Please bare with me: Nursting test question

[jalana]

I just took my 3rd nursing test and I want some input on one of the questions. Please bare with me as I try to rephrase it as best as possible without leaving out any critical information.

The question went something like Which client shows the best client outcome from a 15x12 cm stage II pressure ulcer.

I was able to come down to two answers and they were:

A: Pressure ulcer is 12x10 with no odor

B: Pressure ulcer is 10x8 with drainage

I chose B only because it was smaller and weren't specific with what type of drainage. Whether it was purulent, serous, etc. And a lot of people are telling me it was A because of no odor means no infection, but does any type of drainage mean infection? or is it specifically purulent drainage is a sign of infection. So I'm not quite sure myself and am looking for more input.

Thanks

[Daytonite, BSN, RN]

the question went something like which client shows the best client outcome from a 15x12 cm stage ii pressure ulcer.

a: pressure ulcer is 12x10 with no odor

b: pressure ulcer is 10x8 with drainage

the key word here was "best" in the question that was asked. best means most desirable. i would leave the size out of it. what do i know about pressure ulcers and their healing? there is always drainage until the wound becomes healed because of the inflammatory response and wound repair that is going on. but, even better is

a: pressure ulcer is 12x10 with no odor

because its referring to a complication that has been avoided after interventions have been done. the use of the words "

with no odor

" is also an interesting way of saying that the wound is

without infection

without using the word

infection

which is a medical diagnosis. we can't use medical diagnoses in nursing care plans and have to find other slick ways to reword them.

with no odor = no infection

works for me.

[Melodix]

Can you explain how infection is a medical diagnoses? If this is so, how can there be a NANDA approved diagnoses of Risk for infection,which can be used on care plans.

[Daytonite, BSN, RN]

Can you explain how infection is a medical diagnoses? If this is so, how can there be a NANDA approved diagnoses of Risk for infection,which can be used on care plans.

That's just the way it is. We don't use the word infection. It is considered a medical decision.

[joneskd]

I think of a medical dx as something a physician has to order labs and/or tx. The labs are ordered for a culture sample of the wound; they are analyzed by the physician who then declares the diagnosis of infection.

Nursing Diagnosis is what we do to assist the physician to help the patient. The NANDA dx of Risk for Infection isn't a confirmation of infection, it is prevention of infection. We wash our hands, foam in/foam out, use sterile (or as ordered) technique to change dressings, encourage fluids, encourage nutritious meals and encourage ambulation for circulation to reduce the chances of infection.