."
Body parts are often experienced decubitus ulcers is the part where there is a protrusion of bone, namely the elbows, heels, hips, ankles, shoulders, back and back of the head.
Although all parts of the body at risk for pressure sores, the lower part of the body are especially at high risk and need special attention.
Common areas of decubitus is a bony ridge above and not covered by sub-cutaneous fat enough, for example; the sacrum, the greater trochanter and the anterior superior spine ischiadica, heel and elbow area.
Decubitus is a serious matter, with morbidity and mortality in elderly clients.
Pressure sores can occur at any stage of life , but this is a particular problem in the elderly. Particularly in clients with immobility. Old age has a great potential for pressure sores occur because the skin changes associated with aging include:
- Reduction of subcutaneous fat tissue.
- Reduced collagen and elastin tissue.
- Decreased efficiency of collateral capillaries on the skin so that the skin becomes thinner and fragile.
Etiology
1. Extrinsic factors
- pressure
- humidity
- friction
- age
- temperature
- nutrition
The other factors are :
- Decreased sensory perception.
- Immobilization, and
- Activity limitation.
Clinical Manifestations and Complications
- The initial injury is a sign of redness that does not disappear when pressed thumb.
- In more severe injuries encountered skin ulcers.
- Can arise pain and signs of systemic inflammation, including fever and increased white blood cell count.
- Infection can occur as a result of weakness and hospitalization is prolonged even in small ulcers.
Assessment for Decubitus Ulcer / Pressure Sores
1. Activity / rest
Signs : decreased strength, endurance, range of motion limitations on the area of pain , eg disturbances ; muscle buds change.
2. Circulation
Signs : hypoxia, decreased peripheral pulse distal extremity injuries, general peripheral vasoconstriction with loss of pulse, white and cold, tissue edema formation.
3. Elimination
Signs : decreased urine output is the absence of the emergency phase, color ; maybe reddish black, in the event, identify muscle damage.
4. Food / fluid
Signs : general tissue edema, anorexia, nausea and vomiting.
5. Neuro sensory
Symptoms : area numb / tingling.
6. Breathing
Symptoms : decreased function of the spinal cord, cord edema, neurological damage, paralysis of abdominal and respiratory muscles.
7. Ego integrity
Symptoms : family problems, work, finances, disability.
Signs : anxiety, crying, dependence, withdrawal, anger.
8. Security
Signs : a fracture due to the location (falls, accidents, tetanic muscle contraction, up to an electric shock).
Nursing Diagnosis for Decubitus Ulcer / Pressure Sores
- Impaired skin integrity
- Impaired physical mobility
- Imbalanced Nutrition : less than body requirements
- Risk for infection
- Pain ( acute / chronic )
