The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.)
a. The patient's expectations are not being met.
b. Skin is intact with no redness or swelling.
c. Nonblanchable erythema is absent.
d. No injuries to the skin and tissues are evident.
e. Granulation tissue is present.
ANS: B, C, D, E
Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Skin intact, nonblanchable erythema absent, no injuries, and presence of granulation tissue are all findings indicating achievement of goals and outcomes. The patient's expectations not being met indicates no progression toward goals/outcomes.
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