Asked by Vansh Agarwal on May 09, 2024

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The nurse is caring for a patient with a stage 2 pressure injury 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.What is the best goal for this patient?

A) The patient's family will demonstrate specific care of the wound site.
B) The patient will state what to look for with regard to an infection.
C) The patient will remain free of an increase in temperature and of malodorous or purulent drainage from the wound.
D) The patient's family members will wash their hands when visiting the patient.

Pressure Injury

Localized damage to the skin and/or underlying tissue, primarily caused by prolonged pressure or friction, frequently occurring in immobilized or bedridden patients.

Risk For Infection

A clinical assessment identifying individuals or groups at increased likelihood of developing an infection due to specific health or situational factors.

Malodorous Drainage

Unpleasant or foul-smelling discharge, commonly associated with infections, wounds, or other medical conditions requiring attention.

  • Understand the significance of maintaining cleanliness and preventing infections in the treatment of wounds.
  • Establish the sequence of interventions for differing levels of pressure ulcers.
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DG
Dezmarie GanuelasMay 14, 2024
Final Answer :
C
Explanation :
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 blood cell count,and malodorous and purulent drainage from the wound.The patient is unconscious and is unable to communicate the signs and symptoms of infection;also,enabling the patient to communicate is an intervention,not a goal,for this diagnosis.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 interventions,not goals or outcomes for this nursing diagnosis.