A nurse is updating the plan of care for a client who has a pressure ulcer on the sacrum. Which of the following outcomes are appropriate for this client?

Choice A reason:

The client will have no signs of infection in the wound by day 7. This is an appropriate outcome because it indicates that the wound is healing properly and that the client is receiving adequate wound care and infection prevention measures. Infection can delay wound healing and increase the risk of complications.

Choice B reason:

The client will report pain level of 4/10 or less during dressing changes. This is not an appropriate outcome because it does not address the wound healing process or the prevention of further skin breakdown. Pain management is important for the client's comfort and quality of life, but it is not a specific goal for pressure ulcer care.

Choice C reason:

The client will consume at least 75% of meals and snacks daily. This is an appropriate outcome because it indicates that the client is receiving adequate nutrition to support wound healing. Nutrition plays a vital role in tissue integrity and repair, and the client should consume enough calories, protein, and micronutrients to meet their needs.

Choice D reason:

The client will reposition self in bed every 2 hours with assistance. This is not an appropriate outcome because it does not reflect the current evidence-based practice for pressure ulcer prevention and treatment. Repositioning should be done more frequently than every 2 hours, and the frequency should be individualized based on the client's risk factors, skin condition, comfort, and support surfaces.

Choice E reason:

The client will demonstrate proper wound care technique before discharge. This is an appropriate outcome because it indicates that the client has learned how to care for their wound at home and prevent further skin breakdown. Wound care education is essential for the client's self-management and adherence to the treatment plan.

Choice A reason:

Teaching the client some exercises to strengthen the core muscles and improve posture is an example of an independent intervention, not a collaborative one. An independent intervention is one that the physical therapist can perform without consulting or coordinating with other members of the health care team.

Choice B reason:

Applying heat therapy to the client's back for 15 minutes before starting the exercises is also an example of an independent intervention, not a collaborative one. Heat therapy is a modality that the physical therapist can use to reduce pain and stiffness, and prepare the client for exercise.

Choice C reason:

Documenting the client's progress and response to the exercises in the medical record is an example of a professional responsibility, not a collaborative intervention. Documentation is essential for communication, quality improvement, and legal purposes, but it does not involve working with other health care providers.

Choice D reason:

Coordinating with the nurse to schedule the exercises after the client receives analgesics is an example of a collaborative intervention. A collaborative intervention is one that requires consultation or coordination with other members of the health care team to achieve a common goal. In this case, the physical therapist and the nurse work together to ensure that the client has adequate pain relief before engaging in exercise, which can improve the client's comfort and compliance.