Pressure Ulcers (Assessment and Nursing Diagnosis)
Assessment
Activity / rest
- Signs: decreased strength, endurance, limited range of motion in the affected area.
- 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.
- Symptoms : area numb / tingling.
- Symptoms : decreased function of the spinal cord, cord edema, neurological damage, paralysis of abdominal and respiratory muscles.
- Symptoms : family, work, finances, disability.
- Signs : anxiety, crying, dependence, withdrawal, anger.
- Signs : a fracture due to location (falls, accidents, muscle contraction, up to an electric shock).
Nursing Diagnosis for Pressure Ulcers
- Impaired Tissue Integrity related to mechanical destruction of tissue secondary to pressure, friction and factions.
- Impaired Physical Mobility related to the restriction of motion required, conditioned status, loss of motor control due to changes in mental status.
- Imbalanced Nutrition Less than Body Requirements related to the inability of oral intake.
- Risk for infection related to exposure base pressure sores, suppression of inflammatory responses.
- Risk for Ineffective management of therapeutic regimen related to insufficient knowledge of the etiology, prevention, treatment and care at home.
