Nursing Diagnosis and Nursing Interventions

Nursing Diagnosis and Nursing Intervention for Decubitus Ulcer

Pressure ulcers are localized injuries to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. The most common sites are the skin overlying the sacrum, coccyx, heels or the hips, but other sites such as the elbows, knees, ankles or the back of the cranium can be affected.

A decubitus ulcer’s symptoms are based on the stage it falls under. Your healthcare provider may look for any of the following:
  • discoloration in the skin
  • pain in the affected area
  • infection
  • open skin
  • skin that does not lighten to the touch
  • skin may be softer or firmer than the surrounding skin

Nursing Diagnosis for Decubitus Ulcer

Impaired tissue integrity related to mechanical tissue destruction secondary to pressure, friction and factions.
Impaired physical mobility related to movement restrictions are required, the status of the conditioned, loss of motor control due to changes in mental status.


Nursing Intervention for Decubitus Ulcer

Impaired tissue integrity related to mechanical tissue destruction secondary to pressure, friction and factions Nursing Intervention :
Apply the principles of prevention of decubitus ulcers.
R: the principle of prevention of decubitus ulcers, including reducing or rotate the pressure of soft tissue.
Adjust the position of the patient as comfortable as possible.
R: minimize the occurrence of decubitus affected tissue.
Wound dressing with a bandage that maintains humidity environment on the foundations of the wound.
R: a moist wound to accelerate recovery.

Impaired physical mobility related to movement restrictions are required, the status of the conditioned, loss of motor control due to changes in mental status.

Nursing Intervention :
Support higher level of mobilization.
R: regular movement relieve pressure consistently above the bony ridge.
Assist / encourage self care / hygiene, like bathing.
R: improve muscle strength and circulation, improve the control patients in the situation and improving environmental health.
Give special attention to the skin.
R: research shows that the skin is very susceptible to damage because the concentration of weight.


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Nursing Diagnosis - Nursing Interventions

NANDA NURSING

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