Decubitus ulcer is damage or death of tissue under the skin until the skin even through the muscle to the bone, because of the emphasis on an area on an ongoing basis, resulting in impaired blood circulation.
Decubitus ulcers are ulcers that result from the strong pressure by the weight on the bed.
Etiology
- Pressure
- Humidity
- Friction
Pressure immobilization a long time, will result in pressure sores, if one part of the body is on a gradient (the difference between the two pressure points). Deeper tissue near the bone, especially muscle tissue with good blood supply will shift towards a lower gradient, while the skin is maintained at the contact surface by increasing friction with the presence of moisture, this situation led to stretching and angulation of blood vessels (micro circulation) in blood and tissue shear forces experienced in, it will be able to experience ischemia and necrosis before moving on to the skin.
Clinical Manifestations and Complications
- Initial injury is a sign of redness that does not disappear when pressed thumb.
- On a more serious injury encountered skin ulcers.
- Can arise pain and signs of systemic inflammation, including fever and increased white blood cell count.
- Infection can occur as a result of weakness and hospitalization is prolonged even in a small ulcer.
- Culture: artificial growth of microorganisms or tissue cells.
- Serum albumin: a major protein in plasma and other serous fluids.
- Changing the position of the patient who is bed rest.
- Relieving pressure on the skin reddened and placement of the pads are clean and thin when they have been shaped decubitus ulcers.
- Systemic: broad-spectrum antibiotic
Assessment - Nursing Care Plan for Decubitus Ulcer
a) Activity / rest
Signs: decreased strength, endurance, limited range of motion in the area of pain disorders, such as muscle buds change.
b) Circulation
Signs: hypoxia, decreased peripheral pulses distal to the injured limb, general peripheral vasoconstriction with loss of pulse, white and cold, the formation of tissue edema.
c) elimination
Signs: decreased urine output is the absence of the emergency phase, the color may be reddish black, in the event, identify potentially damage the muscle.
d) Food / fluid
Signs: tissue edema, anorexia, nausea and vomiting.
e) Neuro-sensory
Symptoms: The area of numbness / tingling
f) Respiratory
Symptoms: decreased function of the spinal cord, cord edema, neurologic damage, abdominal and respiratory muscle paralysis.
g) The integrity of the ego
Symptoms: family problems, employment, finances, disability.
Signs: anxiety, crying, dependency, self mmenarik, angry.
h) Security
Signs: a fracture due to location (fall, accident, tetanik muscle contraction, up to an electric shock).
Nursing Diagnosis - Nursing Care Plan for Decubitus Ulcer
1.Impaired Skin Integrity related to tissue destruction secondary to mechanical pressure, friction and factions.
2.Impaired Physical Mobility related to restriction of movement required, the conditioned status, loss of motor control due to changes in mental status.
3. Imbalanced Nutrition Less Than Body Requirements related to the inability of oral intake.
