Which of the following nursing diagnoses is correct for a client with a three cm red

charlottegirl · Aug 20, 2009

I would say C because the patient already has what sounds like a stage 1 pressure ulcer. Therefore the skin integrity is already impaired.

beth66335, BSN, RN · Aug 20, 2009

I agree, skin integrity is already impaired and it is not cause by a patients level of consciousness, skin integrity impairment is caused by poor patient care and poor nutrition usually.

bekindtokittens · Aug 20, 2009

I agree with C being the answer for the reasons already given.

Daytonite, BSN, RN · Aug 22, 2009

read the question carefully: which of the following nursing diagnoses is correct for a client with a three cm area on the skin over the sacrum unrelieved by pressure change?

a. risk for tissue integrity related to infrequent turning

b. risk for impaired skin integrity

c. impaired skin integrity related to tissue ischemia secondary to infrequent turning and positioning

d. impaired skin integrity related to the effects of level of consciousness

the construction of a nursing diagnosis follows this format: p-e-s and this is what p-e-s means:

p - the nursing problem stated as the nursing diagnosis
e - the etiology which is the cause of the nursing problem
s - the symptoms of the nursing problem that prove its existence

the stem of the question is giving you much of the information to chose the correct answer. on the skin, the 3 cm area of depth and pressure are big hints. which of the following nursing diagnoses is correct for a client with a three cm area on the skin over the sacrum unrelieved by pressure change?

risk for tissue integrity related to infrequent turning and risk for impaired skin integrity are automatically eliminated because "risk for" diagnoses are anticipated problems. a three cm area over the sacrum is an actual problem that already exists.

think about the information you were given in the stem of the question. does it say anything about the etiology (cause) of this nursing problem? the diagnosis of impaired skin integrity related to the effects of level of consciousness is telling us that the impaired skin (that part is correct) occurred because the person was unconscious and laid in one position for a long time. i didn't see that information anywhere.

p - impaired skin integrity
e - effects of level of consciousness
s - not listed, but would be: three cm area on the skin over the sacrum

impaired skin integrity related to tissue ischemia secondary to infrequent turning and positioning is telling us that the impaired skin (that part, again, is correct) occurred because there was poor circulation and in addition the person not being turned and repositioned frequently. the stem of the question states: which of the following nursing diagnoses is correct for a client with a three cm area on the skin over the sacrum unrelieved by pressure change? pressure changes (infrequent turning and repositioning) would contribute to the development of an ulcer if there were also poor circulation, or "tissue ischemia".

p - impaired skin integrity
e - tissue ischemia (secondary to infrequent turning and repositioning)
s - three cm area on the skin over the sacrum