Asked by Cecilie Anderson on Sep 27, 2024
A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
A) Administer pain medication every 4 hours as needed.
B) Turn the patient every 2 hours, even hours.
C) Monitor vital signs, especially rhythm.
D) Keep the bed side rails up at all times.
Shearing Forces
Forces applied in opposite directions, leading to potential injury or damage, often used in the context of pressure ulcers or wounds.
Impaired Skin Integrity
A condition where the skin is broken, damaged, or has an alteration in its normal integrity.
- Analyze and handle risk determinants in patient care, with a special focus on fall prevention and skin integrity maintenance.
Learning Objectives
- Analyze and handle risk determinants in patient care, with a special focus on fall prevention and skin integrity maintenance.
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