Wound Care in Nursing: Diagnosis for Pressure Ulcers and Prevention

Nursing diagnosis for pressure ulcers

Pressure ulcers are an unfortunate and potentially serious complication faced by patients often already experiencing conditions of poor health or limited mobility. Pressure ulcers can cause significant pain and discomfort, impact a patient’s quality of life, and worsen the financial burden of care through additional treatment. 

Further complicating the situation is the added frustration that pressure injuries are preventable. Appropriate screening for patients who would be considered at risk for developing a pressure ulcer and early intervention can significantly reduce the prevalence of pressure ulcers.

Establishing a nursing diagnosis for pressure ulcers requires nursing professionals to be familiar with what puts a patient at risk for developing a pressure ulcer, how to properly assess for and stage pressure injuries, and what interventions are appropriate.

Pressure Ulcers: A Brief Overview

Pressure ulcers are also sometimes referred to by other names. These names may include pressure injury, decubitus ulcers, and bed sores. Whichever you may be used to hearing, they all amount to the same physiologic process.

Our skin is a living organ made of many layers that need to be fed a steady supply of oxygen and nutrients to remain healthy. Our skin’s cells receive this oxygen and nutrients by blood flowing through tiny vessels and capillaries. When that blood flow is interrupted, the skin is deprived of what it needs and is at risk of breaking down if not corrected.

In the situation of a pressure ulcer, there is increased pressure on those tiny vessels and capillaries feeding the skin. The vessels get pressed between something hard like a bone and something outside of our body, slowing or stopping the blood flow. This is why there is a high incidence of pressure ulcers around bony prominences.

If the pressure interrupting the supply of blood to the cells of our skin is allowed to remain in place for too long, as occurs with decreased mobility, the skin starts to change. Early pressure ulcers may start with redness on the skin. As the injury progresses, the redness may darken and the skin may start to break down where an open wound is noticed. Without relieving the pressure, the wound will continue to worsen affecting deeper layers of the skin.

When it comes to pressure ulcers, the best intervention is prevention. Limiting any risk of unnecessary pressure on the skin in high-risk areas is key. This can be done with evidence-based practices in offloading the skin like turning and positioning or using resources to lift parts of the body off bed surfaces.

If an ulcer does develop, there are ways to manage that, as well. Specialized dressings and topical treatments to promote healing and limit infection can be decided on in collaboration with medical providers. 

Understanding why pressure ulcers develop, and meaningful ways to prevent them in those at risk, can further support the development of a working nursing diagnosis for pressure ulcers.

What Do Nurses Need to Know About Pressure Ulcers?

Pressure ulcers are a serious problem in the United States as the estimated cost of hospital-acquired pressure injuries is more than 26 billion dollars annually. All medical professionals need to appreciate the significance of these injuries.

That dollar amount combined with the fact that such injuries are, for the most part, preventable tells us that there is a significant opportunity for increased knowledge aboutrisk assessment, prevention, wound staging, and proper wound management to lessen the impact of pressure ulcers.

Education is key. A course like Wound Care: Pressure Ulcers 101, designed by an advanced practice wound care specialist at Premiere Education, covers everything from recognizing who is at risk, to prevention strategies and wound staging, to management.   

Nursing Diagnosis for Pressure Ulcers

Nurses are in a prime position to make a measurable difference in the prevalence of pressure injuries. This is one reason why skin assessments have been integrated into admission assessments. Assessing your patient’s skin immediately upon their arrival to the inpatient unit will allow you to clarify their current skin integrity and identify any pressure injuries present on arrival.

Identifying pressure ulcers that are present on arrival is important information that can prevent that pressure ulcer from being attributed to the care provided while under the care of you and your colleagues.

In addition to skin assessments, there are other key components to pressure ulcer prevention and management. Routine lab work will give a basic overview of the patient’s general state of health. Nutrition plays a significant role in developing and healing pressure ulcers, so an assessment of a patient’s current nutritional status is important.

Braden Scale

Supplementing the elements of your nursing assessment would be using validated assessment scales like the Braden Scale

The Braden scale allows for a scoring system to be applied across 6 domains. They include information pertaining to sensory, moisture on the skin, mobility, activity, nutrition, and external forces on the skin. 

The total possible score for the Braden scale is 23, and like many other scoring systems we are used to, higher is better. Scoring 18 or less means that the patient is at greater risk.  

Staging of Pressure Ulcers

The staging of pressure ulcers is often something that provokes a little anxiety in nurses. Whether they’re unfamiliar with the different stages, or they’re afraid of making a mistake it is sometimes a challenge.

Generally speaking a pressure ulcer is staged according to how deep it is. It doesn’t matter how long or how wide it is—what matters is how many layers of the skin have been affected.

The staging of pressure ulcers is also a continuous and fluid process. What an ulcer is staged as today might not be what it is tomorrow. Repeated staging allows for meaningful feedback that can tell us how well preventative interventions and wound management is doing at supporting the healing process. 

Like our skin, the topic of pressure ulcers has many layers. The management should begin before the injury has even started by appreciating good preventative interventions. Should an ulcer develop, knowledge about skin assessments, staging, physiology, and wound management is essential to mitigating this unfortunate yet prevalent problem faced by our healthcare system.  

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