DIAGNOSIS. Impaired skin integrity related to pressure over bony prominences or shearing forces

OUTCOMES. Tissue integrity: Skin and mucous membranes; Wound healing: Primary intention; Immobility consequences: Physiological; Knowledge: Treatment regime; Nutritional status; Tissue perfusion: Peripheral; Treatment behavior: Illness or injury

INTERVENTIONS. Wound care; Skin surveillance; Positioning; Pressure management; Pressure ulcer prevention; Medication administration: Topical; Circulatory precautions; Infection control; Nutrition management