Pressure ulcers—also known as bedsores or decubitus ulcers—are localized injuries to the skin and underlying tissues caused by prolonged pressure, shear, or friction over bony prominences. They are a major patient safety concern in hospitals, long-term care facilities, and home care settings. Because prevention and early intervention are essential responsibilities of nurses, understanding the causes, risk factors, assessment tools, and nursing care strategies is crucial for improving patient outcomes.
What Are Pressure Ulcers?
According to Morison (2004), pressure ulcers occur when continuous pressure on soft tissue reduces blood flow to the affected area, leading to ischemia, tissue damage, and eventually necrosis. Patients who are immobilized for long periods—24 to 72 hours—are at particularly high risk. Pressure ulcers can develop in as little as 48 hours in bed-bound patients.
Common Locations of Pressure Ulcers
- Sacrum
- Coccyx
- Ischial tuberosities
- Heels
- Back of the head (occiput)
- Spine and shoulder blades
Pressure ulcers vary in severity, from redness of the skin (Stage 1) to full-thickness tissue loss exposing bone (Stage 4). Nurses must be able to identify early signs to prevent further deterioration.
Causes and Contributing Factors
Prolonged pressure is the primary cause of pressure ulcers. However, research shows that several other factors also contribute.
1. Pressure
Continuous pressure impedes capillary blood flow, resulting in local tissue ischemia and cell death.
2. Shear Forces
Shearing occurs when skin remains stationary while deeper tissues move, such as when a patient slides down in bed.
3. Friction
Friction damages the superficial skin layers, making them more vulnerable to breakdown.
4. Excessive Moisture
Moisture from sweat, urine, feces, or wound drainage weakens the skin and increases the risk of ulcer formation.
5. Infection
Infection delays healing, causes inflammation, and promotes tissue destruction (Maklebust & Sieggreen, 2001).
6. Poor Nutrition
Low protein, malnutrition, anemia, and dehydration impair tissue healing and weaken skin integrity.
7. Immobility
Medical conditions causing prolonged immobility—such as stroke, traumatic brain injury, spinal cord injury, fractures, or hepatic encephalopathy—significantly increase the risk.
Risk Assessment for Pressure Ulcers
Prevention begins with identifying patients at risk. Several standardized tools are used in clinical practice.
Common Pressure Ulcer Risk Assessment Tools
- Braden Scale – Assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear
- Norton Scale – Evaluates physical condition, mental state, activity, mobility, and continence
- Gosnell Scale – Includes mental status, continence, mobility, nutrition, and medication
Patients with lower scores on these scales have a higher risk of developing pressure ulcers and require focused interventions.
Nursing Role in Preventing Pressure Ulcers
Potter & Perry (2005) highlight three primary areas of nursing interventions:
1. Skin Care
- Maintain hygiene
- Use moisturizers and protective barriers
- Keep skin dry and clean
2. Mechanical Prevention
- Reposition patients at least every 2 hours
- Use therapeutic beds, pressure-relieving mattresses, and cushions
- Keep linens wrinkle-free
3. Education
- Teach family caregivers about repositioning
- Provide instructions on skin monitoring and nutrition
Evidence-Based Strategies to Prevent Pressure Ulcers
Based on multiple studies and guidelines:
- Apply moisturizers (low alcohol content) to prevent dryness (RNAO, 2005)
- Use protective dressings on bony areas
- Manage nutrition: high protein, zinc, vitamins A & C
- Optimize hydration
- Implement scheduled repositioning and mobility plans
- Ensure proper documentation and care coordination (Sullivan & Schoelles, 2013)
Case Example
A 70-year-old stroke patient with limited mobility shows redness over the sacral area. The skin is moist due to incontinence, and the Braden score is 14 (moderate risk). The nurse initiates prevention interventions: repositioning every 2 hours, applying moisture barriers, improving nutritional intake, and monitoring skin daily.
Nursing Diagnosis: Impaired Skin Integrity related to Pressure Ulcers
This diagnosis applies when the patient has damaged skin due to pressure, immobility, moisture, or friction.
Associated Data (Signs & Symptoms)
- Redness over bony areas
- Skin discoloration
- Open wound or blister
- Warmth, swelling, or tenderness
- Immobility
- Moisture-associated skin damage
NOC and NIC for Impaired Skin Integrity
NOC Outcomes (Expected Results)
- Skin Integrity: Wound Healing
- Tissue Perfusion
- Nutritional Status
- Comfort Level
NIC Interventions
- Pressure Management
- Skin Surveillance
- Wound Care
- Positioning
- Nutritional Management
Intervention Table with Rationale
| Intervention | Rationale |
|---|---|
| Assess skin, especially bony prominences, every shift | Early detection allows timely intervention and prevents ulcer progression |
| Reposition patient at least every 2 hours | Reduces pressure duration, preventing capillary occlusion and ischemia |
| Use pressure-relieving devices (foam pads, air mattresses) | Distributes pressure and reduces stress on vulnerable skin areas |
| Keep skin clean and dry; apply moisture barriers for incontinence | Prevents maceration and reduces risk of breakdown from moisture |
| Encourage high-protein, nutrient-dense diet | Protein is essential for collagen synthesis and tissue repair |
| Educate caregivers about proper repositioning and skin care | Improves continuity of care and reduces risk of recurring ulcers |
Conclusion
Pressure ulcers are preventable but require consistent nursing assessment, evidence-based interventions, and collaboration among healthcare professionals. By implementing proper skin care, repositioning techniques, pressure-relief strategies, and nutritional support, nurses can maintain skin integrity and reduce complications. Early identification and comprehensive prevention efforts significantly improve patient outcomes and reduce healthcare costs.
References
- Morison, M. (2004). Preventing Pressure Ulcers.
- Maklebust, J. & Sieggreen, M. (2001). Pressure Ulcers Guidelines.
- Potter & Perry (2005). Fundamentals of Nursing.
- Registered Nurses’ Association of Ontario (2005). Best Practice Guidelines.
- Sullivan, N., & Schoelles, M. (2013). Agency for Healthcare Research and Quality.
Impaired Skin Integrity - Nursing Diagnosis, Outcomes and Interventions
