Nursing Diagnosis

nurslng ulagnosls SclenLlflc 8asls Þlannlng lnLervenLlons 8aLlonale LvaluaLlon

Sť ºuugay naman nl
slyang slge gahlgdaţ" as
verballzed by Lhe SŦC of
Lhe paLlenLŦ

Cť 8ecelved paLlenL lylng
on bedţ asleepŦ
Ŵ redness on Lhe sacral
area
Ŵ senlle skln Lurgor
Ŵ on compleLe bed resL


8lsk for lmpalred Skln
lnLegrlLy r/L physlcal
lmmoblllzaLlon as
evldenced by redness
on Lhe sacral areaŦ


Þressure ulcers may be caused by
lnadequaLe blood supply and
resulLlng reperfuslon ln[ury when
blood reŴenLers LlssueŦ A slmple
example of a mlld pressure sore may
be experlenced by healLhy
lndlvlduals whlle slLLlng ln Lhe same
poslLlon for exLended perlods of
Llmeť Lhe dull ache experlenced ls
lndlcaLlve of lmpeded blood flow Lo
affecLed areasŦ WlLhln hoursţ Lhls
shorLage of blood supplyţ called
lschemlaţ may lead Lo Llssue damage
and cell deaLhŦ 1he sore wlll lnlLlally
sLarL as a redţ palnful areaţ whlch
evenLually Lurns purpleŦ LefL
unLreaLedţ Lhe skln may break open
and become lnfecLedŦ MolsL skln ls
more senslLlve Lo Llssue lschemla
and necrosls and ls also more llkely
Lo geL lnfecLedŦ

















looLnoLeť
hLLpť//bsnurseŦcom/?pƹ2734

AfLer 3Ŵ4 hours of
nurslng
lnLervenLlonsţ Lhe
paLlenL wlll be able
Lo malnLaln skln
lnLegrlLy as
evldenced by lnLacL
sklnŦ

1Ŧ SLrlcLly follow Lhe
lmplemenLaLlon and posLlng of
a Lurnlng scheduleţ resLrlcLlng 2
hours or less and Llme ln one
poslLlon Lo cusLomlzlng Lhe
schedule Lo paLlenL's rouLlne
and careglver's needsŦ

2Ŧ Lncourage lmplemenLaLlon
of pressureŴrellevlng devlces
such as plllows on bony
promlnences speclally on Lhe
sacral areaŦ

3Ŧ MalnLaln funcLlonal body
allgnmenLŦ

4Ŧ lncrease Llssue perfuslon by
massaglng around affecLed
areaŦ

3Ŧ Cleanţ dryţ and molsLurlze
sklnţ especlally over bony
promlnencesţ Lwlce dally or as
lndlcaLed by lnconLlnence or
sweaLlngŦ

6Ŧ Lncourage adequaLe
nuLrlLlon and hydraLlonŦ




7Ŧ 1eocb coteqlvet tbe coose(s)
of ptessote olcet Jevelopmeot
pressure on sklnţ especlally
over bony promlnences
shearlng or frlcLlon agalnsL
sklnŦ


1Ŧ A scbeJole tbot Joes oot
lotetfete wltb tbe potleot´s ooJ
coteqlvets´ octlvltles ls most
llkely to be followeJŦ




2Ŧ 1bese wlll teJoceJ ptessote
becoose tbey ote moJe of
foomŦ



JŦ 1o dlsLrlbuLe Lhe bodles
wleghL equallyŦ

4Ŧ Mossoqloq teJJeoeJ oteo
moy Jomoqe sklo fottbetŦ


5Ŧ ÞrevenL developmenL of
bedsoresŦ




6Ŧ lf dlflclenL calorlesproLeln
and flulds ln Lhe dleLţ Lhere
would be decrease ln Llssue
Lolerance and more vulnerable
Lo lower amounL of pressureŦ

7Ŧ So LhaL careglvers wlll be
gulded on whaL Lo do Lo lessen
Lhe rlsk of havlng pressure
ulcersŦ