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
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
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

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

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

  1. Individualize care plan based on patient needs
    and preference
  2. Teach patient and family on strategies to
    manage the impaired skin
  3. To identify the type of cleaning agents used, water
    temperature, and skin cleansing frequency
  4. Holistic care will help predict and prevent pressure
    ulcers in the future.
  5. 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
 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)

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

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

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
  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
  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

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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)

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  1. Encourage patient for adequate rest to
    boost her immune system
  2. Teach patient and the care giver proper
    hygiene technique such as washing hands,
    keeping nails short, wearing clean clothes
  3. Physical and emotional stress lowers
    patients’ immune function
  4. 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
 Patient demonstrates the need to incorporate the taught health regimen into her
 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.

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  1. Assess patients family/care giver support
    and need for assistive daily living equipment
  2. 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
  3. Social support improves success patients ability
    to adopt the new lifestyle recommended
  4. This is especially important to protect the
    patients bony region (Singh, Dhayal, Sehgal &
    Rohilla, 2015)


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

 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

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).

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Date &

Nursing diagnostic

Nursing intervention and outcome Date

  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
  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,
  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

Care plan- Pressure Ulcer 11


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