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Nursing Management for Pressure Ulcers (Assessment and Nursing Diagnosis)

Pressure Ulcers (Assessment and Nursing Diagnosis)

Assessment

Activity / rest

  • Signs: decreased strength, endurance, limited range of motion in the affected area.
Circulation
  • Signs : hypoxia, decreased peripheral pulse on the distal extremity injuries, general peripheral vasoconstriction with loss of pulse, white and cold, tissue edema formation.

Elimination
  • Signs : decreased urine output is the absence in the emergency phase, the black color may be red, when it occurs, identifying muscle damage.

Food / fluid
  • Signs : general tissue edema, anorexia, nausea and vomiting.
Neurosensory
  • Symptoms : area numb / tingling.
Breathing
  • Symptoms : decreased function of the spinal cord, cord edema, neurological damage, paralysis of abdominal and respiratory muscles.
Ego integrity
  • Symptoms : family, work, finances, disability.
  • Signs : anxiety, crying, dependence, withdrawal, anger.
Security
  • Signs : a fracture due to location (falls, accidents, muscle contraction, up to an electric shock).

Nursing Diagnosis for Pressure Ulcers
  1. Impaired Tissue Integrity related to mechanical destruction of tissue secondary to pressure, friction and factions.
  2. Impaired Physical Mobility related to the restriction of motion required, conditioned status, loss of motor control due to changes in mental status.
  3. Imbalanced Nutrition Less than Body Requirements related to the inability of oral intake.
  4. Risk for infection related to exposure base pressure sores, suppression of inflammatory responses.
  5. Risk for Ineffective management of therapeutic regimen related to insufficient knowledge of the etiology, prevention, treatment and care at home.


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Demo Blog NJW V2 Updated at: November 20, 2014

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