Question

The nurse assesses a client with a 5 × 2 stasis ulcer just above the left malleolus. the wound is open with irregular, reddened, swollen edges and there is a moderate amount of yellowish tan drainage coming from the wound. the client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. to maintain tissue integrity, the primary nursing goal should focus on:

Answer 1

As the patient has pain and rates the discomfort as 7, the nursing goal should focus on protecting the left ankle from the pressure of bed linens by providing an over-the-bed cradle to maintain the tissue integrity. Tissue integrity is necessary to human to have a healthy physiological process.