Asked by vishal patel on May 30, 2024
Verified
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan?
A) Readiness for enhanced nutrition
B) Impaired physical mobility
C) Impaired skin integrity
D) Chronic pain
Stage IV Pressure Ulcer
A severe injury to the skin and underlying tissue, characterized by extensive tissue damage and possibly involving muscle or bone, typically due to prolonged pressure.
Nursing Diagnosis
A clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes, forming the basis for selecting nursing interventions.
Impaired Skin Integrity
A condition where the skin is damaged, leading to a breakdown in the barrier it provides against infection and injury.
- Identify the indicators of wound recovery and the variety of tissues implicated.
- Prioritize care for patients exhibiting various stages of pressure sores within the nursing domain.
Verified Answer
GM
Grace MackeyJun 01, 2024
Final Answer :
C
Explanation :
After the assessment is completed and the information that the patient has a Stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain do not support the current data in the question.
Learning Objectives
- Identify the indicators of wound recovery and the variety of tissues implicated.
- Prioritize care for patients exhibiting various stages of pressure sores within the nursing domain.