Details

Care Plan Detail

Pressure ulcer or altered skin integrity related to [specify] as evidenced by [specify]

Description
The subject involves a ... Please Login or Join to access this information
Record Id
290
Code
00290
Downloads
85
References
Beeckman, D., Van Damme, N., Schoonhoven, L., Van Lancker, A., Kottner, J., Beele, H., ... & Verhaeghe, S. (2019). Interventions for preventing and treating incontinence-associated dermatitis in adults. Cochrane Database of Systematic Reviews, (11).
Agrawal, K., & Chauhan, N. (2020). Pressure ulcers: Back to the basics. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India, 53(1), 5–13.

Outcomes

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Will demonstrate progressive healing ... Please Login or Join to access this information
Description: Client will show ... Please Login or Join to access this information
Rationale: This outcome emphasizes ... Please Login or Join to access this information
Record Id
1564
Downloads
12,735
Evaluate in days
90
Evaluation Date
06/08/2026
Outcome References
Jaul, E., & Calderon-Margalit, R. (2018). Systemic factors and mortality in elderly patients with pressure ulcers. International wound journal, 15(2), 262-269.
Kottner, J., Cuddigan, J., Carville, K., Balzer, K., Berlowitz, D., Law, S., ... & Haesler, E. (2017). Pressure injury prevention and treatment: a clinical practice guideline update from the international skin tear advisory panel: joint statement of the International Skin Tear Advisory Panel (ISTAP) and the European Pressure Ulcer Advisory Panel (EPUAP). Journal of tissue viability, 26(2), 47-60.

Actions

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Observe, document and notify ... Please Login or Join to access this information
Description: Monitoring skin changes, ... Please Login or Join to access this information
Rationale: Monitoring and documenting ... Please Login or Join to access this information
Record Id
2293
Downloads
20,951
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Body audits per facility ... Please Login or Join to access this information
Description: Body audits per ... Please Login or Join to access this information
Rationale: Body audits per ... Please Login or Join to access this information
Record Id
2294
Downloads
20,951
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CNA to notify nurse ... Please Login or Join to access this information
Description: The certified nursing ... Please Login or Join to access this information
Rationale: Early notification allows ... Please Login or Join to access this information
Record Id
2295
Downloads
20,951
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Turn 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
Record Id
513
Downloads
20,951
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Adjust client's bed to ... Please Login or Join to access this information
Description: Involves maintaining a ... Please Login or Join to access this information
Rationale: Keeping the bed ... Please Login or Join to access this information
Record Id
2296
Downloads
20,951
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Use lifting device, draw ... Please Login or Join to access this information
Description: Involves utilizing tools ... Please Login or Join to access this information
Rationale: Using lifting devices ... Please Login or Join to access this information
Record Id
2297
Downloads
20,951
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Encourage use of bed ... Please Login or Join to access this information
Description: Advises promoting bed ... Please Login or Join to access this information
Rationale: Using bed rails ... Please Login or Join to access this information
Record Id
2298
Downloads
20,951
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Monitor nutritional status and ... Please Login or Join to access this information
Description: Involves observing the ... Please Login or Join to access this information
Rationale: Monitoring nutritional status ... Please Login or Join to access this information
Record Id
2030
Downloads
20,951
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Obtain and monitor lab/ ... Please Login or Join to access this information
Description: It involves gathering ... Please Login or Join to access this information
Rationale: Regularly acquiring and ... Please Login or Join to access this information
Record Id
2037
Downloads
20,951
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Administer medications as ordered ... Please Login or Join to access this information
Description: Involves the proper ... Please Login or Join to access this information
Rationale: Administering medications as ... Please Login or Join to access this information
Record Id
2137
Downloads
20,951
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Administer treatment to area ... Please Login or Join to access this information
Description: The nurse applies ... Please Login or Join to access this information
Rationale: This action ensures ... Please Login or Join to access this information
Record Id
2029
Downloads
20,951
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Use pressure redistribution surface ... Please Login or Join to access this information
Description: Incorporating pressure redistribution ... Please Login or Join to access this information
Rationale: Pressure redistribution surfaces ... Please Login or Join to access this information
Record Id
2299
Downloads
20,951
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Preventive skin care per ... Please Login or Join to access this information
Description: Involves applying preventive ... Please Login or Join to access this information
Rationale: This advice helps ... Please Login or Join to access this information
Record Id
2300
Downloads
20,951
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Incontinence care q 2 ... Please Login or Join to access this information
Description: Provides care for ... Please Login or Join to access this information
Rationale: Regular incontinence care ... Please Login or Join to access this information
Record Id
2301
Downloads
20,951
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Wound debridement as ordered ... Please Login or Join to access this information
Description: Wound debridement entails ... Please Login or Join to access this information
Rationale: Wound debridement is ... Please Login or Join to access this information
Record Id
2695
Downloads
20,951
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Skin risk assessment (Braden, ... Please Login or Join to access this information
Description: Regular skin risk ... Please Login or Join to access this information
Rationale: Regular skin risk ... Please Login or Join to access this information
Record Id
2696
Downloads
20,951
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If cognitive function allows, ... Please Login or Join to access this information
Description: Involves promoting regular ... Please Login or Join to access this information
Rationale: Shifting weight frequently ... Please Login or Join to access this information
Record Id
2697
Downloads
20,951
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Assess for pain and ... Please Login or Join to access this information
Description: Involves pain evaluation ... Please Login or Join to access this information
Rationale: To ensure client ... Please Login or Join to access this information
Record Id
2698
Downloads
20,951