High risk for pressure ulcer due to [specify].

Description
Record Id: 210 Code: 00210
The possibility of developing ... Please Login or Join to access this information
References
Moore, Z., & Patton, D. (2018). Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, 2018(1), CD006471. https://doi.org/10.1002/14651858.CD006471.pub4
Agrawal, K., & Chauhan, N. (2019). Pressure ulcers: Back to the basics. Indian Journal of Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India, 52(1), 27–33. https://doi.org/10.1055/s-0039-1683915
icon-outcomeOutcomes
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Record Id: 1541Will maintain skin integrity ... Please Login or Join to access this information
Description Client maintains skin ... Please Login or Join to access this information
Suggested days to Evaluation: 90
Rationale This nursing outcome ... Please Login or Join to access this information
Suggested Evaluation Date: 07/14/2026
Outcome References
Kosiak, M. (2017). Risk factors for pressure ulcer development in a best practice surgical intensive care unit. The American Journal of Surgery, 214(4), 567-572. doi: 10.1016/j.amjsurg.2017.01.024
Bergquist-Beringer, S., Gajewski, B., Dunton, N., & Klaus, S. (2017). The reliability of the National Database of Nursing Quality Indicators pressure ulcer indicator: a triangulation approach. Journal of Nursing Care Quality, 32(1), 75-84. doi: 10.1097/NCQ.0000000000000239
icon-actionActions
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Record Id: 1579Observe and record condition ... Please Login or Join to access this information
Description Involves regularly monitoring ... Please Login or Join to access this information
Rationale Checking skin routinely ... Please Login or Join to access this information
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Record Id: 1580Position in proper body ... Please Login or Join to access this information
Description Involves correctly positioning ... Please Login or Join to access this information
Rationale Positioning the body ... Please Login or Join to access this information
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Record Id: 1581Change client's postion every ... Please Login or Join to access this information
Description Involves routinely repositioning ... Please Login or Join to access this information
Rationale Changing a client's ... Please Login or Join to access this information
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Record Id: 1582Use pressure redistribution surface ... Please Login or Join to access this information
Description Involves using a ... Please Login or Join to access this information
Rationale Using a pressure ... Please Login or Join to access this information
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Record Id: 1583Use ____ cushion in ... Please Login or Join to access this information
Description Indicates the use ... Please Login or Join to access this information
Rationale Using a cushion ... Please Login or Join to access this information
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Record Id: 1584Use lifting device to ... Please Login or Join to access this information
Description A lifting device ... Please Login or Join to access this information
Rationale Lifting devices minimize ... Please Login or Join to access this information
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Record Id: 1585Observe all bony prominences ... Please Login or Join to access this information
Description Involves daily monitoring ... Please Login or Join to access this information
Rationale Regularly checking bony ... Please Login or Join to access this information
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Record Id: 1586Gentle massage with lotion ... Please Login or Join to access this information
Description Involves daily gentle ... Please Login or Join to access this information
Rationale Gentle daily massage ... Please Login or Join to access this information
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Record Id: 1587Observe for signs of ... Please Login or Join to access this information
Description Involves monitoring the ... Please Login or Join to access this information
Rationale Monitoring for infection ... Please Login or Join to access this information
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Record Id: 1588Keep skin clean and ... Please Login or Join to access this information
Description Involves maintaining client ... Please Login or Join to access this information
Rationale Maintaining clean, dry ... Please Login or Join to access this information
Action References
Watkins, T., Whisman, L., & Booker, P. (2021). Early recognition and response to increases in surgical site infections using optimized statistical process control charts—The case for real-time surveillance. Surgery, 169(5), 1069-1073. https://doi.org/10.1016/j.surg.2020.11.021
Moore, C., & Wilson, M. (2020). Nurses lead efforts at surveillance of surgical site infections. AORN Journal, 111(4), 408-415. https://doi.org/10.1002/aorn.12959
Lipsky, B. A., Dryden, M., Gottrup, F., Nathwani, D., Seaton, R. A., & Stryja, J. (2016). Antimicrobial Stewardship in Wound Care: A Position Paper from the British Society for Antimicrobial Chemotherapy and European Wound Management Association. Journal of Antimicrobial Chemotherapy, 71(11), 3026–3035. https://doi.org/10.1093/jac/dkw287
Vermeulen, H., Westerbos, S. J., & Ubbink, D. T. (2017). Benefit and harm of iodine in wound care: a systematic review. Journal of Hospital Infection, 77(1), 7-16. https://doi.org/10.1016/j.jhin.2010.06.027
Gray, M., Skinner, C., & Kaler, W. (2019). Perineal Skin Care for the Incontinent Patient. Journal of Wound, Ostomy and Continence Nursing, 46(3), 233-240. doi:10.1097/won.0000000000000537
Bliss, D. Z., Savik, K., Thorson, M. A., Ehman, S. J., Lebak, K., & Beilman, G. (2016). Incontinence-Associated Dermatitis in Critically Ill Adults: Time to Development, Severity, and Risk Factors. Journal of Wound, Ostomy and Continence Nursing, 43(4), 414–420. https://doi.org/10.1097/won.0000000000000238
Murch, N., Baker, P., Kennedy, J., & Parks, T. (2018). Right documentation-Right medication: The impact of electronic medication management systems on the work of nurses and the nurse-patient relationship. Journal Of Clinical Nursing, 27(21-22), 4106-4121. https://doi.org/10.1111/jocn.14591
Taxis, K., Barber, N. (2020). Ethnographic study of incidence and severity of intravenous drug errors. BMJ, 326(7391), 684. https://doi.org/10.1136/bmj.326.7391.684
National Institute for Health and Care Excellence. (2019). Surgical site infections: prevention and treatment. NICE Guideline 125. https://www.nice.org.uk/guidance/ng125
Hu, D., Li, H., Wang, H., Xu, H., Wu, Y., & Yang, X. (2017). Aseptic technique in total joint arthroplasty: An observational study. Journal of orthopaedic surgery and research, 12(1), 120. https://doi.org/10.1186/s13018-017-0629-7.
Perry, A. G., Potter, P. A., & Ostendorf, W. (2018). Clinical Nursing Skills and Techniques (9th ed.). Mosby Elsevier.
Lippincott. (2017). Lippincott procedures: Verification, preparation, and administration of medications. Wolters Kluwer.