Pressure Ulcers – are lesions caused by the primary barrier of the body against the outside environment – the skin. It is common in bony prominences in the body wherein friction usually occurs. The reduction of blood flow in the area leads to skin breakdown. Pressure ulcers can occur in patients with long-term stay on a wheelchair or stay in a bed. Most of the patients are elderly who have apparently the difficulty to change position, that is why assistance is needed in order to prevent further skin damage. Urinary and bowel incontinence can also precipitate pressure ulcers since fecal material and urine can corrode the skin. A reddened skin and sometimes with blisters can signal that the patient is developing pressure ulcers. The sites of pressure ulcers can be in the following areas: elbow, back of the head, shoulders, hips and heels.
There is a classification of pressure ulcers that is followed so that universally, caregivers can know what to give in order to prevent worsening conditions.
- Stage 1 – Reddened skin
- Stage 2 – Blisters are present
- Stage 3 – Crater can be observed, the skin eventually opens losing its ability to heal
- Stage 4 – The damage now reaches the bones and tendons
Nursing Diagnosis: Impaired Skin Integrity
1. To assess the contributing factors leading to lack of tissue perfusion.
2. To assess the extent of injury.
3. To promote compliance to medication and preventing future injury.