A client has episodes of bowel and bladder incontinence. When planning

A client has episodes of bowel and bladder incontinence. When planning care for this client, the nurse would identify which nursing diagnosis as being appropriate?

1. Impaired Skin Integrity
2. Risk for Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Infection

ANSWER

Correct Answer: 2
Rationale 1: Impaired Skin Integrity is appropriate if the client has an alteration in the epidermis or dermis.
Rationale 2: Because the client is experiencing episodes of incontinence without any current changes in skin integrity, the client is at Risk for Impaired Skin Integrity.
Rationale 3: Impaired Tissue Integrity is appropriate if the client has damage to mucous membranes, integument, or subcutaneous tissues.
Rationale 4: Risk for Infection would be appropriate if the client has severe skin impairment, the client is immunosuppressed, or the wound is caused by trauma.