Which outcomes are appropriate for the patient with the nursing diagnosis risk for impaired skin integrity related to immobility and muscle weakness?

A) The patient's skin will remain intact without redness or ulceration.
B) The nurse will assess the patient's skin daily for any sign of breakdown.
C) The patient will verbalize at least two methods to prevent skin breakdown.
D) The patient's wounds will be kept clean and will not develop signs of infection.
E) The nurse will reposition the patient every 2 hours and pad bony prominences.

Question

Andriana Ruscitto · Accepted Answer

Final Answer : A,C, Explanation :  Appropriate goals for risk for impaired skin integrity include maintenance of intact skin and patient verbalization of methods to prevent skin breakdown.Daily wound assessment and repositioning are interventions.The presence of wounds makes the risk for impaired skin integrity nursing diagnosis inappropriate as wounds have already developed.

Definitions

Learning Objectives

Learning Objectives

Related questions