The nurse has determined the following outcome for a client with a skin impairment: "Erythema will be reduced in 3 days." What will the evaluation specifically focus on?
a. Selection of appropriate wound care
b. Notation of the odour and colour of drainage
c. Inspection of the colour and condition of the area
d. Measurement of the diameter of the ulceration daily
C
Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspec-tion of the colour of the skin, as stated in the outcome criterion.
Selection of appropriate wound care is an intervention, not an evaluation of a client's behaviour or response. The outcome criterion does not state anything about drainage.
Noting the colour and amount of drainage may be a part of reassessment of the client, but is not what the nurse is evaluating according to this outcome criterion.
The outcome criterion states the erythema, not the size of the ulceration, will be reduced. During the evaluation step of the nursing process, the client's behaviour or response should be compared to the outcome criterion and judged for the degree of agreement between the two.
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