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NCP for Pressure Sores / Decubitus Ulcer - Physical Examination, Assessment and 6 Nursing Diagnosis


Basic Concepts of Nursing Care

ASSESSMENT

1. Identity
Age need to be asked because of an association with wound healing or regeneration of cells. While race and ethnicity need to be assessed for skin that looks normal on certain nationalities and races, sometimes appear abnormal on the client with other nationalities and races (Smeltzer & Brenda, 2001). Jobs and hobbies are also asked to determine whether the client sedentary or less active, causing suppression of blood vessels that causes reduced oxygen supply, the cells do not get enough nutrients and metabolic waste accumulated garbage results. Eventually the cells die, the skin ruptured and there was a shallow pit and decubitus sores on the surface (Carpenito, LJ, 1998).

2. Main Complaint
Most complaints are perceived by clients that are looking for help. Complaints are disclosed clients in general, ie the pain. Location injuries usually found in prominent areas, for example in the area behind the head, buttocks area, heel, shoulder and groin area that suffered ischemia causing decubitus ulcers (Bouwhuizen, 1986).

3. Disease History Now
Things that need to be assessed is started when a complaint is felt, the location of the complaint, intensity, duration or frequency, of the factors that aggravate or mitigate the attack, as well as other complaints that accompany and efforts that have been made nurses here have to connect with the skin problems symptoms such as itching, burning, numbness, immobilization, pain, fever, edema, and neuropathy (Carpenito, LJ, 1998)

4. Personal and Family History
Family history of disease needs to be asked because the wound healing can be affected by inherited diseases, such as diabetes, allergies, hypertension (CVA). A history of skin diseases and medical procedures ever experienced by the client. This is to provide information on whether the change in the skin is a manifestation of systemic diseases such as chronic infections, cancer, diabetes.

5. History of Medicine
Do clients ever used drugs. Which need to be assessed by a nurse ie: When treatment starts, dose and frequency, end time of taking the medication.

6. History Diet
Assessed namely; weight, height, body growth and food consumed daily. Inadequate nutrition which causes the skin susceptible to lesions and a long process of wound healing.

7. Socio-Economic Status
To identify environmental factors and the level of the economy that may affect the pattern of daily life, as this allows can cause skin diseases.

8. Health History, such as: Long bed rest, immobilization, incontinence, nutrition or hydration inadequate.

9. Psychosocial Assessment
The possibility that psychosocial examination results appear on the client, namely: Feelings of depression, frustration, anxiety, desperation.

10. Activities of daily
Patients were immobilized in a long time there will be an ulcer in the area that stands out because of the weight rests on a small area that is not much tissue under the skin to hold the skin damage. So it is necessary to increase range of motion exercises and weight lifting. But in case of paraplegia, there will be no muscle power (in the lower limbs), decreased intestinal peristalsis (Constipation), decreased appetite and sensory deficits in the area of paraplegia.


PHYSICAL EXAMINATION

General state
Generally, people come in sick and agitated or anxious as a result of the damage suffered skin integrity.

Vital Signs
Normal blood pressure, rapid pulse, increased temperature and increased respiration rate.

Examination Head And Neck
  • Head And Hair: Examination covering the head shape, deployment and change of hair color as well as the examination of the wound. If there is a wound in the area, causing pain and skin damage.
  • Eyes: Covers symmetry, conjunctiva, pupillary reflexes to light and impaired vision.
  • Nose: Includes examination of the nasal mucosa, hygiene, do not arise nostril breathing, no secretions.
  • Mouth: Record the state of cyanosis or dry lips.
  • Ears: Record forms of hearing loss due to foreign objects, bleeding and wax. In patients who are bed rest at an angle left / right, then, is likely to occur ulcer area earlobe.
  • Neck: Knowing the position of the trachea, carotid pulse, whether there is enlargement of the jugular veins and glands linfe.

Examination Chest and Thorax
Inspection forms of thorax and lung expansion, auscultation of the respiratory rhythm, vocals premitus, the additional sounds, heart sounds, and an extra heart sounds, percussion thorax to look for abnormalities in the thorax area.

Abdomen
Form a flat stomach, bowel sounds decreased due to immobilization, there was a time because of constipation, and abdominal percussion hypersonor if abdominal distention or tense.

Urogenital
Inspection abnormalities in perinium. Usually clients with ulcers and paraplegia catheterized to urinate.

Musculoskeletal
The existence of fractures would cause the client bet rest for a long time, resulting in decreased muscle strength.

Neurological examination
Level of consciousness be assessed with GCS system. The value could be decreased if there is severe pain (neurogenic shock) and heat or high fever, nausea, vomiting, and stiff neck.


Physical Assessment: Skin

Inspection of the skin
Assessment involves the skin around the area of ​​the skin including mucous membranes, scalp, hair and nails. The appearance of skin that needs to be examined is the color, temperature, humidity, dryness, skin texture (rough or smooth), lesions, vascularity. Which must be observed by nurses, namely:
  • Color, influenced by blood flow, oxygenation, temperature and pigment production.
  • Edema, during the inspection of the skin, the nurse noted the location, distribution and color of local edema.
  • Humidity, Normally, humidity increases due to increased activity or high ambient temperature, dry skin can be caused by several factors, such as dry or moist environments unsuitable, inadequate fluid intake, the aging process.
  • Integrity, which must be considered that the location, shape, color, distribution, if there is drainage or infection.
  • Skin hygiene.
  • Vascularization, bleeding from blood vessels produce petechie and echimosis.
  • Palpation of the skin, Noteworthy are lesions on the skin, moisture, temperature, texture or elasticity, skin turgor.


NURSING DIAGNOSES
  1. Impaired Skin Integrity related to mechanical damage of tissue, secondary to pressure, shearing and friction.
  2. Chronic pain related to skin trauma, infection of skin and wound care.
  3. Risk for infection related to the display of decubitus ulcers to feces / urine drainage.
  4. Imbalanced Nutrition: Less than Body Requirements related to anorexia secondary to insufficient oral input.
  5. Impaired physical mobility related to restriction of movement required, the status of which is not conditioned, loss of motor control or change in mental status.
  6. Ineffective family coping related to chronic wounds, changes in body image.

Nursing Care Plan for Decubitus Ulcer / Pressure Sores

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