Definition of Decubitus Ulcer
Decubitus ulcer is damage or death of tissue under the skin until the skin even through the muscle to the bone, due to the emphasis on an area of ongoing, resulting in blood circulation disorders.
Decubitus ulcer is ulcers caused by strong pressure by the weight on the bed.
Etiology of Decubitus Ulcer
- Pressure
- Humidity
- Friction
- The initial injury is a reddish mark which does not disappear when pressed thumb.
- On a more serious injury encountered skin ulcers.
- It can arise pain and signs of systemic inflammation, including fever and increased white blood cell count.
- It can occur as a result of the weakness of infection and treatment in hospitals that continue even on a small ulcer.
Nursing Care Plan for Decubitus Ulcer
Nursing Assessment
- Activity / rest
Sign: decrease in strength, endurance, range of motion limitations in the area of pain. - Circulation
Signs: hypoxia, decreased peripheral pulse distal to the injured limb, general peripheral vasoconstriction with loss of pulse, white and cold skin, tissue edema formation. - Elimination
Signs: decreased urine output is the absence of the emergency phase, reddish color may be black, when it occurs, identify the muscle damage. - Food / fluid
Signs: general tissue edema, anorexia, nausea and vomiting. - Neuro Sensory
Symptoms: The area of numbness / tingling - Respiratory
Symptoms: Reduced function of the spinal cord, spinal edema, neurologic damage, paralysis of abdominal and respiratory muscles. - Ego Integrity
Symptoms: family problems, employment, finances, disability.
Signs: anxiety, crying, dependence, withdrawal, angry. - Security
Signs: a fracture due to location (fall, accident, up to electric shock).
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Nursing Diagnosis and Nursing Intervention for Decubitus Ulcer
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