Pressure ulcers — also known as decubitus ulcers, pressure sores, or bedsores — are localized injuries to the skin and underlying tissue caused by prolonged pressure, shear, friction, or moisture exposure. These ulcers most commonly develop over bony prominences such as the sacrum, heel, ischium, and scapula, especially in individuals who are immobile, critically ill, or have impaired sensory perception.
Pressure ulcers significantly increase patient morbidity, hospital length of stay, treatment costs, and the risk of severe complications such as cellulitis, osteomyelitis, sepsis, and even mortality. Therefore, nurses play a crucial role in early identification, prevention, and management of impaired skin integrity to ensure patient safety and improve clinical outcomes.
Understanding Pressure Ulcers
Pathophysiology
Pressure applied continuously over a bony prominence compresses the soft tissue between bone and external surface. This pressure obstructs capillary blood flow, leading to:
- Tissue ischemia
- Cellular death
- Inflammation and necrosis
- Eventual ulcer formation
Without timely intervention, the ulcer may extend to muscles, tendons, and even bone.
Common Risk Factors
- Immobility for 24–72 hours
- Sensory impairment (e.g., neuropathy, stroke)
- Diabetes mellitus
- Malnutrition or dehydration
- Moisture exposure (urine, sweat, stool)
- Advanced age
- Anemia
- Fever or infection
- Peripheral circulation problems
Conditions such as paraplegia, quadriplegia, stroke, multiple fractures, liver failure, and intracranial bleeding also increase the risk due to prolonged bed rest.
Nursing Diagnosis: Impaired Skin Integrity
Related to (Etiological Factors)
External Factors
- Mechanical pressure
- Friction and shear forces
- Excess moisture
- Physical immobility
- Temperature extremes
- Chemical irritants
- Radiation
- Medical devices causing pressure
Internal Factors
- Impaired circulation
- Decreased metabolic status
- Bony prominence
- Immunological deficit
- Decreased sensation
- Poor nutritional status (obesity or cachexia)
- Altered fluid balance
- Age-related skin changes
- Poor skin turgor
Objective Data
- Skin discoloration or redness
- Open wounds involving dermis or epidermis
- Blisters, abrasions, or ulceration
- Warm or cool skin temperature in affected area
- Loss of skin integrity
Nursing Outcomes Classification (NOC)
Primary NOC Outcomes:
- Tissue Integrity: Skin & Mucous Membranes
- Wound Healing: Primary and Secondary Intention
Expected Outcomes:
- Maintains intact skin with normal elasticity, temperature, hydration, and pigmentation.
- No new pressure ulcers or skin injuries.
- Good tissue perfusion.
- Demonstrates understanding of skin protection strategies.
- Moisture balance of skin is maintained.
- Shows progressive wound healing stages.
Nursing Interventions Classification (NIC)
1. Pressure Management
- Reposition patient every 2 hours.
- Encourage use of loose, soft clothing.
- Avoid wrinkles on the bed to reduce friction.
- Provide pressure-relieving surfaces (e.g., foam mattress, air mattress).
- Assess equipment causing direct pressure (e.g., oxygen tubing, casts).
2. Skin Surveillance
- Monitor skin for redness, warmth, or breakdown daily.
- Assess wound characteristics: size, depth, exudate, granulation tissue, necrosis, signs of infection.
- Keep skin clean and dry.
- Apply moisturizer to dry or vulnerable skin.
3. Nutrition Management
- Monitor nutrition status (albumin, prealbumin, weight changes).
- Collaborate with a dietitian for high-calorie, high-protein diets.
- Provide adequate hydration unless contraindicated.
4. Hygiene and Moisture Control
- Bathe with mild soap and warm water.
- Use barrier creams for moisture protection.
- Prevent urine and stool contact with skin using moisture-wicking pads.
5. Patient and Family Education
- Teach repositioning techniques.
- Educate on early signs of skin breakdown.
- Inform about nutrition importance in wound healing.
- Explain safe lifting and mobility assistance.
Interventions + Rationales (Table)
| Intervention | Rationale |
|---|---|
| Reposition every 2 hours | Reduces pressure duration and restores blood flow to tissues. |
| Use pressure-relieving mattress | Distributes weight more evenly to minimize localized ischemia. |
| Keep skin clean and dry | Moisture increases friction and makes skin more vulnerable to breakdown. |
| Monitor skin daily | Early detection prevents progression to deeper pressure injuries. |
| Provide high-protein diet | Protein supports collagen synthesis and wound healing. |
| Educate family on positioning | Improves continuity of care and reduces risk of recurrence. |
| Perform sterile wound care | Prevents infection and supports healing environment. |
| Apply moisturizer on dry areas | Maintains skin elasticity and prevents cracks leading to infection. |
Clinical Example
A 78-year-old bedridden patient with diabetes and stroke presents with redness on the sacral area (Stage 1 pressure ulcer). The nurse initiates repositioning every 2 hours, applies moisture barrier cream, provides a high-protein diet, and monitors skin changes daily. Within 5 days, the skin shows reduced redness and improved integrity.
Conclusion
Impaired skin integrity related to pressure ulcers is a critical nursing concern requiring comprehensive assessment, prevention, and evidence-based interventions. Through proper pressure management, nutritional support, skin surveillance, and patient education, nurses play a vital role in preventing complications and promoting optimal wound healing. A structured nursing care plan using NOC and NIC helps ensure consistent, high-quality care for at-risk patients.
References
- Bulechek, G.M., Butcher, H., & Dochterman, J. (2013). Nursing Interventions Classification (NIC). 6th Ed. Elsevier.
- Herdman, T.H. (2012). NANDA International Nursing Diagnoses: Definitions & Classification. Wiley-Blackwell.
- Maklebust, J., & Sieggreen, M. (2001). Pressure Ulcers: Guidelines for Prevention & Management.
- Potter, P., & Perry, A. (2005). Fundamentals of Nursing. Mosby.
- Sullivan, N. & Schoelles, M. (2013). Prevention of Pressure Ulcers. Agency for Healthcare Research & Quality.
- WHO. (2005). Diabetes Fact Sheet.
