A client has a documented stage III pressure ulcer on the right hip. Which nursing diagnosis is most appropriate for use with this client?
1. Ineffective Peripheral Tissue Perfusion
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Injury
3. Impaired Tissue Integrity
Rationale:
Since a stage III pressure ulcer involves tissues, not just skin, this client has criteria that qualify for impaired tissue integrity. While it is true that pressure ulcers result from ineffective peripheral tissue perfusion, the diagnosis impaired tissue integrity is the more specific diagnosis. Impaired skin integrity deals with the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury and so risk for injury does not apply.
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