The nurse has determined the following outcome for a client with a ski

The nurse has determined the following outcome for a client with a skin impairment: “Erythema will be reduced in 3 days.” Evaluation will specifically focus on:

1. Selection of appropriate wound care
2. Notation of the odor and color of drainage
3. Inspection of the color and condition of the area
4. Measurement of the diameter of the ulceration daily

ANSWER

ANS: 3
Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspec-tion of the color of the skin, as stated in the outcome criterion. Selection of appropriate wound care is an intervention, not an evaluation of a client’s behavior or response. The outcome criterion does not state anything about drainage. Noting the color and amount of drainage may be a part of reassessment of the client, but is not what the nurse is evaluating according to this outcome criterion. The outcome criterion states the erythema will be reduced, not the size of the ulcera-tion. During the evaluation step of the nursing process, the client’s behavior or response should be compared to the outcome criterion and judged for degree of agreement between the two.