W3 · Pressure sore present
Actual Wounds and skin
Definition
Skin and tissue over a bony area has broken down from pressure.- Prolonged pressure
- moisture
- friction
- poor nutrition
- Open sore over a bony area
- pain
- discharge
📋 Scenario
A bedbound patient has an open sore on the tailbone.
Subjective (S): "My tailbone is open."
Objective (O): Open sore on the sacrum, 4 cm; bedbound; moist skin.
Assessment tools for this scenario: CP-SKIN Skin & Wound Score
Validated scales to consider: Braden Scale, TIME wound chart
**CarePath diagnosis:** Pressure sore present related to prolonged pressure, as evidenced by a 4 cm open sore over the sacrum and moist skin.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Relieve pressure. | Pressure is what caused the damage, so taking it off the area allows blood to reach the tissue and healing to begin. |
| Dress as ordered. | The ordered dressing protects the wound, keeps it moist and clean, and lowers the chance of infection. |
| Turn regularly. | Changing position regularly stops pressure from building over the same bony area and protects other skin. |
| Support nutrition. | Protein, calories, fluids and vitamins supply what the body needs to repair damaged tissue. Good intake also helps the skin resist further damage. |
| Monitor. | Regular checks of size, color, drainage and pain show whether the wound is healing or getting worse. |
**Expected outcomes**
- Wound size reduces.
- No infection.
- Pressure relieved.
- Nutrition improves.
**Linking the data to the diagnosis**
The patient says, 'My tailbone is open.' There is an open sore on the sacrum measuring 4 cm, and he is bedbound with moist skin. Skin has already broken down, so this is an actual problem and not a risk of pressure injury. It rests on prolonged pressure and an open sore over a bony area. The plan aims for the wound to reduce in size, stay free of infection, keep pressure relieved and improve nutrition.
CarePath diagnosis
Pressure sore present related to prolonged pressure, as evidenced by a 4 cm open sore over the sacrum and moist skin.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Relieve pressure. | Pressure is what caused the damage, so taking it off the area allows blood to reach the tissue and healing to begin. |
| 2. Dress as ordered. | The ordered dressing protects the wound, keeps it moist and clean, and lowers the chance of infection. |
| 3. Turn regularly. | Changing position regularly stops pressure from building over the same bony area and protects other skin. |
| 4. Support nutrition. | Protein, calories, fluids and vitamins supply what the body needs to repair damaged tissue. Good intake also helps the skin resist further damage. |
| 5. Monitor. | Regular checks of size, color, drainage and pain show whether the wound is healing or getting worse. |
Expected outcomes
- Wound size reduces.
- No infection.
- Pressure relieved.
- Nutrition improves.
Linking the data to the diagnosis
The patient says, 'My tailbone is open.' There is an open sore on the sacrum measuring 4 cm, and he is bedbound with moist skin. Skin has already broken down, so this is an actual problem and not a risk of pressure injury. It rests on prolonged pressure and an open sore over a bony area. The plan aims for the wound to reduce in size, stay free of infection, keep pressure relieved and improve nutrition.