The client has a pressure ulcer, and the nurse plans care for the nursing diagnosis of Impaired skin integrity. Which does the nurse use for a client outcome?

Question

1. Client has persistent low-grade fever.
2. Wound exudate is consistent amount.
3. Wound scarring is minor at 6 months.
4. Wound dimensions decrease in 2 months.

Answer 1

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4. The nurse expects to observe smaller wound dimensions after 2 months of wound care for the client with a pressure ulcer and impaired skin integrity because this indi-cates progress in wound healing and a therapeutic treatment plan.
1. A persistent low-grade fever is consistent with clinical indicators of many things, including unresolved infection; thus, the nurse does not want 2 months of treatment to result in client infection.
2. Pressure ulcers healing without complications can have small amounts of serosan-guinous drainage; however, exudate from the site is consistent with a wound infec-tion.
3. If the wound heals enough to form a scar after 6 months of therapy, the scar is likely to be pink, shiny, and visible.