Primary Nursing Diagnosis

Impaired skin integrity related to pressure over bony prominences or shearing forces

OUTCOMES. Tissue integrity: Skin and mucous membranes; Wound healing: Primary intention; Immobility consequences: Physiological; Knowledge: Treatment regime; Nutritional status; Tissue perfusion: Peripheral; Treatment behavior: Illness or injury

INTERVENTIONS. Wound care; Skin surveillance; Positioning; Pressure management; Pressure ulcer prevention; Medication administration: Topical; Circulatory precautions; Infection control; Nutrition management

U PLANNING AND IMPLEMENTATION Collaborative

In the early stages, pressure ulcers are best handled by nursing rather than medical interventions. Surgical intervention may be necessary to excise necrotic tissue in late stages of ulcer development. Skin grafts or musculocutaneous flaps may be indicated in very deep wounds in which healing is difficult or has been unsuccessful in completely covering the area. Drains may be inserted to prevent fluid buildup in the wound. The drains facilitate the removal of blood and bacteria from the wound that can increase the risk of infection.

Mechanical débridement by an enzymatic agent (collagenase [Santyl]) may be ordered. Other types of wound care dressings include hydrocolloid, hydrogels, calcium alginates, film dressings, and topical agents and solutions. The type of dressing depends on the depth of the wound and the amount of débridement of necrotic tissue or support of granulation tissue required. In general, the following guidelines might be helpful in ulcer management, although management may depend on the particular ulcer and patient:

Stage I ulcers require no type of dressings.

Stage II pressure ulcers are treated with moist or occlusive dressings to maintain a moist, healing environment.

Stage III ulcers require débridement, usually with an enzymatic agent or wet-to-moist normal saline soak.

Stage IV ulcers are treated like stage III ulcers or by surgical excision and grafting.

All wounds are assessed before treatment because all wounds are different, and similar treatments may not be successful for dissimilar wounds. Other therapies include supplementing the patient's nutrition, hyperbaric oxygen therapy for wounds that are deep and difficult to treat, and electrotherapy to deliver low-intensity direct current to wounds in attempts to assist the healing process.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Hydrocolloids

No dosage; prepack

Occlusive, adhesive

Provides a moist and protective

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