Planning
Planning ( 5 Questions)
A nurse is updating the plan of care for a client who has a pressure ulcer on the sacrum. Which of the following outcomes are appropriate for this client?
The client will have no signs of infection in the wound by day 7. This is an appropriate outcome because it indicates that the wound is healing properly and that the client is receiving adequate wound care and infection prevention measures. Infection can delay wound healing and increase the risk of complications.
The client will report pain level of 4/10 or less during dressing changes. This is not an appropriate outcome because it does not address the wound healing process or the prevention of further skin breakdown. Pain management is important for the client's comfort and quality of life, but it is not a specific goal for pressure ulcer care.
The client will consume at least 75% of meals and snacks daily. This is an appropriate outcome because it indicates that the client is receiving adequate nutrition to support wound healing. Nutrition plays a vital role in tissue integrity and repair, and the client should consume enough calories, protein, and micronutrients to meet their needs.
The client will reposition self in bed every 2 hours with assistance. This is not an appropriate outcome because it does not reflect the current evidence-based practice for pressure ulcer prevention and treatment. Repositioning should be done more frequently than every 2 hours, and the frequency should be individualized based on the client's risk factors, skin condition, comfort, and support surfaces.
The client will demonstrate proper wound care technique before discharge. This is an appropriate outcome because it indicates that the client has learned how to care for their wound at home and prevent further skin breakdown. Wound care education is essential for the client's self-management and adherence to the treatment plan.
Choice A reason:
The client will have no signs of infection in the wound by day 7. This is an appropriate outcome because it indicates that the wound is healing properly and that the client is receiving adequate wound care and infection prevention measures. Infection can delay wound healing and increase the risk of complications.
Choice B reason:
The client will report pain level of 4/10 or less during dressing changes. This is not an appropriate outcome because it does not address the wound healing process or the prevention of further skin breakdown. Pain management is important for the client's comfort and quality of life, but it is not a specific goal for pressure ulcer care.
Choice C reason:
The client will consume at least 75% of meals and snacks daily. This is an appropriate outcome because it indicates that the client is receiving adequate nutrition to support wound healing. Nutrition plays a vital role in tissue integrity and repair, and the client should consume enough calories, protein, and micronutrients to meet their needs.
Choice D reason:
The client will reposition self in bed every 2 hours with assistance. This is not an appropriate outcome because it does not reflect the current evidence-based practice for pressure ulcer prevention and treatment. Repositioning should be done more frequently than every 2 hours, and the frequency should be individualized based on the client's risk factors, skin condition, comfort, and support surfaces.
Choice E reason:
The client will demonstrate proper wound care technique before discharge. This is an appropriate outcome because it indicates that the client has learned how to care for their wound at home and prevent further skin breakdown. Wound care education is essential for the client's self-management and adherence to the treatment plan.