pub Nursing Care Bed Sore Pressure Sores and Diagnosis ~ Nursing Care Plan

Nursing Care Bed Sore Pressure Sores and Diagnosis

An injuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks.

Stages of Bed Sore pressure sores
  • reddened or darkened skin that will not turn white when firmly pressed
  • partial skin loss that may appear as an abrasion, blister or shallow crater
  • full skin loss extending to underlying tissue
  • full skin loss extending beyond the underlying tissue to muscle and bone
Nursing Diagnosis for Bed Sore (Pressure Sores)Patient:
  • Impaired Wheelchair Mobility
  • Impaired Physical Mobility
  • All the Self-Care Deficits
  • Impaired Bed Mobility
  • Ineffective Protection
  • Risk for Trauma (if restraints are being used)
  • Chronic Pain
  • Risk for Impaired Skin Integrity
  • Risk for Infection
  • Impaired Comfort
Nursing Care For Bed sore (pressure sores)Patient.
  • Keep the patient's skin moisturized
  • Use of Water Filled Mattresses or Sheep Skin Pads
  • Clean the pressure sore by irrigating the wound with a saline solution (available from drug stores) or other cleaning solution recommended by a health care professional.
  • Remove all dead tissue and scabs. A health professional can recommend the best approach, depending on the severity of the pressure sore.
  • Pat the wound dry.
  • Bandage the wound with a dressing that keeps the pressure sore moist while keeping surrounding tissues dry.
  • Use pillows and padded protectors to support arms, legs and vulnerable areas.
  • Change the position of a bed-bound person every two hours. Handle and move carefully to avoid skin tears and scrapes.
  • Change the position of a chair-bound person hourly.
  • Use of foam wedges to prevent skin contact between legs or ankle bones
  • Clean skin with warm water and minimal friction. Apply lotion often.
  • Avoid direct pressure to bony areas such as ankles and hips.
  • Discourage the bed-bound or chair-bound person from sitting with the head elevated more than 30 degrees, except for short periods of time.
  • Check and change bed linens as often as necessary
  • Use continence management products if necessary to reduce exposure to moisture

Sources
http://www.mayoclinic.com
http://allnurses.com
http://www.howtocare.com

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