Pressure Ulcers and Nursing Diagnosis

  1. Hi, I am a first year nursing student at a local two year community college. I just have a question regarding pressure ulcers and am appropriate nursing diagnosis.

    So for a pressure ulcer there are 4 steps. Now hypothetically, if a patient had a ulcer that was on the back of their heel, with the appearance of black towards the anlke and going more distally, the underlying tissue looks fresh. I was wondering what stage that would be. To me it seemed like the distal part would be stage 2, but the proximal part would be recovering, But I'm not sure because it is black.

    Also I was wondering what type of nursing diagnosis. If they were a diabetic patient, would it be like Impaired tissue perfusion related to opening of the left ankle manifested by lowered blood sugar, bed restriced, limited mobility?

    Also for the long term and short them. Would long term be to go down in stages? and short term would be the occurance of new epithelium?

    Thanks so much for any input!
  2. Visit Calmperfection profile page

    About Calmperfection

    Joined: Nov '07; Posts: 1


  3. by   Daytonite
    hi, calmperfection, and welcome to allnurses!

    pressure ulcers are given as one stage, not staged by each geographical area of the ulcer. so, your patient's ulcer should be definitively stated as being a stage 1, 2, 3, or 4. some authorities would call this an unstageable ulcer because of that black stuff in the center of the ulcer. that black stuff is necrotic eschar, or built up dead tissue. gross, isn't it? under it is the viable, live tissue. because you cannot actually see the live tissue under it, that is the base of the ulcer, to determine how deep this thing actually is makes it hard to stage. the ulcer is a lot deeper than it appears. this ulcer defaults to a stage 3 unless any open muscle, bone, tendon or a joint capsule can definitely be identified in the open parts of the wound, in which case it would be classified as a stage 4 ulcer.

    here is some information on pressure ulcers and staging:
    i usually have a whole spiel i give about choosing nursing diagnoses because it involves the nursing process and really has nothing to do with what the patient's medical diagnoses are. nursing diagnoses are based upon symptoms the patient has that you discover through the process of assessing the patient. in this case you have an open wound for which you should have descriptive information (location, length, width, depth, appearance, presence of any drainage, any pain) which are all symptoms. the appropriate diagnosis to use is impaired skin integrity r/t destruction of skin layers aeb [location, length, width, depth, appearance, presence of any drainage, any pain of this pressure ulcer on the heel] here is a link to an online page about this nursing diagnosis: [color=#3366ff]impaired skin integrity your nursing goals and interventions are based upon the symptoms the patient has. those aebs things are what you are going to develop nursing interventions for (i.e., this foot ulcer). your short term goals/outcomes are nothing more than your prediction of what should occur as a result of performing those interventions. long term goals can aim more at the etiology of the problem--that would be the "destruction of skin layers" part of the nursing diagnostic statement. specifically, a long term goal would be to demonstrate some serious healing of the ulcer, perhaps to the stage 2 level. this means that you will need to know how healing occurs, so get a pathophysiology book and read up on cell and tissue healing because you'll need to know this information in order to make a good educated prediction (goal).

    does your patient also have problems with lowered blood sugar, bed restrictions and limited mobility? what specifically are they? this is information that should come from your assessment of the patient. is the diabetes out of control? how limited is the patient's mobility? can they walk? how far? do they need an assistive device? what kind?
    all this information needs to be known before an appropriate nursing diagnosis can be chosen.

    (from page 4 of nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig)
    "when the assessment is complete, identify common patterns/symptoms of response to actual or potential health problems and select an appropriate nursing diagnosis label using critical thinking skills.
    1. highlight or underline the relevant symptoms.
    2. make a short list of the symptoms.
    3. cluster similar symptoms.
    4. analyze/interpret the symptoms.
    5. select a nursing diagnosis label that fits with the appropriate related factors and defining characteristics.
    the process of identifying significant symptoms, clustering or grouping them into logical patterns, and then choosing an appropriate nursing diagnosis involves diagnostic reasoning (critical thinking) skills that must be learned in the process of becoming a nurse."
    there are two sticky threads (they always appear at the top of forum thread listings) on allnurses to help with care plan writing:
    also, since you are a student, you should be posting on either the nursing student assistance forum ( or the general nursing student discussion forum ( where you will get more response to your questions. you can also link into them by clicking on the "students" tab at the top of every allnurses page you are on. i will ask the moderators to move this thread to the nursing student assistance forum.

    if you are still needing help with choosing your nursing diagnoses please list more specific assessment information so i can help you out. i think that there are probably many more nursing diagnoses you can use, but without the assessment symptoms it would only be second guessing shots in the dark and i would want you to learn from doing this care plan as well as do a great job of it.
  4. by   Chloe'sinNYNow
    Hiya Day2nite,
    HUGEly helpful answer you have provided. Again I find myself so appreciative of your excellence in this profession and willingness to pass it on to us newbies. I am soooooooooooo grateful for both the links you provide as well as the explanation you write to go along w/ them.

    You show you care in so much you do. Thank you! You must be such a terrific nurse. I'll be your pt anyday!!!

  5. by   Daytonite
    Thank you, Chloe. It's more likely that I'll be your patient before you ever get to be mine. :icon_hug:
  6. by   Chloe'sinNYNow
    Quote from Daytonite
    Thank you, Chloe. It's more likely that I'll be your patient before you ever get to be mine. :icon_hug:
    Backatcha!!! :kiss