Author Question: The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis ... (Read 19 times)

lb_gilbert · **on:** Jul 23, 2018

The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client?

1. Altered Tissue Perfusion
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Injury

Question 2

The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected?

1. Clean areas of granulation tissue
2. Exudate in the bottom of the wound
3. A pus-coated area on the side of the wound
4. Intact skin at the edge of the wound

mmj22343 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 3
Rationale 1:Although it is true that pressure ulcers result from altered tissue perfusion, the diagnosis problem statement Impaired Tissue Integrity is more specific.
Rationale 2: Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue.
Rationale 3: Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria for using the NANDA nursing diagnosis problem statement Impaired Tissue Integrity.
Rationale 4: This client has already suffered injury, so this is not a Risk for Injury situation.

Answer to Question 2

Correct Answer: 1
Rationale 1: Microorganisms that are most likely to be responsible for wound infections live in viable tissue such as granulation tissue.
Rationale 2: Exudate contains a variety of components and will not give a good indication of what is causing the infection.
Rationale 3: Pus contains a variety of components and will not give a good indication of what is causing the infection.
Rationale 4: The skin at the edge of the wound contains skin organisms that may or may not be present in the wound itself.