Author Question: The nurse collects the following assessment data: right heel with reddened area that does not ... (Read 119 times)

notis · **on:** Jul 22, 2018

The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?

a. Imbalanced nutrition: less than body requirements
b. Ineffective peripheral tissue perfusion
c. Risk for infection
d. Acute pain

Question 2

The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection.

The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. Which is the best goal for this patient?
a. The patient will state what to look for with regard to an infection.
b. The patient's family will demonstrate specific care of the wound site.
c. The patient's family members will wash their hands when visiting the patient.
d. The patient will remain free of odorous or purulent drainage from the wound.

dellikani2015 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: B
The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective peripheral tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition do not support the data in the question.

Answer to Question 2

ANS: D
Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection. It is important for the patient's family to be able to demonstrate how to care for the wound and wash their hands, but these statements are not goals or outcomes for this nursing diagnosis.