The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client?

Question

1. Altered Tissue Perfusion
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Injury

Answer 1

Correct Answer: 3
Rationale 1:Although it is true that pressure ulcers result from altered tissue perfusion, the diagnosis problem statement Impaired Tissue Integrity is more specific.
Rationale 2: Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue.
Rationale 3: Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria for using the NANDA nursing diagnosis problem statement Impaired Tissue Integrity.
Rationale 4: This client has already suffered injury, so this is not a Risk for Injury situation.