Care plan: Pressure Ulcer

In care plan following is required relevant to Australia:
Nursing Problems:
Four nursing diagnostic statements need to be identified and listed in order of priority.
Expected Outcomes:
You will need to write one expected outcome for each nursing diagnostic statement
identified.
Nursing Interventions:
Four nursing interventions for each nursing diagnostic statement need to be identified.
Scientific Rationales:
A scientific rationale needs to be provided for each nursing intervention. Each rationale
will relate to,nsupport and provide validity for the intervention. Each rationale is to be
referenced.
Handover of Care:
You will need to provide a handover of care for each identified nursing diagnostic
statement usingnISOBAR.
Discharge Plan:
You will need to include a discharge plan for each identified nursing diagnostic
statement.

Care plan: Pressure Ulcer

a) Nursing diagnosis: Impaired Tissue integrity related to friction, shear, and compression
pressure, which causes mechanical destruction of tissue.
Expected outcome:
 Patient regains skin integrity on the skin surface
 Patient reports reduced pains sensation at the site of impaired skin tissue
 Patient understands care plan to prevent re-injury of the site
Nursing interventions Scientific rationales

1. Assess the site of the impaired skin to
   determine the specific aetiology
2. Determining the extent of skin impairment/
   classification of the pressure ulcers
3. Monitor skin impairment to check for
   swelling, redness, change of colour, pain
   intensity or any other indicators of infection
4. Understanding the aetiology is critical to identify
   the appropriate nursing intervention.
5. To identify if the skin impairment is Stage or Stage
   II, III or IV
6. This systematic inspections is important in early
   detection of impending associated health care
   complications

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4.Monitor Patient skin care practices to identify
the appropriate and inappropriate skin practices
(Lewis, 2014)

5. Individualize care plan based on patient needs
   and preference
6. Teach patient and family on strategies to
   manage the impaired skin
7. To identify the type of cleaning agents used, water
   temperature, and skin cleansing frequency
8. Holistic care will help predict and prevent pressure
   ulcers in the future.
9. This will help reduce future pressure ulcers

b) Nursing diagnosis: Impaired physical mobility related mobility restrictions associated
with the loss of motor control and deconditioned status
Expected outcome:
 Improve patient physical activity
 Patient to meet the mutual defined goals that improve patient mobility
 Patient verbalizes increased strength and movement ability
 Patient is taught how to use adaptive equipment to increase mobility
Nursing interventions Scientific rationales
NIC labels suggested
 Exercise therapy: Joint mobility and
ambulation
 Improved positioning

1. Screen patient mobility ability as follows:
   a) Bed mobility
   b) transition movements for example from sit
   to stand and sitting down again
   c) supported and unsupported movements
   e.g. walking and standing
   2.Monitor client to determine the exact cause
   for the impaired mobility to know if they are
   they physical or psychological factors (Jaul,

Patient advised to change their position
every 20 minutes, or if confined to bed; once
every two hours to release further pressure
and give the wound a good chance to heal.

The screening patient mobility skills is
important as it allows the nursing staff to
integrate movements exercises in the routine
customary care (Jaul, 2013)

2. Some patients refuses to move due to
   psychological issues such as depression or
   poor coping strategies

Care plan- Pressure Ulcer 3
2014)

3. Treat pain using therapeutic interventions.
   Apply interventions to improve patients
   coping strategies
4. Consult physical therapist for more
   evaluation on gait training, strength training
   as they are effective in the rehabilitation of
   the clients (Stafford & Brower, 2012)
5. Monitor patient’s client ability to tolerate
   activity using all four extremities
6. Teach client and carer givers to work
   together with the clients when performing
   daily activities
7. Pain causes limitation of movement as
   movement exacerbates pain. Hopelessness
   and despair may make patient not move
8. These techniques have been found to be
   effective in improving patient coordination
   and balance.
9. Any activity intolerance noted must be
   addressed
10. Using a series of activities can
    effectively modify patient attitudes towards
    mobility

c) Nursing diagnosis: Imbalanced nutrition more than what is required by the body related
to patient’s poor appetite.
Expected outcome:
 Patient indicates tolerance to dietary requirements
 Patient body weight and body mass retained within the normal range
 Patient reports adequate energy levels
 Patient describes the influence of nutrition in prevention of infection
Nursing interventions Scientific rationales

1. Teach and establish a plan meal with the
   patient which will ensure patient ears
   regularly
2. Patient family and relatives requested to
   support the patient by giving her food from
   home (Suttipong & Sindhu, 2011)
3. Maintain high carbohydrate, proteins and
   vegetables
4. Monitor patients laboratory values e.g.
5. To ensure the patient learns to balance the
   intake of food.
6. Patients may prefer to eat home food and
   may improve patient appetite thus
   improving their nutritional intake (Guihan et
   al., 2016)
7. Proteins, carbohydrates and vegetables are
   required during treatment
8. Determining the deficiencies, glucose

Care plan- Pressure Ulcer 4

albumin, blood glucose, Hb blood, haemoglobin associated with delayed
healing (Matsuo, Oie & Furukawa, 2013)

d) Nursing diagnosis: High risk for infection in the pressure ulcer wound related to
exposure to germs
Expected outcome:
 Patient is relieved from symptoms infection
 Patients white blood cell count remains within the normal range
 Patient demonstrates appropriate care for the area prone to infection
 Patient indicates meticulous body hygiene by the time the patient is discharged
including handwashing, cutting long nails, and daily baths

Nursing interventions Scientific rationales

1. Monitor and report indicators of infection
   including discharge from the infected site,
   redness and fever
2. Assess temperature for neutropenic
   patient after every 4 hours (Sobotka &
   Meguid, 2010)
3. Monitor laboratory values including
   serum protein, cultures, serum albumin and
   white blood cells (Singh, Dhayal, Sehgal &
   Rohilla, 2015).
4. Advice of fluid intake
5. Onset of infection of the pressure ulcer
   activates the immune system and signs of
   infection appear
6. Neutropenic patients may not present
   inflammatory response, thus fever is the first
   indicator of infection
7. Laboratory values provide useful insights
   of the patients’ immune function which is
   helpful when designing patient care plan.
8. High intake of fluid is important so as to
   replace fluid lost during fever (Schols, 2010)

Care plan- Pressure Ulcer 5

5. Encourage patient for adequate rest to
   boost her immune system
6. Teach patient and the care giver proper
   hygiene technique such as washing hands,
   keeping nails short, wearing clean clothes
7. Physical and emotional stress lowers
   patients’ immune function
8. Consistent and meticulous hygiene is
   important factor in reducing the frequency
   for nosocomial infections

e) Nursing diagnosis: In effective therapeutic regimen management related to inadequate
knowledge to disease aetiology and management practices.
Expected outcome:
 Patient explains the disease, understands treatment and recognizes the need for
medication
 Patient demonstrates the need to incorporate the taught health regimen into her
lifestyle
 Patient states the ability to cope with the current health situation and improve her
quality of life
Nursing interventions Scientific rationales

1. Monitor patient’s readiness and ability to
   learn (mental acuity, hearing or sight deficits,
   language barriers, cultural barriers etc.
2. Assess patients knowledge and skills
   related to pressure ulcers and influence their
   willingness to learn
3. Patients sensory, physical, and psychosocial
   changes may impair patients ability and readiness
   to learn
4. Assimilation of the new information into
   existing information will need some negotiation
   and stalling.

Care plan- Pressure Ulcer 6

3. Assess patients family/care giver support
   and need for assistive daily living equipment
4. The patient is educated to reposition
   herself, that help people to reposition, and
   use of specialised mattress such as foam
   mattress pad, air-filled mattress and special
   cushions
5. Social support improves success patients ability
   to adopt the new lifestyle recommended
6. This is especially important to protect the
   patients bony region (Singh, Dhayal, Sehgal &
   Rohilla, 2015)

HANDOVER OF CARE

Identity: Jane Candy, UR 124512, under medical ward 9A, bed 24

Situation: Mrs Sophie is admitted at ward 9A. She is 45 y/o and diagnosed with Grade 2
pressure ulcer on her sacrum. She was admitted this morning to manage the pressure ulcer
and weight. Her BMI is 43.7 kg.m 2 .

Background: Mrs Sophie is single and works as a part –time IT, but she is currently on sick
leave. Her appearance is unkempt as she is wearing stained clothes. She has offensive odour,
halitosis and her foot wear is inappropriate. She has impaired mobility and requires assistive
devices for mobility (using a wheelchair). Her current medication includes Paracetamol 1g
orally administered, and Avapro 300mg daily. The reason for seeking medical attention is to
manage an ulcer on her sacrum. The patient says that she has gained weight lately, which
makes it difficult to move as it exacerbates the ulcer pain. Thus, she prefers to spend the
whole day resting as it is comfortable. She has a poor feeding habit as she says that she feeds
on lots of canned food and lots of soft drinks.

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Assessment: The patient seeks medication attention to manage an ulcer on her sacrum. The
pressure ulcer is Grade 2 and has partial loss of skin on the sacrum. The patient is
overweight with BMI of 43.7 kg.m 2 ,which indicates that she is obese.

Recommendation: To manage pressure ulcer the patient should be given the following
medication:

 Ibuprofen 800mg daily to manage pain especially before debridement and dressing
procedures as needed

 Diazepam 10 mg three times a day to be for muscle relaxants to prevent muscle spam
as needed

 Metronidazole tablets 400mg after 8 hours to manage bacterial infection for seven
days

Cleaning of the wounded site should be done to reduce the rates of infection. Cleaning
should be done using saline solution every time dressing is changed. Dressings must be
applied in order to keep the wound moist and prevent infection. Dressing choice
recommended are those made with gels because they are moisture retentive. The pressure
ulcer debridement should be done using autolytic debridement. The patient is scheduled to
meet a dietician to promote healthy diet. The patient is advised to increase in fluid intake,
foods rich in vitamins and minerals. The patient should also be given dietary supplements
Vitamin C and Zinc. The care plan should be followed in order to improve patient coping
strategies (Skipper, 2010).

Additionally, the patient knowledge skills related to the disease should be assessed. This
is because the previous knowledge, cultural barriers, language barriers and myths influence

Care plan- Pressure Ulcer 8
patient lifestyle and their willingness to adopt a new lifestyle. The patient, family or care
giver should be educated on preventive measures such as frequent repositioning, use of foam
mattress pad, air-filled mattress and special cushions. This will ensure that the patient
healing is holistic (Singh, Dhayal, Sehgal & Rohilla, 2015).

Care plan- Pressure Ulcer 9
DISCHARGE PLAN

Date &
sign

Nursing diagnostic
statement

Target
date
Nursing intervention and outcome Date
achieved

1. Impaired Tissue integrity
   related to friction, shear and
   compression pressure which
   causes mechanical
   destruction of tissue.
2. Impaired physical mobility
   related mobility restrictions
   associated with the loss of
   motor control and
   deconditioned status
3. Imbalanced nutrition more
   than what is required by the
   body related to patient’s poor
   appetite.
4. High risk for infection in
   the pressure ulcer wound
   related to exposure to germs
5. In effective therapeutic
   regimen management related
   to inadequate knowledge to
   disease aetiology and
   management practices.
6. Skin Care: Patient/ care giver should clean
   the skin as soon as it gets soiled. The patient
   should use absorbent pads and skin moisturizer
   to control skin moisture. Patient should avoid
   massaging bony points (Doley, 2010).
7. Mobility: Consult physical therapist for more
   evaluation on gait training, strength training as
   they are effective in the rehabilitation of the
   clients (Biesalski, 2010).
8. Nutrition: Appropriate nutrition is important
   for healing. Patient should eat balanced diet as
   directed by the dietician. Patient should take
   vitamin and mineral supplements as directed by
   the doctor. Patient should take 8 glasses of water
   each day, and avoid caffeinated drinks, sugary
   drinks and alcohol (Cai, Rahman & Intrator,
   2013)
9. Dressing changes: Patient/care giver to start
   by washing their hands with antibacterial soap.
   Clean the ulcer using saline water and a clean
   cloth once a day and use a new gel to dress.
   Keep off pressure on the ulcer by using special
   mattresses and chair cushion. Change sitting or
   sleeping position every 15 minutes and two
   hours respectively.
10. Warning signs: Patient should report to the
    clinic immediately if there is increased redness,
    soreness, chills, fever or odorous discharges
    (Demarre et al., 2014)

_________________________Patient/Significant other signature

Care plan- Pressure Ulcer 10
 ______________
RN signature

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References

Biesalski, H. (2010). Micronutrients, wound healing, and prevention of pressure ulcers.