A client has a documented stage III pressure ulcer on the right hip.Which nursing diagnosis is most appropriate for this client?
A) Impaired Skin Integrity
B) Risk for Injury
C) Impaired Tissue Integrity
D) Ineffective Peripheral Tissue Perfusion

Question

Quizplus · Accepted Answer

A) Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure ulcers result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury and so Risk for Injury does not apply.
B) Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure ulcers result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury and so Risk for Injury does not apply.
C) Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure ulcers result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury and so Risk for Injury does not apply.
D) Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure ulcers result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury and so Risk for Injury does not apply.

A Client Has a Documented Stage III Pressure Ulcer on the Right