Pressure Ulcers : Nursing Implementation

Pressure Ulcers : Nursing Implementation 150 150 Tony Guo

Nursing Implementation

  • Health promotion
    • Prevention is the best treatment for pressure ulcers
      • Identification of patients at risk for developing pressure ulcers
      • Implementation of pressure ulcer prevention strategies for those who are at risk.
      • Teach the patient about the etiology of pressure ulcers, prevention techniques, early signs, nutritional support, and care techniques for actual pressure ulcers.
    • Remove excessive moisture
    • Avoid massage over bony prominences
    • Use lift sheets
    • Skin care
      • Position with pillows or elbow and heel protectors
      • Use specialty beds
      • Cleanse skin if incontinence occurs
        • Use pads or briefs that are absorbent
    • Ulcer care
      • Document and describe stage, size, location, exudate, infection, pain, and tissue appearance
        • Measure length and width
        • Measure depth
      • Relieve pressure
      • Debride
      • Cleanse with nontoxic solutions
      • Caloric intake elevated to 30 to 35 cal/kg/day or
        1.25 to 1.50 g protein/kg/day

        • Supplements, enteral, or parenteral feedings may be necessary
  • Acute care
    • Care of a patient with a pressure ulcer requires local care of the wound and support measures of the whole person, like:-
      • Adequate nutrition
      • Pain management
      • Control of other medical conditions
      • Pressure relief
    • Initiate interventions based on the ulcer characteristics (e.g., stage, size, location, amount of exudate, type of wound, presence of infection or pain) and the patient’s general status (e.g., nutritional state, age, cardiovascular status, level of mobility).
    • Carefully document the size of the pressure ulcer
      • Wound-measuring card or tape (length and width)
      • Sterile cotton-tipped applicator (depth)

Evaluation

  • Healing of pressure ulcer
  • Intact skin with no further breakdown

Leave a Reply

Your email address will not be published.