Question

Develop a nursing care plan for
patient with a stage 3 pressure
ulcer.

Answer 1

Ans) Nursing care plan for patient with a stage 3 pressure ulcer.

Impaired Skin Integrity: Altered epidermis and/or dermis related to Chronic disease state.

Desired Outcome:
- Patient will experience healing of current pressure wounds, prevention of further skin injury and maintain optimal skin integrity

Nursing care plan:
Subjective Data:
Tender areas of skin
Pain, burning of skin
Itching
Objective Data:
Changes in skin color or texture
Swelling
Drainage from wounds
Stage 1 – non-blanchable redness
Stage 2 – open skin, pink/red, blister
Stage 3 – Exposed subcutaneous tissue
Stage 4 – Exposed muscle/bone
Nursing Interventions and Rationales
1) Assess skin for signs of hydration pressure injury, and note areas of increased risk
- Get a baseline of skin status to compare changes; note areas that are at risk for developing pressure injury such as heels, sacrum or shoulder blades

2) Monitor for signs of infection:

Note odor and appearance of exudate
Fever
Warmth to touch
Obtain wound cultures as needed
Monitor white blood count (WBC)
Administer antibiotics as required
- Not all pressure ulcers are infected. Know and monitor for signs and symptoms of developing infection. Treat current infections appropriately to avoid systemic complications.

3) Reposition patient at least every 2 hours or more frequently as needed

- Use and reposition pillows under arms, between knees (if side-lying) and behind back to reduce pressure and friction
Place rolled sheet or towel under ankles (not heels) to reduce pressure of heels against bedding
Provide cushions and padding on assistive devices such as wheelchairs, walkers, crutches, etc.
4) Redistribute weight to remove pressure and prevent tissue injury. Provide for comfort.

Assess patient’s level of sensation

Patients with pre-existing conditions, such as diabetes, will be at greater risk of developing pressure ulcers, but may have decreased sensation. Assess sensation to know if patient will be able to feel pain or discomfort before a pressure injury occurs.

5) Assess for incontinence of bowel or bladder
Provide perineal care
Assistance with toileting
Apply barrier cream
- Incontinence increases risk of skin breakdown and risk of pressure injury. Protective devices such as diapers and incontinence pads/liners withhold moisture which can speed up breakdown.

6) Assess patient’s mobility and provide assistance as necessary
- Patients with limited mobility require extra assistance to relieve pressure points

Assess and manage pain
Positioning
Administer analgesics, opioids

7) Prophylactic pain management may be necessary

Provide appropriate wound care
Cleaning
Debridement
Dressings
Emollients
Skin barriers
Negative pressure wound therapy

8) Treat current wounds and prevent localized or systemic infection. Promote wound healing.

Promote nutrition and education
Consult dietitian
Offer high-protein, high-calorie diet
Encourage hydration
- Optimal nutrition helps aid in wound healing and strengthens tissues to prevent further injury; hydrated skin is at slightly less risk for injury than dry, dehydrated skin.