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3 Pressure Ulcer (Bedsores) Nursing Care Plans

By Paul Martin, BSN, R.N. - Updated on April 12, 2019

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A pressure ulcer (also known as bedsores or decubitus ulcer) is a localized skin injury where
tissues are compressed between bony prominences and hard surfaces such as a mattress.
They are caused by pressure in combination with friction, shearing forces, and moisture. The
pressure compresses small blood vessels and leads to impaired tissue perfusion. The
reduction of blood ow causes tissue hypoxia leading to cellular death.
Nursing Care Plans
Pressure ulcers stage I through III can be managed with aggressive local wound treatment
and proper nutritional support while stage IV pressure ulcers usually require surgical
intervention.

Nursing care for clients experiencing pressure ulcer (bedsores) includes assessing the
contributing factors leading to a lack of tissue perfusion, assessing the extent of the injury,
promoting compliance to the medication regimen, preventing further injury.

Here are three (3) nursing care plans (NCP) and nursing diagnosis for pressure ulcers
(bedsores):

1. Impaired Skin Integrity

2. Risk For Infection

3. Risk For Ine ective Health Maintenance

 1 - Impaired Skin Integrity 

Impaired Skin Integrity

Impaired Skin Integrity: Altered epidermis and/or dermis.

May be related to

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 Chronic disease state.

Extreme of ages.

Imbalanced nutritional state.

Impaired cognition.

Impaired sensation.

Immobility.

Immunological de cit.

Incontinence.

Mechanical factors (friction, pressure, shear).

Moisture.

Poor circulation.

Pronounced body prominence.

Radiation.

Possibly evidenced by
 Destruction of skin layers.

Disruption of skin surfaces.

Drainage of pus.

Invasion of body structures.

Pressure ulcer stages:

Deep tissue injury (new stage):
Purple or maroon localized area of intact skin or blood- lled blister resulting from
pressure damage of underlying soft tissue.

Stage I:
Epidermis is intact.

Non-branch able erythema of intact skin. Discolouration of the skin, warmth, edema,
induration or hardness may also be used as indicators, particularly on individuals
with darker skin.

Stage II:
Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is super cial
and presents clinically as an abrasion or blister.

Stage III:
Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that
may extend down to, but not through, underlying fascia.

Slough may be present; may include undermining and tunneling.

Stage IV:
Extensive destruction, tissue necrosis or damage to muscle, bone or supporting
structures, with or without full-thickness skin loss.

Undermining and tunneling may develop.

Unstageable:
Full-thickness tissue loss in which actual depth of ulcer is completely obstructed by
slough or eschar in the wound bed.

Desired Outcomes

Client will get stage-appropriate wound care and has controlled risk factors for prevention
of additional ulcers.

Client will experience healing of pressure ulcers and experiences pressure reduction.

Nursing Interventions Rationale

Even clients with an existing pressure ulcer

Assess the speci c risk factors for pressure continue to be at risk for further injury,
ulcer: Nurses should consider all potential risk
factors for pressure ulcers development.
Determine the client’s age and general
condition of the skin.
Assess the client’s nutritional status,
including weight, weight loss, and serum
albumin levels, if indicated.
Assess for a history of preexisting chronic
diseases (e.g., diabetes mellitus, acquired
immune de ciency syndrome, guillain-
barré syndrome, peripheral and/or
cardiovascular disease).
Assess the skin on admission and daily
for an increasing number of risk factors.
Assess for a history of radiation therapy.
Assess the client’s awareness of the
sensation of pressure.
Assess for fecal and urinary incontinence.
Assess client’s ability to move (shift
weight while sitting, turn over in bed,
move from the bed to a chair).
Assess for environmental moisture
(excessive perspiration, high humidity,
Elderly clients have less elastic skin, less
moisture, less padding and have thinning of
the epidermis, making it more prone to skin
impairment.
A severe protein depletion has an albumin
level of less than 2.5 g/dL. Clients with
pressure ulcer lose big amounts of protein
in wound exudates and may require 4000
kcal/day or more to remain anabolic.
Clients with chronic diseases typically
exhibit multiple risk factors that predispose
them to pressure ulceration. These include
poor nutrition, poor hydration,
incontinence, and immobility.
The incidence of skin breakdown is directly
related to the number of risk factor present.
Irradiated skin becomes thin and brittle,
may have less blood supply, and is at a
higher risk for skin breakdown.
 Usually, people shift their weight o
pressure areas every few minutes; this
occurs more or less automatically, even
during sleep. Clients with decreased
sensation are unaware of unpleasant stimuli
and do not shift weight, thereby exposing
the skin to excessive pressure.
 The urea in urine turns into ammonia
within minutes and is erosive to the skin.
While the stool may contain enzymes that
cause skin breakdown. Diapers and
incontinence pads with plastic liners trap
moisture and speed up breakdown.
 Immobility is a huge risk factor for pressure
ulcer development among adult
hospitalized clients.
 Moisture may contribute to skin
maceration.
 wound drainage).

 Shearing forces are most commonly noted

Assess the amount of shear (pressure on the sacrum, scapulae, heels, and elbows
exerted laterally) and friction (rubbing) on from skin-sheet friction, from semi-Fowler’s
the client’s skin. position and repositioning, and from lift
sheets.

Assess the surface that the clients spend  Clients who spend the majority of time on
a majority of time on (mattress for one surface need a pressure reduction or
bedridden clients, cushion for clients in pressure relief device to reduce the risk of
wheelchairs). skin breakdown.

Assess the skin over bony prominences

These areas at highest risk for breakdown
(sacrum, trochanters, scapulae, elbows,
resulting from tissue ischemia from
heels, inner and outer malleolus, inner
compression against a hard surface.
and outer knees, back of the head).

The Braden scale is the most widely used

risk assessment. It consists of six subscales
namely: activity, mobility, moisture,
nutrition, sensory perception, and friction.
Use an objective tool for pressure ulcer risk
Acute care: Assessment should be carried
assessment:
out on all patients on admission and every
Braden scale. 24 to 48 hours or sooner if the patient’s
condition changes.
Norton scale.

Long-term care: Assess on admission,

weekly for 4 weeks, then quarterly and
whenever the resident’s condition changes.

Assess the client’s level of pain, especially Prophylactic pain medication may be
related to dressing change and procedures. indicated.

Staging is essential because it determines

the treatment plan. Staging should be
assessed at each dressing stage. It re ects
whether the epidermis, dermis, fat, muscle,
bone, or joint is exposed. If the ulcer is
Assess and stage the pressure ulcers.
covered with necrotic tissue (eschar), it
cannot be accurately staged. Stage I ulcers
are di cult to detect in darkly pigmented
skin. The use of mirrors or a penlight may
be helpful.
Determine the condition of the wound or wound bed.
Presence of necrotic tissue.
Color.
Odor.
Viability of bone, joints, or muscle.
Measure the size of the ulcer, and note the
presence of undermining.
Assess the condition of wound edges and
surrounding tissue.
Assess the wound exudate.
 
Necrotic tissue is tissue that is dead and
eventually must be removed before healing
can take place. Necrotic tissue exhibits a
wide range of appearance: black, brown,
leathery, hard, shiny, thin, tough, white.
The color of tissue is an indication of tissue
viability and oxygenation. White, gray, or
yellow eschar may be present in stage II and
III ulcers. Eschar may be black in stage IV
ulcers.
Odor may arise from infection present in
the wound; it may also arise from the
necrotic tissue. Some local wound care
products may create or intensify the odors
and should be distinguished from wound or
exudate odors.
In stage IV pressure ulcers, these may be
apparent at the base of the ulcer. Wounds
may demonstrate multiple stages or
characteristics in a single wound.
The ulcer dimensions include length, width,
and depth. An ulcer begins in the deepest
tissue layers before the skin breaks down.
Hence the opening of the skin’s surface may
not represent the true size of the ulcer.
Surronding tissue may be healthy or may
have various degrees of impairment.
Healthy tissue is necessary for the use of
local wound care products requiring
adhesion to the skin. The presence of
healthy tissue demarcates the boundaries
of the pressure ulcer.
Exudate is a normal part of wound
physiology and must be di erentiated from
pus which is an indication of infection.
Exudate may contain serum, blood, and
white blood cells, and may appear clear,
cloudy, or blood-tinged. The amount may
vary from a few cubic centimeters, which
are easily managed with dressings, to

Assess ulcer healing, using a pressure ulcer
scale for healing (PUSH) tool.
Provide local wound care:
Stage I: 
Apply a topical vasodilator (e.g., Proderm)
Apply a exible hydrocolloid dressing
(e.g., Duoderm) or a vapor-permeable
membrane dressing (Tegaderm).
Apply a vitamin-enriched emollient to the
skin every shift.
Stage II:
Apply a Alginates (Sorbsan, Kalginate,
Kaltostat).
Apply hydrocolloids or a vapor-
permeable membrane dressing.
Apply gauze with sodium chloride
solution.
Apply Hydrogels (Carrasyn V, Aqua Skin).
copious amounts not easily managed.
Drainage is considered excessive when
dressing changes are needed more often
than every 6 hours.
This tool provides standardization in the
measurement of wound healing. It
quanti es surface area, exudate, and the
type of wound tissue.
It increases skin circulation.
It prevents shear and friction.
It moisturizes the skin.
Alginate dressings are a type that is highly
absorbent and so can absorb the uid
(exudate) that is produced by some ulcers.
These are often used for ulcers with
moderate-to-heavy exudate.
Hydrocolloids are used to promote healing
and wound debridement. They are not
advised to use for heavy-exudate-producing
wounds.
This maintains a moist environment but
requires multiple dressing changes.
Dressings must be removed while still wet.
Dressings absorb small amounts of
drainage.
Hydrogels provide moisture to dry, sloughy
or necrotic wounds and assists autolytic
debridement. Can be used on wounds with
 low exudate. Usually use for shallow ulcers
without exudates.
Stage III and IV: 
Di erent foams have di erent levels of
absorbency. They are best used on
Foams.
granulating wounds. Foams lessen odor and
repel bacteria and water.

This maintains a moist environment but

Gauze with sodium chloride solution. requires multiple dressing changes as
describe for stage II.

Wound llers are used as a primary

Wound llers. dressing and to pack wounds, maintain a
moist environment.
Using a hydrocolloid or hydrogel, these
create a moist wound interface that
enhances the activity of endogenous
Autolytic debridement.
proteolytic enzymes within the wound,
liquefying and separating necrotic tissue
from healthy tissue.

This procedure removes the necrotic tissue

and senescent cells that slow down the
Sharp or surgical debridement.
tissue repair process, converting a chronic
wound into an acute one in the process.

Involves allowing a traditional gauze-type

dressing to dry out and adhere to the
Mechanical debridement. surface of the wound before manually
removing the dressing, debriding any tissue
attached to it.

Stimulation of many cellular processes

Electrical stimulation.
improves healing.

Therapeutic use of live blow y larvae

Biosurgery.
(maggots) for a quick debridement.

Nerve-growth factors, colony-stimulating

factors, and broblast growth factors are
Topical growth factors.
found to be e ective in treating diabetic and
venous ulcers.
A wound dressing systems that
continuously or intermittently apply
Negative pressure wound therapy.
a subatmospheric pressure to the surface of
a wound to assist healing.
 Enzymatic debridement (chlorophyll,
collagenase, papain).
Enzymatic debridement uses proteolytic
enzymes to remove necrotic tissue. These
agents work by selectively digesting the
collagen portion of the necrotic tissue. Care
should be taken to prevent damage to
surrounding healthy tissues.

 1 - Impaired Skin Integrity 

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 Paul Martin, BSN, R.N.
Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-
surgical nurse for ve years, he handled di erent kinds of patients and learned how to provide individualized care to
them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve
their goals. He is currently working as a nursing instructor and have a particular interest in nursing management,
emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his
clinical knowledge and skills to students and nurses helping them become the best version of themselves and
ultimately make an impact in uplifting the nursing profession.

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