Question

wound care consult: client has been spending several hours each day in a wheelchair and has now developed a pressure injury on the coccyx. prior to the accident, the client lived alone at home and was independent with all activities of daily living. pre - existing conditions included morbid obesity and hypertension controlled with a beta blocker. current labs significant for low albumin of 2.9 g/dl (29 g/l). the pressure injury is irregularly shaped, approximately 5.7 inches (14.48 cm) in diameter across the coccyx. there is a bright red skin border of intact skin about 1 inch (2.54 cm) wide, leading into an area of approximately 3.6 inches (9.14 cm) diameter where the skin is completely broken down and subcutaneous fat is clearly visible. the area is damp with oozing serous fluid. no undermining or tunneling is noted; no slough or eschar is seen; no foul odor is noted. plan: negative pressure wound treatment system will be applied with dressing changes bi - weekly by wound care team. note: each section must have at least 1 response option selected goal potential nursing interventions pressure injury is healed within 8 weeks. ☐ reposition the client every 2 hours or more often. ☐ keep plastic sheet under clients buttocks at all tim ☐ keep client from putting pressure on the coccyx. albumin level is increased to 3.5 g/dl (35 g/l) within 4 weeks. ☐ limit fluid intake to 1500 ml/day. ☐ limit total intake to 1800 calories per day. ☐ provide high protein meals and snacks. client maintains normal respiratory function through ☐ suction airway every 4 hours and prn. ☐ place client on oxygen 2 l/minute per nasal cannu ☐ encourage use of incentive spirometer for 10 brea

Explanation:

For the goal "Pressure injury is healed within 8 weeks":

• Reposition the client every 2 hours or more often: Repositioning helps relieve pressure on the coccyx, preventing further damage and promoting healing of the pressure injury.
• Keep client from putting pressure on the coccyx: Reducing pressure on the injured area is crucial for wound healing as pressure can impede blood flow and tissue repair.
• Keep plastic sheet under client’s buttocks at all time: This is incorrect. Plastic sheets trap moisture and heat, which can worsen pressure injuries by macerating the skin. So this option should not be selected.

For the goal "Albumin level is increased to 3.5 g/dL (35 g/L) within 4 weeks":

• Limit fluid intake to 1500 mL/day: Limiting fluid intake is not related to increasing albumin levels. Albumin is a protein, so dietary protein intake is more relevant.
• Limit total intake to 1800 calories per day: Limiting calories, especially in a client with morbid obesity, but the key for albumin (a protein) is protein intake, not calorie restriction alone.
• Provide high protein meals and snacks: Protein is essential for albumin synthesis. Increasing dietary protein can help raise albumin levels.

For the goal "Client maintains normal respiratory function through...":

• Suction airway every 4 hours and PRN: Suctioning is for clearing secretions, but there's no indication of airway secretions issues here.
• Place client on oxygen 2 L/minute per nasal cannula: There's no indication of hypoxia or respiratory compromise requiring oxygen.
• Encourage use of incentive spirometer for 10 breat: Incentive spirometry helps prevent atelectasis and maintain lung function, which is important for a client who may have limited mobility (due to wheelchair use and pressure injury), reducing the risk of respiratory complications.

Answer:

s for each goal:

• Pressure injury is healed within 8 weeks: Select "Reposition the client every 2 hours or more often" and "Keep client from putting pressure on the coccyx".
• Albumin level is increased to 3.5 g/dL (35 g/L) within 4 weeks: Select "Provide high protein meals and snacks".
• Client maintains normal respiratory function through...: Select "Encourage use of incentive spirometer for 10 breat" (assuming the full option is "Encourage use of incentive spirometer for 10 breaths..." as it's cut off, but the logic is about maintaining lung function with spirometry).