Outcomes (NOC)	Interventions (NIC) and Rationales
Thermoregulation	Fever Treatment
• Hyperthermia ___ • Increased skin temperature ___ • Skin color change ___ • Dehydration ___ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None • Apical heart rate ___ • Respiratory rate ___ • Reported thermal comfort ___ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	• Monitor temperature as frequently as is appropriate to evaluate patient status. • Monitor blood pressure, pulse, and respiration to determine responses to increased temperature. • Administer antipyretic medication to lower temperature. • Cover the patient with only a sheet to aid in lowering body temperature. • Monitor for electrolyte abnormalities, acid-base imbalances, cardiac dysrhythmias, and decreasing level of consciousness to identify untoward responses to fever. • Monitor temperature closely to prevent treatment-induced hypothermia, which will cause a rebound rise in temperature. Temperature Regulation • Adjust environmental temperature to the patient’s needs to prevent negative environmental influence on body temperature. • Give appropriate medication to prevent or control shivering which would increase body temperature.

Nursing Diagnosis

Risk for deficient fluid volume related to increased metabolic rate, diaphoresis, and decreased oral intake.

Patient Goal

Maintains adequate fluid volume in the presence of fever

Outcomes (NOC)	Interventions (NIC) and Rationales
Fluid Balance	Hypovolemia Management
• Blood pressure ___ • Radial pulse rate ___ • Central venous pressure ___ • 24-hour intake and output balance ___ • Stable body weight ___ • Skin turgor ___ • Moist mucous membranes ___ • Hematocrit ___ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised • Orthostatic hypotension ___ • Thirst ___ • Soft, sunken eyeballs ___ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	• Monitor fluid status including intake and output and insensible fluid loss (e.g., diaphoresis) to determine risk for or presence of fluid volume deficit. • Encourage oral fluid intake to promote fluid balance. • Monitor weight because fluid loss is reflected in decreasing body weight. • Maintain a steady IV infusion flow rate to replace fluid lost as a result of fever and diaphoresis. • Monitor vital signs because increasing pulse and respirations and decreasing blood pressure can indicate hypovolemia. • Observe for indications of dehydration (e.g., poor skin turgor, delayed capillary refill, weak or thready pulse, severe thirst, dry mucous membranes, decreased urine output, hypotension) to ensure early treatment of fluid deficit. • Assist the patient with ambulation in case of postural hypotension, which results from hypovolemia.

^*Nursing diagnoses listed in order of priority

eNursing Care Plan 12-2 Patient With a Pressure Ulcer

Nursing Diagnosis

Impaired skin integrity related to mechanical factors, moisture, physical immobilization, imbalanced nutritional state, skeletal prominence, and/or impaired circulation as evidenced by presence of destructed skin layers consistent with a pressure ulcer

Patient Goals

1. Reduces or eliminates risk factors for pressure ulcers

2. Experiences no extension of ulcer stage

3. Experiences healing of pressure ulcer

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Integrity: Skin and Mucous Membranes	Pressure Ulcer Prevention
• Skin temperature ___ • Sensation ___ • Tissue perfusion ___ • Skin integrity ___ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised • Erythema ___ • Blanching ___ • Necrosis ___ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None Wound Healing: Secondary Intention • Purulent drainage ___ • Serous drainage ___ • Serosanguineous drainage ___ • Necrosis ___ • Sloughing ___ • Tunneling ___ Measurement Scale 1 = Extensive 2 = Substantial 3 = Moderate 4 = Limited 5 = None	• Use an established risk assessment tool to monitor individual’s risk factors (e.g., Braden scale [eTable 12-4]) to reduce or eliminate factors that contribute to development or progression of the pressure ulcer. • Document any previous incidences of pressure ulcer formation to identify specific risks to patient. • Remove excessive moisture on the skin resulting from perspiration, wound drainage, and fecal or urinary incontinence to prevent maceration. • Avoid massaging over bony prominences to prevent further tissue damage. • Turn every 1 to 2 hours to avoid prolonged pressure in one area. • Turn with care (e.g., avoid shearing) to prevent injury to fragile skin. • Position with pillows to elevate pressure points off the bed. • Use specialty beds and mattresses as needed to provide pressure relief and increase circulation to the site. • Use devices on the bed (e.g., sheepskin) that protect the individual from pressure. • Apply elbow and heel protectors as appropriate to avoid pressure. • Assist individual in maintaining a healthy weight as the risk for pressure ulcers is increased in people who are obese or very thin. Pressure Ulcer Care • Describe characteristics of the ulcer at regular intervals, including size (length × width × depth), stage (I to IV), location, exudate, granulation or necrotic tissue, and epithelialization to provide baseline and ongoing data for monitoring pressure ulcer. • Keep the ulcer moist to aid in healing. • Cleanse the ulcer with the appropriate nontoxic solution, working in a circular motion from the center to increase circulation to the site. • Debride ulcer, as needed, to promote new tissue growth. • Apply a permeable adhesive membrane, saline soaks, ointments, and/or dressings, as appropriate, to promote healing. • Verify adequate caloric and high-quality protein intake to provide nutrients necessary for tissue repair. • Teach individual or family member(s) wound care procedures to enhance self-care. • Instruct family member/caregiver about signs of skin breakdown to prevent recurrence. • Initiate consultation services of the enterostomal therapy nurse, as needed, for specialized direction of ulcer care.

eTABLE 12-1

WOUND CLASSIFICATION BY ETIOLOGY

The following classification system is based on the etiology of the wound.
Wound Type	Clinical Presentation
Diabetic Ulcers
Ischemic ulcers	• Occur distally as circulation is compromised and may present as a gangrenous toe or a wound with necrotic tissue. • Rubor (purple/dark red) will be associated with the affected tissue because of hypoxia. • With nerves intact, pain can be severe and increases as the limb is elevated.
Neuropathic ulcers	• Present on plantar surface of foot over metatarsal head prominences with a circular shape and pink wound bed. • Dorsal-aspect foot ulcers are associated with poorly fitting shoes.
Vascular Ulcers
Arterial ulcers	• Also known as ischemic ulcers, and the same description applies. • With nerves intact, these ulcers can be extremely painful. • If granulation tissue develops, it may be smooth and light pink in color. • Healing is slow, and wounds are prone to infection.
Venous ulcers	• Usually located on the inner (gaiter) or outer aspect of the lower leg just above the ankle. • Usually shallow with an irregular shape with sharp borders and beefy red wound bed. • May be accompanied by brown pigmentation of lower leg at ankle up to mid-calf area (hemosiderin deposits), scaly skin (dermatitis), and edema (long-term thickening of the tissue causing brawny edema).
Pressure ulcers	• Generally located over bony prominences and named as such (i.e., sacral ulcer). • Refer to stages in Table 12-13 for descriptions.
Atypical wounds	• Varied in clinical appearance and should be treated by a specialist. • Examples: Autoimmune disease (vasculitis, pemphigus), malignancies (melanoma, squamous cell carcinoma), sickle cell ulcerations, deep fungal infections, metabolic disorders (calciphylaxis presenting as cutaneous necrosis associated with end-stage renal disease), or external causes (e.g., brown recluse spider bite).

eTABLE 12-2

WOUND CLASSIFICATION SYSTEMS

Classification System	Description	Clinical Use
Surgical	Wounds are approximated and heal by primary intention if there are no complications.	All surgical incisions
Depth of Skin Destruction (superficial, partial, and full thickness)	Superficial has intact and inflamed tissue, partial thickness involves only dermis and epidermis, and full thickness extends through the dermis.	Abrasions, burns, skin grafts including donor sites
NPUAP Staging	See Table 12-13 in text	Pressure ulcers only
Payne-Martin	Category I: Skin tears without tissue loss. Linear types: skin is pulled apart with a linear tear. Flap types: an epidermal flap covers within 1 mm of the wound margin. Category II: Skin tears with partial tissue loss. Scant tissue loss types: Less than 25% or less of the epidermal flap is lost. Moderate to large types: More than 25% of the epidermal flap is lost. Category III: Skin tears with complete tissue loss.	Skin tears
Meggit-Wagner	Grade 0: No open lesion but may have deformity or cellulitis Grade 1: Superficial ulcer, partial or full-thickness Grade 2: Ulcer extends to ligament, tendon, joint capsule, or fascia; no abscess or osteomyelitis Grade 3: Deep ulcer with abscess, osteomyelitis, or joint sepsis Grade 4: Gangrene localized to forefoot or heel Grade 5: Extensive gangrene	Originally developed to classify diabetic foot ulcers. This system has been modified and used with other ulcers and wounds because of descriptors of tissue depth, infection, and necrosis.
University of Texas	Grading Grade 0: Epithelialized wound Grade 1: Superficial wound Grade 2: Wound penetrates to tendon or capsule Grade 3: Wound penetrates to bone or joint Stages Stage A: No infection or ischemia Stage B: Infection present Stage C: Ischemia present Stage D: Infection and ischemia present	Originally developed for diabetic foot wounds. Has been validated in other locations. This system uses two tiers; grades a wound 0-3 and uses stage descriptors A-D to more specifically describe the wound.

eTABLE 12-3

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK

Patient Name ____________________________________			Evaluator’s Name _______________________________
Point Value				Date of Assessment and Score
1	2	3	4
Sensory Perception: Ability to Respond Meaningfully to Pressure-Related Discomfort
Completely limited: unresponsive (does not moan, flinch, or grasp) to painful stimuli, because of diminished level of consciousness or sedation OR limited ability to feel pain over most of body	Very limited: responds only to painful stimuli; cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment that limits the ability to feel pain or discomfort over half of body	Slightly limited: responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment that limits ability to feel pain or discomfort in one or two extremities	No impairment: responds to verbal commands; has no sensory deficit that would limit ability to feel or to voice pain or discomfort
Moisture: Degree to Which Skin Is Exposed to Moisture
Constantly moist: skin is kept moist almost constantly by perspiration, urine, etc.; dampness is detected every time patient is moved or turned	Very moist: skin is often, but not always, moist; linen must be changed at least once per shift	Occasionally moist: skin is occasionally moist, requiring an extra linen change approximately once per day	Rarely moist: skin is usually dry; linen only requires changing at routine intervals
Activity: Degree of Physical Activity
Bedfast: confined to bed	Chairfast: ability to walk severely limited or nonexistent; cannot bear own weight and/or must be assisted into chair or wheelchair	Walks occasionally: walks occasionally during day, but for very short distances, with or without assistance; spends most of each shift in bed or chair	Walks frequently: walks outside room at least twice per day and inside room at least once every 2 hours during waking hours
Mobility: Ability to Change and Control Body Position
Completely immobile: does not make even slight changes in body or extremity position without assistance	Very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently	Slightly limited: makes frequent although slight changes in body or extremity position independently	No limitation: makes major and frequent changes in position without assistance
Nutrition: Usual Food Intake Pattern
Very poor: never eats a complete meal; rarely eats more than half of any food offered; eats two servings or less of protein (meat or dairy products) per day; takes fluids poorly; does not take a liquid dietary supplement or is NPO and/or maintained on clear liquids or IVs for more than 5 days	Probably inadequate: rarely eats a complete meal and generally eats only about half of any food offered; protein intake includes only three servings of meat or dairy products per day; occasionally will take a dietary supplement or receives less than optimum amount of liquid diet or tube feeding	Adequate: eats over half of most meals; eats four servings of protein (meat or dairy products) per day; occasionally will refuse a meal, but will usually take a supplement when offered or is on a tube feeding or parenteral nutrition regimen that probably meets most nutritional needs	Excellent: eats most of every meal; never refuses a meal; eats four or more servings of protein (meat or dairy products); occasionally eats between meals; does not require supplementation
Friction and Shear
Problem: requires moderate to maximum assistance in moving; complete lifting without sliding against sheets is impossible; frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance; spasticity, contractures, or agitation lead to almost constant friction	Potential problem: moves feebly or requires minimum assistance; during a move, skin probably slides to some extent against sheets, chair, restraints, or other devices; maintains relatively good position in chair or bed most of the time but occasionally slides down	No apparent problem: moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move; maintains good position in bed or chair
Scoring: To obtain a patient’s pressure ulcer risk assessment score, add the numeric scores for the factors in each of the six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction and shear) to obtain the total score. Scores can range from 6 to 23. The lower the numeric score, the higher the patient’s predicted risk of developing a pressure ulcer. Incremental changes in the score indicate the level of risk: no risk (19 to 23), at risk (15 to 18), moderate risk (13 to 14), high risk (10 to 12), and very high risk (9 or below).

From Braden B, Bergstrom N: Predictive validity of the Braden scale for pressure sore risk in a nursing home population, Res Nurs Health 17:459, 1994.

eTABLE 12-4

PRESSURE ULCER SCALE FOR HEALING (PUSH)
PUSH Tool 3.0

Patient Name ___________________________________	Patient ID# __________________
Ulcer Location ___________________________________	Date _______________________

Directions
Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area, exudate, and type of wound tissue. Record a sub-score for each of these ulcer characteristics. Add the sub-scores to obtain the total score. A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing.
LENGTH × WIDTH (in cm²)	0 0	1 <0.3	2 0.3-0.6	3 0.7-1.0	4 1.1-2.0	5 2.1-3.0	Sub-score
		6 3.1-4.0	7 4.1-8.0	8 8.1-12.0	9 12.1-24.0	10 >24.0
EXUDATE AMOUNT	0 None	1 Light	2 Moderate	3 Heavy			Sub-score
TISSUE TYPE	0 Closed	1 Epithelial Tissue	2 Granulation Tissue	3 Slough	4 Necrotic Tissue		Sub-score
							TOTAL SCORE
*Length × Width*
Measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler. Multiply these two measurements (length × width) to obtain an estimate of surface area in square centimeters (cm²). caveat: Do not guess! Always use a centimeter ruler and always use the same method each time the ulcer is measured.
*Exudate Amount*
Estimate the amount of exudate (drainage) present after removal of the dressing and before applying any topical agent to the ulcer. Estimate the exudate (drainage) as none, light, moderate, or heavy.
*Tissue Type*
This refers to the types of tissue that are present in the wound (ulcer) bed. Score as a “4” if there is any necrotic tissue present. Score as a “3” if there is any amount of slough present and necrotic tissue is absent. Score as a “2” if the wound is clean and contains granulation tissue. A superficial wound that is reepithelializing is scored as a “1.” When the wound is closed, score as a “0.”
4. Necrotic tissue (eschar): Black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin. 3. Slough: Yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. 2. Granulation tissue: Pink or beefy red tissue with a shiny, moist, granular appearance. 1. Epithelial tissue: For superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface. 0. Closed/resurfaced: The wound is completely covered with epithelium (new skin).
www.npuap.org PUSH Tool Version 3.0: 9/15/98.
11F ©National Pressure Ulcer Advisory Panel.
Pressure Ulcer Healing Chart
To monitor trends in PUSH Scores over time

Patient Name ___________________________________	Patient ID# ________________
Ulcer Location ___________________________________	Date _____________________
Directions
Observe and measure pressure ulcers at regular intervals using the PUSH Tool.
Date and record PUSH Sub-scores and Total Scores on the Pressure Ulcer Healing Record below.

Pressure Ulcer Healing Record
Date
Length × width
Exudate amount
Tissue type
PUSH Total Score
Graph the PUSH Total Scores on the Pressure Ulcer Healing Graph below.
PUSH Total Score	Pressure Ulcer Healing Graph
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Healed = 0
Date