Which patients are at increased risk for tissue breakdown (the development of decubitus ulcers)?
Identify nursing interventions to implement to reduce patients’ risk to their tissue (decubitus ulcer prevention)
- 1. External pressure that compresses blood vessels
- 2. Friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin
Patients compromised by the following conditions are at risk for pressure ulcer development:
negative nitrogen balance
skin moisture and hygiene
diminished pain awareness
previous pressure ulcers
obesity or extreme thinness
- Assess and clean the skin daily
- Maintain high humid environment and use skin moisturizers for dry skin
- Do not massage over bony prominences
- Protect the skin from moisture
- Minimize skin friction and shearing forces by using proper positioning, turning, and transferring techniques.
- Use appropriate support surfaces
- maintain healthy nutrition balance
- improve mobility and activity, encourage movement (ROM, walking etc.)
- Document measures used to prevent pressure ulcers and the results of these interventions.