Question

d care consult: client has been spending several hours
day in a wheelchair and has now developed a pressure
on the coccyx. prior to the accident, the client lived alone at
and was independent with all activities of daily living. pre-
ng conditions included morbid obesity and hypertension
olled with a beta blocker. current labs significant for low
nin of 2.9 g/dl (29 g/l).
ressure injury is irregularly shaped, approximately 5.7
es (14.48 cm) in diameter across the coccyx. there is a bright
kin border of intact skin about 1 inch (2.54 cm) wide, leading
an area of approximately 3.6 inches (9.14 cm) diameter
e the skin is completely broken down and subcutaneous fat
early visible. the area is damp with oozing serous fluid. no
ermining or tunneling is noted; no slough or eschar is seen; no
eodor is noted. plan: negative pressure wound treatment
em will be applied with dressing changes bi - weekly by wound
e team.
which goal does the nurse add when updating the clients plan of care?
(select all that apply.)

1. pressure injury is healed within 8 weeks.
2. client increases oral fluid intake to 1500 ml/day.
3. albumin level is increased to 3.5 g/dl (35 g/l) within 4 weeks.
4. client maintains normal respiratory function through discharge.
5. client decreases bmi to 35 within 8 weeks.
6. client is able to self transfer to wheelchair within 2 weeks.

Explanation:

1. Option 1: Pressure injuries, especially with the given treatment (negative pressure wound therapy), can typically heal within 8 weeks, so this is a valid goal.
2. Option 2: Adequate fluid intake (1500 mL/day is reasonable) helps with wound healing, tissue hydration, and overall health, so this applies.
3. Option 3: The client has low albumin (2.9 g/dL), and increasing it to 3.5 g/dL (normal range) within 4 weeks supports wound healing (protein is needed for tissue repair), so this is appropriate.
4. Option 4: Maintaining normal respiratory function is a general goal for any client, but there's no indication of respiratory issues in the scenario. So this is not directly related to the client's current main issues (pressure injury, low albumin, etc.).
5. Option 5: The client has morbid obesity (BMI > 40, likely, since current goal is to 35 in 8 weeks which is still obese but a reduction). However, a BMI change from morbid obesity to 35 in 8 weeks is very aggressive and not realistic, so this is not a feasible goal.
6. Option 6: The client was independent prior to the accident, and self - transfer to wheelchair is a functional goal related to regaining independence, which is appropriate for a client in a wheelchair with a pressure injury (to reduce pressure on the coccyx by proper transfer).

Answer:

1. Pressure injury is healed within 8 weeks.
2. Client increases oral fluid intake to 1500 mL/day.
3. Albumin level is increased to 3.5 g/dL (35 g/L) within 4 weeks.
4. Client is able to self transfer to wheelchair within 2 weeks.