Question

An older adult patient with a history of type II diabetes presents for a follow-up visit after a melanoma removed from his cheek. He weighs 90 lb, has a BP of 90/60, and states he feels fatigued. During the physical examination, she notes the surgical incision is healing well without infection, but finds an unhealed pressure ulcer on the patient's right elbow. Which is the most appropriate nursing diagnostic statement?

a) Impaired Skin Integrity related to compromised nutritional status and immobility, as evidenced by pressure ulcer on the elbow.
b) Acute Pain related to wound on elbow, as evidenced by patient rating pain at 3 of 10 during wound care.
c) Imbalanced Nutrition: Less Than Body Requirement related to increased demand, secondary to healing wounds, as evidenced by continued weight loss.
d) Knowledge Deficit related to lack of familiarity with care products, as evidenced by inability to correctly perform wound care.

Answer 1

The most appropriate nursing diagnosis for the patient with type II diabetes and a pressure ulcer on the elbow is 'Impaired Skin Integrity related to compromised nutritional status and immobility'.

Step-by-step explanation:

The most appropriate nursing diagnostic statement for an older adult patient with a pressure ulcer on the elbow is a) Impaired Skin Integrity related to compromised nutritional status and immobility, as evidenced by pressure ulcer on the elbow. This diagnosis considers the patient's weight loss, fatigue, and the presence of an existing pressure ulcer, all of which can contribute to impaired skin integrity and delayed wound healing.

Factors such as the patient's history of type II diabetes and sedentary lifestyle increase the risk for skin integrity issues. Furthermore, the nutritional status of an elderly patient is crucial for skin regeneration and wound healing. Pressure ulcers, particularly in areas over bony prominences where prolonged pressure can restrict blood flow, are common among immobile patients and can lead to tissue necrosis without proper care.