Pressure Ulcer Nursing Care Plan
Use this guide to create pressure ulcer and injury nursing care plans to deliver superior care and prevention.
Fact Checked by Nate Lacson.
What is a Pressure Ulcer Nursing Care Plan template?
Pressure injuries, also referred to as bedsores or pressure ulcers, represent a prevalent issue within the healthcare sector. They occur due to prolonged pressure on a specific skin area without relief. The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury as localized skin and underlying tissue damage, typically occurring over a bony prominence or associated with medical or other devices (Kirman & Geibel, 2022). These injuries can affect individuals who are bedridden, use wheelchairs, or have limited mobility. Pressure ulcers can cause intolerable levels of pain and discomfort for the patient and may lead to infection, sepsis, and potentially fatal outcomes.
A pressure injury manifests as localized skin damage where tissues experience compression between bony areas and firm surfaces like a mattress. These injuries result from pressure and friction, shearing forces, and moisture. The applied pressure constricts small blood vessels, leading to compromised tissue circulation, and this decrease in blood flow induces tissue hypoxia, eventually causing cell death.
While terms like decubitus ulcer, pressure sore, and pressure ulcer have traditionally been used interchangeably, the NPIAP has recommended "pressure injury" as the preferred term since open ulceration doesn't always occur. These injuries can appear as unbroken skin or an open sore, causing discomfort (Kirman & Geibel, 2022). A pressure injury is often defined within healthcare settings in the following system:
- Stage 1 pressure injury: Nonblanchable erythema of intact skin
- Discoloration of the skin that doesn't turn white when pressed
- Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis
- Stage 3 pressure injury: Full-thickness skin loss
- Stage 4 pressure injury: Full-thickness skin and tissue loss
- Unstageable pressure injury: Obscured full-thickness skin and tissue loss
- Deep pressure injury: Persistent non-blanchable deep red, maroon, or purple discoloration
The weight of an individual against a surface applies pressure to the skin, soft tissue, muscles, and bones, often surpassing the capillary filling pressure of 32 mm Hg. Pressure injuries are prevalent among patients in both acute and chronic care settings. Estimates suggest that around one million pressure injuries occur in the United States. Older adults admitted to acute care hospitals for non-elective orthopedic procedures face an elevated risk of these injuries compared to other hospitalized patients. Annually, approximately 60,000 individuals die from complications arising from pressure injuries (Kirman & Geibel, 2022).
Downloadable Pressure Ulcer Nursing Care Plan PDF
Check out our free Pressure Ulcer Nursing Care Plan PDF here
How does it work?
Step 1: Gather your resources
Pressure ulcer nursing care plans are a valuable resource and essential to keep on hand. Make sure that you have a copy of the free printable PDF when the need arises by either clicking the “Download Template” or “Use Template” button or by searching “ Pressure Ulcer Nursing Care Plan” on Carepatron’s template library’s search bar on the website or app.
Step 2: Collate essential information
Prevention is key for pressure wounds, yet this care plan focuses on intervention and treatment for patients already suffering from pressure damage. Once the stage of the pressure injury is identified, collate all relevant patient information, including wheelchair use, need for long periods of time in bed, rotation, or pressure relief plan from a care facility if relevant. All of this information and notes on interventions can then be stored in Carepatron’s centralized workspace. The care plan allows for individualized treatment options and acts as a scaffolding to ensure goals of care are met, and the next steps are recorded for future reference or distribution to other healthcare specialists who are part of the patient's care team.
Step 3: Store the chart securely
After reviewing the Pressure Ulcer Nursing Care Plan and creating a viable and individualized plan for the patient, you need to secure the plan so that access is only granted to relevant parties.
Ensure this through Carepatrons HIPAA-compliant free patient records software. All relevant medical records can be safely stored and collated for ease and security.
Pressure Ulcer Nursing Care Plan example (sample)
Eager to utilize this essential care planning tool? Acquire a free, downloadable, and printable pressure ulcer nursing care plan template PDF that comes pre-filled with fictional data.
Our crafted sample template is designed to aid you in efficiently utilizing the chart and evaluating the goals of care for patients with pressure ulcers. It includes dedicated sections for clinical notes and outlines the key components of an efficient pressure ulcer nursing care plan.
Secure your copy by either previewing the sample below or clicking the "Download Example PDF" button.
Download your free Pressure Ulcer Nursing Care Plan example PDF
When would you use this template?
A pressure ulcer nursing care plan is typically employed when a patient has or is at risk of developing pressure ulcers. These care plans are crucial in various scenarios:
Existing pressure ulcers
When a patient already has pressure ulcers, a care plan is devised to manage and treat the existing wounds. It includes strategies for wound care, infection prevention, pain management, and promoting healing.
Prevention
For individuals at risk of developing pressure ulcers due to immobility, limited sensation, or other factors, a preventive care plan is essential. This plan focuses on reducing pressure, such as repositioning schedules, using specialized cushions or support surfaces, maintaining skin integrity, and ensuring proper nutrition and hydration.
Hosptalized patients
In healthcare facilities, especially hospitals and long-term care settings, care plans are used to monitor and prevent pressure ulcers in patients with limited mobility or extended bed rest. Nurses and healthcare professionals follow these plans to prevent the occurrence of ulcers during hospital stays.
Home care settings
Patients receiving care at home, particularly those with limited mobility or chronic conditions, benefit from pressure ulcer care plans. These plans help caregivers and family members understand preventive measures and wound care techniques to manage and prevent ulcers.
The care plan's primary goal is to prevent the development of pressure ulcers or manage existing ones effectively, ensuring the patient's comfort, promoting healing, and reducing the risk of complications. Nurses and healthcare professionals tailor these plans to individual patient needs and regularly assess and adjust them based on the patient's condition and response to treatment.
Aspects of the Pressure Ulcer Nursing Care Plan
While pressure injuries can be identified and categorized through the stages outlined above, further nursing intervention is required past the assessment point. Early detection and action taken on signs of tissue damage through regular and routine assessment, nutritional intervention, skin care product use, and decreasing the time of tissue exposure to pressure through regular position changes and relief means, such as dressings and props, are all key aspects of pressure ulcer nursing care plans.
Impaired skin integrity
Pressure injuries represent localized soft tissue damage commonly observed in older adults, individuals with restricted mobility, those confined to beds or chairs, post-injury or surgery, and clients with compromised nutrition. These conditions reduce the skin and underlying tissue's ability to withstand forces that can harm them, leading to potential damage to the skin and circulation if pressure, friction, or shear persists. The instigation of this nursing care plan will be evidenced by skin lesions and ulcers and redness on bony prominences. Goals of care for this plan may include the expectation of the client to be free of or display improvement in wound and tissue healing, and instigate and follow through with techniques that prevent skin breakdown and promote healing. To reach these goals of care, intervention may include:
- Inspecting the patient's skin routinely.
- Focusing on common pressure points during skin assessment.
- Assessing for the presence of medical devices that could cause pressure.
- Assessing the skin for signs of possible tissue damage.
- Determining the stage of the pressure injury.
- Assessing nutritional status and initiating corrective measures, as indicated.
- Encouraging adequate fluid intake.
- Maintaining strict skincare and hygiene.
- Changing position frequently in the chair and bed.
Risk for infection
Inadequate treatment or complications, such as infections, can hinder the healing process of pressure injuries. The application of unsuitable therapies corresponding to the ulcer's stage can lead to treatment delays in patients experiencing worsening tissue damage. While pressure injuries are frequently observed, interdisciplinary management and implementing essential preventive and therapeutic strategies can mitigate these injuries and their associated complications. The goals of care for the patient should lead to them being free of infection, achieving timely wound healing, a good level of education and understanding around the patient exposure and risk factors, and knowledge and instigation of measures that prevent or reduce future infection risk. To reach these goals of care, nursing intervention may include:
- Assessment of signs and symptoms of systemic infection. Monitor temperature routinely.
- Observation of the wound, noting the presence of drainage and inflammation.
- Recording risk factors for the occurrence of infection.
- Instruct the client or family members in techniques to prevent the spread of infection.
Risk for impaired peripheral tissue perfusion
Applying pressure to soft tissue exceeding the pressure levels in the blood vessels supplying that area can lead to ischemia and swelling (edema), ultimately resulting in pressure injuries. The skin tends to withstand pressure better than muscle, occasionally masking more profound tissue damage. Prolonged pressure, approximately double the closing pressure of capillaries, maintained for 2 hours, causes irreversible ischemic harm to the tissue (Ricci et al., 2017). The instigation of this care plan is of value for people with impaired mobility, under anesthesia, or who suffer from advanced dementia, whereby sensation detection may not be present. The patient's care goals are met when there is sufficient tissue perfusion and no signs of edema or necrotic tissue formations. Meeting these goals of care can be done through the following interventions:
- Assessing for the presence of peripheral vascular/arterial diseases.
- Monitoring the client’s blood glucose levels routinely. Assess for peripheral neuropathy.
- Monitoring the client’s vital signs.
- Repositioning or turning the patient every 2 hours.
- Utilization of special support surfaces for pressure reduction such as foam, air, or gel-filled mattress overlays.
Why use Carepatron as your Pressure Ulcer Nursing Care Plan app?
Selecting Carepatron as your preferred application for creating a pressure ulcer nursing care plan offers numerous advantages for healthcare practitioners.
Carepatron provides a centralized workspace, allowing you to manage clinical documents and electronic patient records, set patient appointment reminders, and handle medical billing seamlessly and efficiently within the platform, eliminating the need for additional software downloads. This integrated and comprehensive approach simplifies, and streamlines processes and tasks related to pressure injury management and care as well as various other activities, giving you peace of mind and allowing you to focus most of your time, attention, and effort on patient care.
Carepatron is dedicated to offering a highly efficient and productive platform for thousands of healthcare professionals, allowing you to customize tools and workflows to meet your unique needs. Additionally, it empowers practitioners and patients to manage administrative tasks such as service booking and completing paperwork. The easy sharing of essential documents and data through the app ensures a top-quality customer experience.
We strongly believe in providing radical accessibility, making our app available on any device you have at your disposal. Our portable medical dictation software simplifies clinical note-making and updates, ensuring an effortless process. With great accessibility comes great responsibility, and we prioritize the security of all notes, clinical records, results, and practitioner data by complying with global security requirements, including HIPAA, GDPR, and HITRUST.
References
Demarré, L., Van Lancker, A., Van Hecke, A., Verhaeghe, S., Grypdonck, M., Lemey, J., Annemans, L., & Beeckman, D. (2015). The cost of prevention and treatment of pressure ulcers: A systematic review. International Journal of Nursing Studies, 52(11), 1754–1774. https://doi.org/10.1016/j.ijnurstu.2015.06.006
European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2019). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. EPUAP/NPIAP/PPPIA.
Kirman, C. N., & Geibel, J. (2022). Pressure Injuries (Pressure Ulcers) and Wound Care: Practice Essentials, Background, Anatomy. EMedicine. https://emedicine.medscape.com/article/190115-overview#a5
Latimer, S., Chaboyer, W., Thalib, L., McInnes, E., Bucknall, T., & Gillespie, B. M. (2019). Pressure injury prevalence and predictors among older adults in the first 36 hours of hospitalization. Journal of Clinical Nursing, 28(21-22), 4119–4127. https://doi.org/10.1111/jocn.14967
Nghiem, S., Campbell, J., Walker, R. M., Byrnes, J., & Chaboyer, W. (2022). Pressure injuries in Australian public hospitals: a cost of illness study. International Journal of Nursing Studies, 130(1), 104191. https://doi.org/10.1016/j.ijnurstu.2022.104191
Ricci, J. A., Bayer, L. R., & Orgill, D. P. (2017). Evidence-Based Medicine: The Evaluation and Treatment of Pressure Injuries. Plastic and Reconstructive Surgery, 139(1), 275e286e. https://doi.org/10.1097/prs.0000000000002850
Commonly asked questions
To create a comprehensive nursing care plan for pressure ulcers simply create a customized plan from the scaffolding provided by Carepatron and cater to the patient's needs through the critical aspects of assessment, diagnosis, planning, intervention, and evaluation.
These valuable plan templates can be used at any point of the treatment journey for a patient with pressure ulcers to track, monitor, and plan all interventions by healthcare professionals and the patient themselves.
Pressure ulcer nursing care plan templates are used as a planning tool for efficient and confident care delivery. They are designed to be customized and meet the individual patient's needs.
A nurse will use this pressure ulcer care plan to help outline treatments and planning, yet the template can be easily used and managed by any healthcare professional, even as an educational tool for the patient's self-management.
