Question

A client is admitted with a pressure injury on the left hip. The nurse has entered the following goal on the standardized care plan, 'skin heals by June 12.' Prior to this date, the nurse evaluates progress on reaching this goal. Which statement is the best notation of progress toward the goal?

a) Turned every 2 hours; avoided positioning on left side.
b) Wet to moist dressing changed every 4 hours.
c) No additional areas of skin breakdown noted.
d) Wound less reddened; granulation tissue noted.

Answer 1

The best notation of progress toward the patient's healing goal is 'Wound less reddened; granulation tissue noted', as it specifically reflects the wound's healing process.

Step-by-step explanation:

The best notation of progress toward the goal of having a patient's pressure injury heal by June 12 would be option (d) "Wound less reddened; granulation tissue noted." This option directly addresses the healing process of the skin, as lessening redness signals a reduction in inflammation, and the presence of granulation tissue indicates new tissue formation, both of which are positive signs that the wound is healing.

In contrast, the other options describe care activities and observations that support wound healing but do not directly indicate the wound's current state of healing.