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NURSING PLAN OF ACTION.

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Precautions: The prevention is one of the basic nursing care, this care is especially relevant in patients admitted to hospital and intensive care units, as given its characteristics many of them are likely to develop pressure ulcers. Assess the risk of developing pressure ulcers at the time of hospital admission, and apply the scale of Braden 48 - 72 hours after hospitalization and periodically monitor the patient's clinical condition.


Any patient in hospital should have a systematic evaluation of the skin at least once every six hours, making emphasis on bony prominences, pressure inspecting each site to assess the status and integrity of the skin, looking for early signs of lesion, erythema, temperature changes, cracks, dryness or humidity. It is important to consider the educational objectives according to specific patient needs, according to a schedule for position changes have a special mattress, cushions, bumpers, etc., use proper body alignment techniques and the use of special support surfaces, to reduce pressure on likely reducing the bony ace! the risk of pressure sores and helping the rapid healing of existing ulcers. Given the Braden Scale, setting out the following preventive measures: Sensory Perception: This refers to the ability to respond appropriately to the discomfort that comes the pressure of the skin. Completely limited and hardly limited to: changes position every 2 hours using proper posture and functional. Lubricating the skin with each change of position, (alcohol-free creams, moisturizers, lanolin, forming protective film and is easily absorbed). Avoid massage over bony prominences. Using anti-bedsore mattress. Heel and elbow protectors. Use of other protection and support, such as pillows, foam wedges, pads, rolls. Place sheet of movement from the axillary region, to the region glútea.Colocar transparent dressings stage I and II or hydrocolloids superficial.Evitar ulceration of the skin moisture, especially in anatomical folds, armpits, breasts, English. Use devices that raise the heels to avoid pressure. Keep postural alignment, distributing the weight through support and protection devices.