Running head: PREVENTING PRESSURE ULCERS IN THE IMMOBILE CLIENT

Preventing Pressure Ulcers In The Immobile Client

Jodie McAmmond
NorQuest College
NFDN 2003, SEC D01
Assignment 2
Kim Harper
October 31, 2013

Bed rest and immobilization is a time honored treatment for managing trauma, acute and
chronic illness. Bed rest and immobilization often benefit the affected part of the body, but they
sometimes harm the rest of the body leading to complications. Pressure ulcers are a serious
health issue for the immobilized patient in all kinds of settings, even for those who are at home.
Pressure sores or decubitus ulcers are localized areas of cellular necrosis, found over bony
prominences that have external pressure greater then capillary pressure for prolonged periods.
Pressure ulcers also occur because of shearing, friction, malnutrition and maceration of the skin.
Pressure ulcers occur most often in immobilized clients such as spinal cord injuries and the
elderly because they are unable to turn themselves without assistance. The prevalence of
pressure ulcers in Canada is 25% in acute care, 30% in non-acute care, 22% in mixed health-care
settings, and 15% in community care (Woodbury, 2004). This data shows that pressure ulcers
are a significant concern in the health field today, causing patient pain, increased work for health
professionals and costs for the health care system. Increased awareness about pressure ulcers,
and commitment to best practice actions to prevent the complication are required by patients,
families and health care professionals.

Nurses and other health care professionals have often used bed linens to reposition
clients, increasing the risk of shear and friction predisposing the clients risk to impaired skin
integrity. Dragging the client on sheets and other bed linens will place the client at high risk of
shearing and friction injuries (Perry & Potter, 2010). Not only has it caused risk to the patient,
but also to the nurses back because of improper body mechanics. The use of a traditional draw
sheet or a soaker pad for repositioning a patient up in bed creates high internal compressive
and anterior-posterior forces at the L5/S1 disk due to the forceful lifting action combined with
bending, twisting and other awkward postures (WCB, 2010). Transfer assist devices such as

slider sheets enable patients to be slid up a surface or over on their side much more easily. Slider
sheets are made of specialized slippery fabric with low-friction inner surfaces that glide over
themselves. They are cost effective for the health system as they range from twenty to forty
dollars, they are comfortable for the client to lie on, and easy to use. Not only do they reduce the
risk of shear and friction to the patients skin, they also reduce the amount of strain repositioning
can put on a nurse.

The prevention measures are series of simple and repeated best practice actions
performed by the individual and the health care team. Identifying who is at risk for developing
pressure ulcers is a crucial step in prevention. Risk Assessment tools such as the Braden Scale is
widely used and effective tool for assessing those at risk. The Braden Scale comprises six
subscales: sensory perception, moisture activity, mobility, nutrition, friction and shear. The total
score ranges from 6 to 23, and a lower total score indicates a higher risk of pressure ulcer
development (Perry and Potter, 2010). The overall goal is to prevent prolonged contact by
repositioning every two hours and identify any signs of redness of the skin by monitoring daily.
Best practice nursing interventions such as educating patients, caregivers and families about the
patients ability to develop ischemic pain related to prolonged pressure. Encourage and educate
patients to be mobile as possible and be as active as their body allows. Making sure the client is
receiving adequate nutrition as it plays an important role in resistance to developing pressure
ulcers. Another best practice intervention is to implement full range of motion pressure reduction
exercises and protect the client skin against forces of friction and shear. Pressure ulcers from
friction and shear occur when the patient slides down in bed or when the patient is moved or
positioned improperly (e.g., dragged up in bed) (Brunner & Suddarths, 2010). Patients who are
exposed to skin maceration caused by urinary, fecal incontinence or perspiration are also at great

risk. It is important for health professionals to educate the patient and family on the importance
of keeping the skin dry, and to monitor daily.

Educating patients, families, and caregivers regarding the purpose of best practice actions
used to prevent pressure ulcers associated with prolonged immobilization is key. Best practice
actions to educate clients on are the importance of being mobile as possible, reposition every two
hours, assistive devices, range of motion exercises and nutrition. A variety of methods can be
implemented for the educational process such as photographs, videos, charts and diagrams.
Consulting with other interdisciplinary team members such as nutrition specialist, occupational
therapist, and physiotherapist can help contribute to home care, prevention plans and goals.
Wound prevention and care is not solely responsibility of the nurse. In fact, it is a team effort
that includes the physiotherapist, occupational therapist, dietician, pharmacist, physician, as well
as the client (Perry and Potter, 2010).

Systematic efforts of education, specific best practice interventions and awareness

practiced by patients, families and health professionals, the high incidence of pressure ulcers can
be reduced. Using assistive transfer devices such as slider sheets help reduce the incidence of
shear and friction to patients skin, and helps reduce injuries to the health professional. Patients
admitted to hospitals, and long-term care facilities need education, daily nursing assessments,
and early interventions to prevent permanent disabilities and life-threatening complications, like
pressure ulcers.

5
Nursing Care Plan (One Page per Nursing Diagnosis)
Nursing Diagnosis

Planning

Use assessment data to establish a

nursing diagnosis that reveals:

an actual problem

a potential problem

an educational need or a
need related to medication
administration

1. Client Goals: Write one

specific and measurable client behavioral
response.
2. Expected Outcomes: Write statements in
measurable terms that support the goal by
using the SMART criteria:
Specific
Measurable
Attainable
Realistic
Time-based

Impaired skin integrity r/t

immobility aeb reddened
skin on coccyx.

Goal: Client will remain free of

further skin breakdown.

Expected Outcome: Client will

show no signs of further skin
breakdown and will be able to
verbalize two interventions
needed to prevent further
breakdown of skin by the end of
my 8 hour shift.

Interventions
1.

List Interventions:
Select nursing interventions to meet the goals
set, and to change or maintain health status

2.

Rationale for Interventions:

Provide rationale for selection of nursing
interventions and use appropriate literature
such as text, articles, and internet sites to
support internet sites to support choices

Evaluation
1.

2.

3.

Achievement of Expected Outcomes:

Assess goal achievement and reasons, and set new plan as
needed
Client Responses and findings:
Describe why goal was met or not met. Summarize the
effectiveness of nursing interventions
Further Nursing Actions: Assess evidence that outcome
was met. Readjust nursing care plan as necessary

1.Reposition every 2 hours to relieve

pressure off bony prominences.

Goal: Goal was met, patients skin has had no

further breakdown of skin

Positioning interventions reduce pressure

and shearing force to the skin (Perry and
Potter, 2010. P 1263)

Expected outcome: Expected outcome met. By

the end of my 8 hour shift patient verbalized she
could not raise the head of her bed more than 30
degrees. Patient stated she would call for nurse if
she felt sore, or has not been repositioned every
two hours

2.Keep the skin clean and dry to prevent

skin maceration
Make an effort to control, contain, or
correct incontinence, perspiration, and
wound drainage (Perry and Potter,2010, p
1264).
3.Keep head of bed elevated less the thirty
degrees
Elevating the head of the bed to 30
degrees or less will decrease the chance of
pressure ulcer development from shearing
forces. (RNAO, 2011)

No further interventions are needed.

6
Nursing Care Plan (One Page per Nursing Diagnosis)
Nursing Diagnosis

Planning

Interventions

Evaluation

Use assessment data to establish a nursing

diagnosis that reveals:

an actual problem

a potential problem

an educational need or a need

related to medication
administration

3. Client Goals: Write one

specific and measurable client behavioral
response.
4. Expected Outcomes: Write statements in
measurable terms that support the goal by using
the SMART criteria:
Specific
Measurable
Attainable
Realistic
Time-based

At risk for joint contractures

r/t immobility aeb clients
decreased range of motion.

Goal: Client will not form

contractures.

1.Client participate in active ROM in

those joint able to perform normal range

Goal: Goal was met, client remains free of

contractures

Expected Outcome: Client will

participate in active ROM
exercises of upper and lower
extremities within normal limits
at least once during my 8 hour
shift.

Active ROM exercises help maintain

function of the musculoskeletal system
(Perry and Potter, 2010).

Expected Outcome: Client remains free of

contractures by participating in active and
passive range of motion exercises at least every
24 hours.

3.

List Interventions:
Select nursing interventions to meet the goals set, and
to change or maintain health status

4.

Rationale for Interventions:

Provide rationale for selection of nursing interventions
and use appropriate literature such as text, articles, and
internet sites to support internet sites to support choices

2.Nurse will perform passive ROM for the

joints unable to perform normal range.
Contractures can begin to form only 8
hours of immobility in the older client
(Perry and Potter, 2010).
3.Educate the patient on how important it
is for her to be as mobile as possible to
prevent further complications
The greater the extent and the longer the
duration of immobility the more
pronounced are the consequences (Potter
and Perry, 2010).

4.
5.

6.

Achievement of Expected Outcomes:

Assess goal achievement and reasons, and set new plan as needed
Client Responses and findings:
Describe why goal was met or not met. Summarize the
effectiveness of nursing interventions
Further Nursing Actions: Assess evidence that outcome was met.
Readjust nursing care plan as necessary

Goal and expected outcomes were met, no

further interventions are needed.

7
Nursing Care Plan (One Page per Nursing Diagnosis)

Nursing Diagnosis

Planning

Use assessment data to establish a nursing diagnosis

that reveals:

an actual problem

a potential problem

an educational need or a need related

to medication administration

5.

Deficient knowledge r/t

pressure ulcer prevention
aeb client stating she does
not know how to prevent
pressure ulcers from
occurring.

Goal: Client learns how to

prevent pressure ulcers.

6.

Client Goals: Write one

specific and measurable client behavioral response.
Expected Outcomes: Write statements in measurable terms
that support the goal by using the SMART criteria:
Specific
Measurable
Attainable
Realistic
Time-based

Expected outcome: Client will

be able to implement a positive
feedback mechanism by
explaining three interventions to
prevent pressure ulcers by the
time of discharge.

Interventions
5.

List Interventions:
Select nursing interventions to meet the goals set, and to change or
maintain health status

6.

Rationale for Interventions:

Provide rationale for selection of nursing interventions and use
appropriate literature such as text, articles, and internet sites to
support internet sites to support choices

1.Assess ability to learn or perform

desired health -related care.
Matching the learners preferred style
with the educational method facilitates
success in mastery of knowledge
(Brunner & Suddarths, 2010).
2.Educate client on daily skin inspection
and blanching.
Routine skin assessments will identify
changes in clients risk of pressure ulcers.
Nonblanchable erythema or discoloration
in clients skin may be early indicator of
skin injury (Perry & Potter, 2010).
3.Educate client on importance of
adequate nutrition and fluids
Deficiencies in any of the nutrients result
in impaired or delayed wound healing.
Physiologic processes of wound healing
depend on the availability of protein,
vitamins (especially A and C), and the
trace minerals zinc and copper (Perry &
Potter, 2010).

Evaluation
7.
8.
9.

Achievement of Expected Outcomes:

Assess goal achievement and reasons, and set new plan as needed
Client Responses and findings:
Describe why goal was met or not met. Summarize the effectiveness of nursing
interventions
Further Nursing Actions: Assess evidence that outcome was met. Readjust
nursing care plan as necessary

Goal was met, patient had positive feedback

mechanism of understanding on how to prevent
pressure ulcers
Expected Outcome was met by client verbalizing
three interventions on how to prevent pressure
ulcers before she was discharged.
No further nursing interventions are needed.

References
Day, R., Paul. P., Williams, B,. Smeltzer. S,. Bare, B., (2010) Brunner & Suddarthss Textbook
of Canadian Medical-Surgical Nursing (second edition). Philadelphia, PA: Lippincott
Williams and Wilkins.
Potter, P and Perry, A. (2010). Canadian Fundamentals of Nursing (revised fourth edition).
Toronto, ON: Reed Elsevier Canada.
Registered Nurses Association of Ontario. (2010). Positioning in Long Term- Care. Self Directed
Learning Package for Health Care Providers. Retrieved October 27, 2013 from:
http://rnao.ca/sites/rnao-ca/files/Positioning_Techniques_in_Long-Term_Care_-_Selfdirected_learning_package_for_health_care_providers.pdf
Woodbury, M and Houghton, P. (2004) Prevalence of pressure ulcers in Canadian health-care
settings. Ostomy/Wound Management. Retrieved October 22, 2013 From:
http://www.preventpressureulcers.ca/library/woodbury.pdf
Workers Compensation Board. (2010). Changing the Sheet: The Slider Sheet System. Work Safe
British Columbia. Retrieved October 22, 2013 from:
http://www.wcb.ns.ca/app/DocRepository/5/Prevention/Education/McGovern_Slider_Sh
eet_Phase_2.pdf