Nursing process to a patient with pressure ulcers

Abstract

This study was carried out during the performance of a clinic practice, for which Virginia Henderson model was used. This paper is part of the nursing degree’s program of the FES Iztacala. An individualized case of a patient with paraplegia and decubitus ulcers, mobility and posture, security, elimination, body hygiene, rest and sleep, communication and learning needs is presented. This work was based on the paraplegia, decubitus ulcers topics and on specific nursing interventions. First, the assessment of the patient was made through a clinical record of Virginia Henderson. Needs were detected and specific objectives and interventions of nursing were planned in order to satisfy the detected needs and trying to lead the individual to independence. Nursing diagnoses were made on the basis of NANDA, among which we find: -Impaired physical mobility in inferior members, related with the incapability to move around. -Infection potential associated with the lost of the skin integrity, reveled by ulcerating lesions in the skin. -Total urinary and faecal incontinence related with medullary lesion of the lumbar vertebras, revealed by the incapability to urinate and evacuate by himself.