Pressure Injury Nursing Care Plan Example

Pressure injuries (formerly known as pressure ulcers or bedsores) are a significant patient safety concern across all care settings. They cause pain, increase infection risk, prolong hospitalization, and are largely preventable with proper nursing care. This example demonstrates a comprehensive nursing care plan for a patient with an existing pressure injury and risk for further skin breakdown, using NANDA-I diagnoses, NIC interventions, and NOC outcomes.

Condition Overview

A pressure injury is localized damage to the skin and/or underlying tissue, usually over a bony prominence or related to a medical device, resulting from sustained pressure or pressure in combination with shear. The underlying mechanism involves compression of tissue between a bony prominence and an external surface, which occludes capillary blood flow (capillary closing pressure is approximately 32 mmHg). When tissue perfusion is impaired for a sustained period, ischemia leads to cellular death, necrosis, and eventual ulceration.

The National Pressure Injury Advisory Panel (NPIAP) classifies pressure injuries into stages: Stage 1 (non-blanchable erythema of intact skin), Stage 2 (partial-thickness skin loss presenting as a shallow open ulcer or blister), Stage 3 (full-thickness tissue loss — subcutaneous fat may be visible), Stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), Unstageable (full-thickness loss obscured by slough or eschar), and Deep Tissue Pressure Injury (persistent non-blanchable deep red, maroon, or purple discoloration). Common locations include the sacrum, coccyx, heels, ischial tuberosities, trochanters, and occiput. Risk factors include immobility, impaired sensation, poor nutrition, moisture exposure (incontinence), advanced age, and conditions that impair perfusion (diabetes, peripheral vascular disease, heart failure).

Typical Patient Presentation

Patients at risk for or presenting with pressure injuries are often those with limited mobility — post-stroke patients with hemiplegia, post-surgical patients with prolonged bed rest, spinal cord injury patients, critically ill patients in the ICU, and elderly patients with multiple comorbidities and nutritional deficiencies. The pressure injury may be discovered during a routine skin assessment (underscoring the importance of admission and daily skin checks) or may be present on admission from a prior care setting.

Assessment of an existing pressure injury includes location, stage, dimensions (length x width x depth in centimeters), wound bed characteristics (granulation tissue, slough, eschar, exposed structures), wound edges (rolled, attached, macerated), drainage (serous, sanguinous, purulent — amount, color, odor), presence of undermining or tunneling (direction and depth), and surrounding skin condition (erythema, induration, temperature, color changes). Pain assessment at the wound site is essential, as pressure injuries can be significantly painful, particularly during dressing changes.

Sample Assessment Scenario

NANDA-I Nursing Diagnoses

1. Impaired Skin Integrity (00046)

Definition: Altered epidermis and/or dermis.

Related factors: Pressure over bony prominences (sacrum), shear forces, immobility (bed-bound since surgery), impaired circulation (PVD, CHF with low EF), malnutrition (albumin 2.8, prealbumin 12, BMI 19.2, poor oral intake), advanced age, diabetes mellitus (impaired wound healing).

Evidence: Stage 2 pressure injury sacrum (3 x 2.5 x 0.2 cm), Stage 1 bilateral heels and right trochanter, Braden Scale 12 (high risk).

2. Imbalanced Nutrition: Less Than Body Requirements (00002)

Definition: Intake of nutrients insufficient to meet metabolic needs.

Related factors: Decreased appetite secondary to depression, pain, hospitalization, and illness. Increased metabolic demands from surgical healing and wound repair.

Evidence: BMI 19.2 (underweight), albumin 2.8 g/dL (below normal 3.5-5.0), prealbumin 12 mg/dL (below normal 15-36, indicating acute protein depletion), eating less than 25% of meals since admission, Braden nutrition subscale score of 1 (very poor).

3. Impaired Physical Mobility (00085)

Definition: Limitation in independent, purposeful physical movement.

Related factors: Post-operative status (ORIF right hip), pain, reluctance to mobilize, deconditioning, depression affecting motivation, Braden activity subscale 1 and mobility subscale 2.

Evidence: Bed-bound since POD 0, has not participated in physical therapy, reluctant to move in bed due to pain and fear.

4. Risk for Infection (00004)

Definition: Susceptibility to invasion and multiplication of pathogenic organisms.

Risk factors: Open wound (Stage 2 pressure injury), malnutrition (impaired immune function), diabetes mellitus (hyperglycemia impairs white blood cell function), chronic kidney disease, advanced age, surgical wound (ORIF site).

NIC Interventions

For Impaired Skin Integrity

• Pressure Injury Prevention (3540): Reposition every 2 hours using a written turning schedule posted at bedside (supine → 30-degree left lateral → supine → 30-degree right lateral, avoiding direct pressure on right trochanter where Stage 1 injury exists). Avoid positioning directly on the sacral wound — use 30-degree lateral positions to offload. Float heels off the bed surface using a pillow under the calves (ensure calves are not creating pressure points). Obtain a pressure redistribution mattress (alternating pressure or low-air-loss surface) — the standard hospital mattress is insufficient for a Braden score of 12. Use a pressure-relieving cushion when in a wheelchair or chair. Limit chair time to 2 hours maximum between repositioning. Manage moisture — apply barrier cream to perineal area, change incontinence pads promptly. Perform comprehensive skin assessment head-to-toe every shift, documenting all bony prominences.
• Wound Care (3660): Perform sacral wound care per wound care team recommendations. For a Stage 2 granulating wound: cleanse gently with normal saline using a 30 mL syringe with an 18-gauge angiocath to achieve adequate irrigation pressure (4-15 psi) without damaging granulation tissue. Apply a moisture-retentive dressing (hydrocolloid or foam dressing) to maintain a moist wound healing environment. Change dressing per protocol (typically every 3 days for hydrocolloid, daily for foam, or as needed if soiled or dislodged). Measure wound dimensions weekly to track healing progress. Document wound bed, drainage, edges, and surrounding skin with each dressing change. Photograph wound weekly per facility policy. Monitor for signs of infection: increased erythema, warmth, swelling, purulent drainage, odor, increased pain.
• Skin Surveillance (3590): Assess Stage 1 areas on bilateral heels and right trochanter every shift for progression. Monitor the surgical incision site (ORIF) for integrity. Inspect under medical devices (oxygen tubing, SCDs, catheter securement) for device-related pressure injury. Document all findings using standardized wound assessment terminology.

For Imbalanced Nutrition

• Nutritional Counseling (5246): Consult dietitian within 24 hours for caloric and protein goals (wound healing typically requires 30-35 kcal/kg/day and 1.25-1.5 g protein/kg/day). For this patient at 112 lbs (50.9 kg), the target is approximately 1,525-1,780 calories and 64-76 grams of protein daily. Offer high-protein supplements (protein shakes) between meals. Provide small, frequent meals if large meals are overwhelming. Assess food preferences and cultural considerations. Request a dietitian evaluation of micronutrient needs (Vitamin C and zinc support wound healing). Monitor blood glucose closely — hyperglycemia impairs wound healing and immune function (target below 180 mg/dL). Address depression as a barrier to appetite — consult psychiatric services or adjust antidepressant if needed.
• Nutritional Monitoring (1160): Weigh patient weekly. Monitor calorie counts for 3 days to assess actual intake versus goals. Track albumin and prealbumin trends (prealbumin has a shorter half-life and reflects recent nutritional changes better). Monitor for refeeding syndrome in severely malnourished patients (electrolyte shifts — check phosphorus, potassium, magnesium). If oral intake remains below 50% of goals after 3 days of intervention, discuss enteral supplementation or tube feeding with the provider and patient.

For Impaired Physical Mobility

• Exercise Therapy: Joint Mobility (0224):Consult PT/OT for mobilization plan within weight-bearing restrictions. Perform passive ROM exercises for unaffected extremities every shift. Encourage active ROM as tolerated. Premedicate for pain before PT sessions (30-45 minutes prior). Address the patient's reluctance to mobilize — explain the connection between immobility and pressure injury development, as well as other complications (DVT, pneumonia, contractures, further deconditioning). Set small, achievable daily goals. Progress from bed mobility → dangling → standing → chair sitting → ambulation as tolerated.

For Risk for Infection

• Infection Protection (6550): Use clean technique for dressing changes (sterile technique for Stage 3-4 wounds). Hand hygiene before and after wound care. Monitor wound at each dressing change for signs of infection (remember: malnutrition and diabetes blunt the inflammatory response, so classic infection signs may be subtle). Monitor systemic signs: temperature every 4 hours, WBC trends, blood glucose trends. Optimize glycemic control (hyperglycemia above 180 mg/dL impairs neutrophil function). Ensure adequate nutrition to support immune function. If wound infection is suspected, obtain wound culture (tissue biopsy or Levine technique, not swab culture from wound surface).

NOC Outcomes

Wound Healing: Secondary Intention (1103)

• Target: Sacral Stage 2 wound showing size reduction (at least 20-40% area reduction in 2 weeks indicates healing trajectory)
• Indicator: Wound bed remains 100% granulation tissue without signs of deterioration
• Indicator: No conversion to Stage 3 or development of new pressure injuries
• Indicator: Stage 1 areas on heels and trochanter resolved (non-blanchable erythema resolves)

Nutritional Status (1004)

• Target: Caloric intake at least 75% of calculated goal within 5 days
• Indicator: Protein intake meeting target of 64-76 g/day with supplements
• Indicator: Prealbumin trending upward by week 2
• Indicator: Blood glucose maintained below 180 mg/dL

Mobility (0208)

• Target: Patient out of bed to chair at least 3 times daily by day 5
• Indicator: Participates in PT sessions without refusal
• Indicator: Assists with repositioning in bed (weight shifts)

Tissue Integrity: Skin & Mucous Membranes (1101)

• Target: No new pressure injuries develop during hospitalization
• Indicator: Skin remains intact over all bony prominences except existing injuries
• Indicator: No signs of wound infection throughout hospitalization

Discharge Planning Considerations

Pressure injury care often continues beyond hospitalization. Discharge planning should include wound care education for the patient and caregivers (or arrangement of home health nursing for wound care), a pressure redistribution mattress for home or the receiving facility, nutritional supplements and dietary counseling continuation, a repositioning schedule that caregivers understand and can implement, a follow-up appointment with wound care clinic or primary care provider within 1-2 weeks, durable medical equipment orders (hospital bed, wheelchair cushion, heel protectors), and communication of the current wound status, treatment plan, and staging to the receiving care team. If discharging to a skilled nursing facility, the pressure injury staging and wound care orders must be clearly communicated in the transfer documentation.

Building Your Own Pressure Injury Care Plan

Pressure injury care plans must be individualized based on the wound stage, location, patient comorbidities (diabetes, PVD, CKD), nutritional status, mobility level, and care setting. This example addresses an elderly post-operative patient with an existing Stage 2 sacral pressure injury, Stage 1 injuries at other sites, and significant nutritional deficits. A patient with a Stage 4 wound or a device-related pressure injury would require different wound care approaches.

CarePlanHQ generates individualized pressure injury care plans from your assessment data. Enter the Braden Scale scores, wound measurements, nutritional labs, and mobility status to receive a complete NANDA-I care plan with evidence-based interventions, measurable outcomes, and a downloadable PDF.