A patient develops a small sore on the sole of the left foot. The nurse notifies the physician and implements a standard care plan for impaired skin integrity. What action by the nurse would help evaluate the effectiveness of the plan?
a. Assess and document the wound condition daily.
b. Monitor and record blood glucose levels daily.
c. Assess the patient's understanding of preventive foot care.
d. Observe the patient's ability to change the dressing.
ANS: A
Evaluation must address skin integrity—assessing and documenting wound condition is the only response that does this. Monitoring glucose levels evaluates diabetes control, not skin integrity. Assessing the patient's understanding or observing a dressing change evaluates the patient's knowledge, not skin integrity.
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