Asked by Vibhor Mathur on May 16, 2024
Verified
The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.)
A) The patient's expectations are not being met.
B) Skin is intact with no redness or swelling.
C) Nonblanchable erythema is absent.
D) No injuries to the skin and tissues are evident.
E) Granulation tissue is present.
Impaired Skin Integrity
A disruption in the normal structure and function of the skin, leading to an increased risk of injury or infection.
Nonblanchable Erythema
Reddening of the skin that does not lighten or turn white (blanch) when pressure is applied, often indicating stage I pressure injury.
Granulation Tissue
New vascular tissue formed on the surface of a healing wound, indicating the process of healing.
- Recognize the indications and manifestations of compromised skin integrity and infection.
Verified Answer
SB
sabrina BhinderMay 20, 2024
Final Answer :
B, C, D, E
Explanation :
Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Skin intact, nonblanchable erythema absent, no injuries, and presence of granulation tissue are all findings indicating achievement of goals and outcomes. The patient's expectations not being met indicates no progression toward goals/outcomes.
Learning Objectives
- Recognize the indications and manifestations of compromised skin integrity and infection.