The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient
What is the best goal for this patient? a. The patient's family will demonstrate specific care of the wound site.
b. The patient will state what to look for with regard to an infection.
c. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound.
d. The patient's family members will wash their hands when visiting the patient.
C
Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection; also, this is an intervention, not a goal for this diagnosis. It is important for the patient's family to be able to demonstrate how to care for the wound and wash their hands, but these statements are interventions, not goals or outcomes for this nursing diagnosis.
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