High risk for pressure ulcer due to [specify].

Description
The possibility of developing ... Please Login or Join to access this information
Record Id
210
Code
00210
Downloads
265
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

Outcomes

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Will maintain skin integrity ... Please Login or Join to access this information
Description: Client maintains skin ... Please Login or Join to access this information
Rationale: This nursing outcome ... Please Login or Join to access this information
Record Id
1541
Downloads
12,927
Evaluate in days
90
Evaluation Date
06/15/2026
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

Actions

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Observe 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
Record Id
1579
Downloads
21,498
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Position 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
Record Id
1580
Downloads
21,498
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Change 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
Record Id
1581
Downloads
21,498
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Use 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
Record Id
1582
Downloads
21,498
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Use ____ 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
Record Id
1583
Downloads
21,498
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Use 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
Record Id
1584
Downloads
21,498
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Observe 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
Record Id
1585
Downloads
21,498
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Gentle 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
Record Id
1586
Downloads
21,498
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Observe 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
Record Id
1587
Downloads
21,498
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Keep 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
Record Id
1588
Downloads
21,498
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.