A client has a documented stage III pressure ulcer on the right ...

[future617RT]

A client has a documented stage III pressure ulcer on the right hip. Which nursing diagnosis is most appropriate for this client?
 
  A) Impaired Skin Integrity
  B) Risk for Injury
  C) Impaired Tissue Integrity
  D) Ineffective Peripheral Tissue Perfusion

Question 2

An older adult client is admitted to the medical-surgical unit for a hip fracture. During postoperative recovery, the nurse notices a stage I pressure ulcer forming on the client's sacrum.
 
  Which action by the nurse is appropriate to reduce the progression of this ulceration?
  A) Maintain the head of the bed at 30  angle, with client positioned on the right or left side.
  B) Apply a heat lamp to the area to increase circulation.
  C) Apply a dry dressing to the pressure ulcer.
  D) Maintain the head of the bed at 45  angle.

[chjcharjto14]

Answer to Question 1

Answer: C

Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure ulcers result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury and so Risk for Injury does not apply.

Answer to Question 2

Answer: A

Keeping the head of the bed at an angle of 30  or less decreases pressure on the sacrum. An angle of 45  would be too severe and could exacerbate pressure ulcer formation on the sacrum. Dry dressings are not indicated with this stage of pressure wound. Heat lamp is a method no longer used because it does not provide therapeutic benefit.