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The nurse assesses a client with a 5 × 2 stasis ulcer just above the left malleolus. the wound is open with irregular, reddened, swollen edges and there is a moderate amount of yellowish tan drainage coming from the wound. the client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. to maintain tissue integrity, the primary nursing goal should focus on:

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Kalahira
As the patient has pain and rates the discomfort as 7, the nursing goal should focus on protecting the left ankle from the pressure of bed linens by providing an over-the-bed cradle to maintain the tissue integrity. Tissue integrity is necessary to human to have a healthy physiological process.

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