Page 87 - LECTURE NOTES

Stage IV

Ulcer extend in to the under lying structure including muscle possibly the bone. The skin
lesion may represent only the tip of ice berg” between small surface ulcer may overlie a

large under lining area.
The appearance of pus or foul odor is suggestive sign of infection

Nursing diagnosis

Impaired skin integrity related to any of the contributing factors.

Nursing goal
The major goals of nursing may include relief of pressure; improve mobility, improved

nutritional status and tissue perfusion.

Nursing interventions
1. Relieving pressure – frequent change of position by using variety of pads &

supportive device to prominent area or if it is possible use flotation or water bed.
2. Improve mobility – patient is encouraged to remain active, passive and active

exercise help to increase muscular skin and vascular tone.

3. Improve sensory perception- by increased awareness of self
4. Improve tissue perfusion- exercise and repositioning will improve tissue perfusion

5. Improve nutritional status- high protein and iron will be given to increase the level
of hemoglobin

6. Reduce friction - Make the bed daily & as needed to give comfort
7. Minimizing moisture- soiled skin should be washed with mild soap and water and

then dry with soft towels and if the patient is in continent urine catheterization will

be done
8. Maintain skin integrity by offering bath

9. Teach the family about frequent position and the important of skin hygiene.
10. Give the prescribed antibiotic

11. Dress the wound accordingly

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