Nursing Care Plan
Decubitus is a condition of local tissue damage caused by ischemia in the skin (cutis and sub-cutis) due to excessive external pressure. Generally occurs in patients with chronic diseases that lie long. Decubitus ulcers are often referred to as ischemic ulcers, pressure ulcers, pressure sores, bedsores.
Decubitus is a serious problem because decubitus results in increased costs, long hospital stay and slow rehabilitation programs for sufferers. In addition, pressure sores can also cause severe complications leading to sepsis, chronic infections, cellulitis, osteomyelitis and increased mortality prevalence in elderly clients.
Decubitus is also at high risk in people who are unable to feel pain, because pain is a sign that normally encourages a person to move. Nerve damage (for example due to injury, stroke, diabetes) and coma. Diabetes mellitus is a chronic disease caused by reduced insulin production by the pancreas, both inherited and acquired, or by the ineffectiveness of insulin production. This deficiency increases glucose concentration in blood, where it can harm the body's system, especially blood vessels and nerves, causing a reduced ability to feel pain, which is one of the risks of pressure sores (WHO, 2005).
Various factors that cause decubitus according to Potter & Perry (2006) include; external factors which consist of pressure, friction, sheer, and moisture. While internal factors include; age, mobilization and activity status, nutrition, circulatory dysfunction, and anemia.
The main factor that causes impaired skin integrity in the form of decubitus is pressure, but there are additional factors that can increase the risk of developing decubitus further on the client. These include friction, moisture, poor nutrition, anemia, infection, fever, peripheral circulation disorders, obesity, cachexia and age.
So far, most researchers have focused their research on external factors such as impaired skin integrity, such as pressure, friction, etc., while internal factors in the form of patient characteristics are less noticed.
Nursing Diagnosis
Impaired Skin Integrity
related to:
External
Internal
Objective Data:
NOC
After nursing actions for ............... damage to the patient's skin integrity is resolved with outcomes criteria:
NIC
Pressure Management
Decubitus is a condition of local tissue damage caused by ischemia in the skin (cutis and sub-cutis) due to excessive external pressure. Generally occurs in patients with chronic diseases that lie long. Decubitus ulcers are often referred to as ischemic ulcers, pressure ulcers, pressure sores, bedsores.
Decubitus is a serious problem because decubitus results in increased costs, long hospital stay and slow rehabilitation programs for sufferers. In addition, pressure sores can also cause severe complications leading to sepsis, chronic infections, cellulitis, osteomyelitis and increased mortality prevalence in elderly clients.
Decubitus is also at high risk in people who are unable to feel pain, because pain is a sign that normally encourages a person to move. Nerve damage (for example due to injury, stroke, diabetes) and coma. Diabetes mellitus is a chronic disease caused by reduced insulin production by the pancreas, both inherited and acquired, or by the ineffectiveness of insulin production. This deficiency increases glucose concentration in blood, where it can harm the body's system, especially blood vessels and nerves, causing a reduced ability to feel pain, which is one of the risks of pressure sores (WHO, 2005).
Various factors that cause decubitus according to Potter & Perry (2006) include; external factors which consist of pressure, friction, sheer, and moisture. While internal factors include; age, mobilization and activity status, nutrition, circulatory dysfunction, and anemia.
The main factor that causes impaired skin integrity in the form of decubitus is pressure, but there are additional factors that can increase the risk of developing decubitus further on the client. These include friction, moisture, poor nutrition, anemia, infection, fever, peripheral circulation disorders, obesity, cachexia and age.
So far, most researchers have focused their research on external factors such as impaired skin integrity, such as pressure, friction, etc., while internal factors in the form of patient characteristics are less noticed.
Nursing Diagnosis
Impaired Skin Integrity
related to:
External
- Hyperthermia or hypothermia
- Chemical Substance
- Humidity
- Mechanical factors (eg tools that can cause injury, pressure, restraint).
- Physical immobility
- Radiation
- Extreme age
- Skin moisture
- Medicine
Internal
- Changes in metabolic status
- Bone protrusion
- Immunological deficit
- Dealing with developments.
- Change of sensation
- Changes in nutritional status (obesity, emaciation)
- Change in fluid status
- Changes in circulation
- Turgor changes (skin elasticity)
Objective Data:
- Disorders of body parts
- Damage to the skin layer (dermis)
- Disorders of the skin surface (epidermis)
NOC
- Tissue Integrity: Skin and Mucous Membranes.
- Wound Healing: Primary and secondary
After nursing actions for ............... damage to the patient's skin integrity is resolved with outcomes criteria:
- Skin integrity can be maintained (sensation, elasticity, temperature, hydration, pigmentation).
- There are no injuries to the skin.
- Tissue perfusion is good
- Demonstrate understanding in the process of repairing the skin and preventing recurring injuries.
- Can protect skin and skin moisture and natural care.
- Shows the wound healing process.
NIC
Pressure Management
- Encourage patients to wear loose clothing
- Avoid wrinkles on the bed
- Keep the skin clean and dry
- Patient mobilization (change patient position) every two hours.
- Monitor the skin for redness.
- Apply lotion to the depressed area.
- Montor patient activity and mobilization.
- Monitor patient nutrition status.
- Bathe the patient with soap and warm water.
- Assess the environment and equipment that causes pressure.
- Observation of wounds: location, dimensions, wound depth, fluid color, granulation, necrotic tissue, signs of local infection, tract formation.
- Teach the family about wounds and wound care
- Collaboration of nutritionists giving diets high in calories and protein.
- Prevent stool and urine contamination.
- Perform wound care sterile.
- Give a comfortable position.
- Herdman.T.H. (2012). NANDA International Nursing Diagnosis: Definition & Classification 2012-2014. Oxford: Wiley-Blackwell.
- Nursing Outcomes Classification (NOC). United States of America: Elsevier.
- Bulechek, G. (2013). Nursing Intervention Classification (NIC). 6th Edition. Missouri: Elseiver Mosby
