Impaired skin integrity due to surgical wound.

Description
Record Id: 115 Code: 00115
The skin integrity is ... Please Login or Join to access this information
References
Marks, M. A., Kelso, M., & Bowling, F. L. (2019). The impact of surgical wound bacterial contamination and subsequent biofilm formation on tissue healing: a review of current evidence. Advances in Wound Care, 8(9), 446-459.
Howley, I., Julia, W., & Fitzsimons, J. (2021). Reducing the risk of surgical site inf?ections: a case controlled study of implementing a surgical safety checklist and postoperative wound management protocol. Journal of Clinical Nursing, 30(17-18), 2710-2721.
icon-outcomeOutcomes
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Record Id: 239Will be free from ... Please Login or Join to access this information
Description The client will ... Please Login or Join to access this information
Suggested days to Evaluation: 30
Rationale Ensuring the client ... Please Login or Join to access this information
Suggested Evaluation Date: 05/21/2026
Outcome References
Kang, J., Kim, E. J., Choi, B. O., Kang, S. K., Park, H. K., & Choi, J. S. (2018). Application of a standardised nursing language to a computerised nursing record system. Sciedu Press, 7(2), 63-73. DOI: 10.5430/jnep.v7n2p63
Olson-Sitki, K., Wendler, C. M., & Forbes, G. (2017). Evaluation of a nurse-driven protocol to remove urinary catheters: Nurses'' perceptions and identified obstacles. American Journal of Infection Control, 45(2), 118-124. DOI: 10.1016/j.ajic.2016.08.005
icon-actionActions
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Record Id: 122Apply moist heat as ... Please Login or Join to access this information
Description 'apply moist heat ... Please Login or Join to access this information
Rationale Moist heat application ... Please Login or Join to access this information
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Record Id: 520Document preventative and treatment ... Please Login or Join to access this information
Description Record both preventative ... Please Login or Join to access this information
Rationale By documenting preventative ... Please Login or Join to access this information
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Record Id: 512High protein diet, vitamins ... Please Login or Join to access this information
Description Involves administering a ... Please Login or Join to access this information
Rationale High-protein diet fuels ... Please Login or Join to access this information
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Record Id: 509Position client off affected ... Please Login or Join to access this information
Description Involves arranging the ... Please Login or Join to access this information
Rationale Shifting the client ... Please Login or Join to access this information
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Record Id: 508Assess and document wound ... Please Login or Join to access this information
Description Refers to the ... Please Login or Join to access this information
Rationale Documenting wound characteristics ... Please Login or Join to access this information
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Record Id: 514Assist/teach to reposition self ... Please Login or Join to access this information
Description Involves helping clients ... Please Login or Join to access this information
Rationale Repositioning helps enhance ... Please Login or Join to access this information
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Record Id: 130Bed cradle prn. ... Please Login or Join to access this information
Description Action, 'bed cradle ... Please Login or Join to access this information
Rationale A bed cradle ... Please Login or Join to access this information
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Record Id: 1045Change dressing per doctor's ... Please Login or Join to access this information
Description Involves updating a ... Please Login or Join to access this information
Rationale Changing dressing as ... Please Login or Join to access this information
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Record Id: 195Exercise caution during transfers ... Please Login or Join to access this information
Description Implies being careful ... Please Login or Join to access this information
Rationale Fragile skin can ... Please Login or Join to access this information
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Record Id: 197Heel / elbow protectors ... Please Login or Join to access this information
Description Includes placing heel ... Please Login or Join to access this information
Rationale Heel and elbow ... Please Login or Join to access this information
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Record Id: 499Keep linens dry and ... Please Login or Join to access this information
Description Involves maintaining client ... Please Login or Join to access this information
Rationale Keeping linens dry ... Please Login or Join to access this information
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Record Id: 494Keep skin clean and ... Please Login or Join to access this information
Description Involves maintaining skin ... Please Login or Join to access this information
Rationale Maintaining skin cleanliness ... Please Login or Join to access this information
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Record Id: 1039Monitor and record skin ... Please Login or Join to access this information
Description Involves regular weekly ... Please Login or Join to access this information
Rationale Keeping a weekly ... Please Login or Join to access this information
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Record Id: 1044Monitor and report signs ... Please Login or Join to access this information
Description Involves observing the ... Please Login or Join to access this information
Rationale Monitoring and reporting ... Please Login or Join to access this information
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Record Id: 1037Notify physician of any ... Please Login or Join to access this information
Description Refers to alerting ... Please Login or Join to access this information
Rationale Informing the doctor ... Please Login or Join to access this information
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Record Id: 198Pressure relieving device to ... Please Login or Join to access this information
Description Denotes the addition ... Please Login or Join to access this information
Rationale Pressure relieving devices ... Please Login or Join to access this information
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Record Id: 1040Pressure relieving device/special mattress ... Please Login or Join to access this information
Description Involves using a ... Please Login or Join to access this information
Rationale A pressure relieving ... Please Login or Join to access this information
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Record Id: 522Skin care to include ... Please Login or Join to access this information
Description Involves providing personalized ... Please Login or Join to access this information
Rationale Incorporating specific skin ... Please Login or Join to access this information
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Record Id: 513Turn every 2 hours ... Please Login or Join to access this information
Description Involves physically moving ... Please Login or Join to access this information
Rationale Turning frequently ensures ... Please Login or Join to access this information
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Record Id: 497Use lift/turn sheet to ... Please Login or Join to access this information
Description Involves the use ... Please Login or Join to access this information
Rationale Using a lift/turn ... Please Login or Join to access this information
Action References
Kwok, T., Yuen, K., Ho, F., Chan, W., Yu, R., Woo, J., & Lee, Y. (2017). A randomized controlled trial of the effectiveness of a modified Recovery Programme on physical health and physical performance in institutionalized frail older people. Journal of Advanced Nursing, 73(7), 1625-1637. https://doi.org/10.1111/jan.13243
Pashikanti, S., & Von Ah, D. (2019). Impact of early mobilization protocol on the medical-surgical inpatient population: An integrated review of literature. Clinical Nurse Specialist, 33(2), 100-108. https://journals.lww.com/clinicalnursespecialist/Citation/2019/03000/Impact_of_Early_Mobilization_Protocol_on_the.8.aspx
Nakamura, N., Hori, K., Tanaka, K., Seki, T., Umeda-Kameyama, Y., Suzuki, K., . . . Kim, H. (2019). The effectiveness of a training for the redirection of care-home residents who exhibit dementia-related wandering: An intervention study. Aging & Mental Health, 23(6), 721-729. https://doi.org/10.1080/13607863.2018.1453485
Hughes, J. C., & Volicer, L. (2017). Comprehensive Clinical Handbook for Therapeutic Interventions in Cognitive Disorders: A Guide for Mental Health and Healthcare Professionals. In Wandering in dementia.(pp. 309-323). Springer. https://doi.org/10.1007/978-3-319-56789-9
Haugan, G. (2018). The relationship between nurse-patient interaction and meaning-in-life in cognitively intact nursing home patients. Journal of Advanced Nursing, 74(1), 107–120. https://doi.org/10.1111/jan.13401
Bangerter, L. R., Griffin, J. M., Harden, K. J., & Rutten, L. J. (2020). Shared decision making in serious illness: what does balancing mean to health care providers in the context of patient/family-focused care. Journal of Clinical Nursing, 29(13-14), 2089-2098. https://doi.org/10.1111/jocn.15226
Holt-Lunstad, J., Robles, T. F., & Sbarra, D. A. (2018). Advancing social connection as a public health priority in the United States. American Psychologist, 73(6), 517. https://doi.org/10.1037/amp0000298
Savikko, N., Routasalo, P., Tilvis, R., Strandberg, T., & Pitkälä, K. (2017). Predictors and subjective causes of loneliness in an aged population. Archives of Gerontology and Geriatrics, 41(3), 223-233. https://doi.org/10.1016/j.archger.2005.03.002