Pressure Ulcer (Bedsores) Nursing Care Plan

Assess risk and skin systematically

• Complete a Braden or comparable risk assessment on admission, with each change in condition, and per unit policy.
• Perform a head-to-toe skin inspection at least daily and with every repositioning, paying particular attention to heels, sacrum and areas under devices.
• Check under oxygen tubing, catheters, casts, splints, cervical collars and compression devices — medical device injuries are common and easily missed.
• Photograph and document wounds per policy, with consistent measurement of length, width, depth, undermining and tunneling.
• Assess blanching in darkly pigmented skin by comparing temperature, firmness and color change against adjacent tissue rather than relying on redness.

Relieve pressure and shear

• Reposition at least every two hours in bed and hourly in a chair, following a written turning schedule the whole team can see.
• Use a 30-degree lateral position with pillows or wedges instead of lying directly on the trochanter.
• Float the heels completely off the mattress with a pillow under the calves or a heel offloading boot.
• Keep the head of the bed at or below 30 degrees except during meals to reduce sliding and shear.
• Lift rather than drag using a draw sheet, slide sheet or mechanical lift with adequate staff.
• Provide a pressure-redistributing mattress or cushion matched to the risk level, and avoid donut-shaped rings, which concentrate pressure.
• Teach chair-bound patients to shift weight every 15 minutes independently when able.

Protect skin from moisture and injury

• Cleanse promptly after each incontinent episode with a pH-balanced no-rinse cleanser and pat dry rather than rub.
• Apply a moisture barrier ointment or film to the perineum and sacrum, and consider a fecal management system for uncontrolled liquid stool.
• Use breathable underpads rather than layers of linen and plastic, which trap heat and moisture.
• Apply prophylactic silicone foam dressings to the sacrum and heels of high-risk patients.
• Moisturize dry skin daily, and never massage over a reddened bony prominence.

Optimize nutrition and hydration

• Consult a dietitian for high-calorie, high-protein needs and offer supplements between meals.
• Encourage fluids to maintain hydration and tissue turgor unless restricted.
• Provide vitamin C, zinc and multivitamins as ordered to support collagen synthesis.
• Track weight, intake, albumin and prealbumin as objective markers of healing capacity.
• Assist with feeding, set up trays and address dentition, dysphagia or depression that limit intake.

Provide wound care and prevent infection

• Cleanse wounds with normal saline or a non-cytotoxic cleanser at low pressure; avoid full-strength antiseptics on granulating tissue.
• Match the dressing to the wound: transparent film or hydrocolloid for stage 1 and shallow stage 2, hydrogel for dry wounds, foam or alginate for moderate to heavy drainage, and specialty products for tunneling.
• Maintain a moist wound bed with dry, intact surrounding skin — moisture heals, maceration destroys.
• Monitor for infection: increasing pain, erythema, warmth, purulence, odor, delayed healing, fever or rising white count, and report exposed bone for osteomyelitis evaluation.
• Assist with debridement as ordered, and leave stable dry heel eschar intact unless drainage, fluctuance or erythema appear.
• Premedicate for pain 30 minutes before dressing changes and allow rest breaks during the procedure.

Promote mobility and educate caregivers

• Coordinate with physical and occupational therapy for progressive mobility, transfer training and seating evaluation.
• Teach the family the turning schedule, safe lifting, skin checks and warning signs before discharge, with return demonstration.
• Arrange home equipment such as a pressure-redistributing mattress or cushion and home health follow-up.
• Document each intervention; consistent prevention documentation is both clinical care and legal protection.

What are the nursing diagnoses for Pressure Ulcer?

Priority nursing diagnoses for Pressure Ulcer: Impaired tissue integrity; Risk for infection; Impaired physical mobility.

What are the nursing interventions for Pressure Ulcer?

Complete a Braden or comparable risk assessment on admission, with each change in condition, and per unit policy. Perform a head-to-toe skin inspection at least daily and with every repositioning, paying particular attention to heels, sacrum and areas under devices. Check under oxygen tubing, catheters, casts, splints, cervical collars and compression devices — medical device injuries are common and easily missed. Photograph and document wounds per policy, with consistent measurement of length, width, depth, undermining and tunneling. Assess blanching in darkly pigmented skin by comparing temperature, firmness and color change against adjacent tissue rather than relying on redness. Reposition at least every two hours in bed and hourly in a chair, following a written turning schedule the whole team can see.

What are the nursing care goals for Pressure Ulcer?

No new pressure injury develops during the hospital stay or care episode. Existing wounds show decreasing size, increasing granulation and no signs of infection at each weekly measurement. The patient or caregiver demonstrates a repositioning schedule and correct offloading technique. Skin over bony prominences remains intact, clean and dry. Nutritional intake meets the prescribed calorie and protein targets and albumin trends upward. Pain during dressing changes is rated at or below the patient's acceptable level.

What should you assess in a patient with Pressure Ulcer?

Pain, burning, tenderness or itching over a bony prominence; Numbness or absent sensation in patients with neuropathy or spinal injury; Reports of being unable to reposition without help; Embarrassment or distress about odor, drainage and dependence; Non-blanchable erythema over the sacrum, heels, trochanters, ischium, elbows, occiput or ears; Skin temperature change, boggy or firm texture compared with surrounding tissue; Partial- or full-thickness loss with measured length, width and depth in centimeters; Undermining or tunneling, described by clock position; Wound bed character: red granulation, yellow slough, black eschar, or exposed bone or tendon; Drainage amount, color and odor; periwound maceration or induration; Braden or comparable risk score, current mobility and continence status; Serum albumin, prealbumin, hemoglobin and weight trend; Fever, leukocytosis, spreading erythema or crepitus suggesting infection