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This week’s case-based question:
While caring for a client who’s immobile, a nurse documents the following information in the client’s chart: ‘Turned client from side to back every 2 hours.’ ‘Skin intact; no redness noted.’ ‘Client up in chair three times today.’ ‘Improved skin turgor noted.’
Which nursing diagnosis accurately reflects this information?
Risk for impaired skin integrity related to immobility.
Disturbed body image related to immobility.
Impaired skin integrity related to immobility.
Constipation related to immobility.
And the answer is …
Correct Answer:Risk for impaired skin integrity related to immobility.
The information documented in the client’s chart reflects the risk for impaired skin integrity. Because the client’s skin is intact, the problem is only a potential one, not an actual one, which makes the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If body image disturbance were a problem, interventions would focus on the client’s feelings about himself and his disease.
Taylor, Carol; Lillis, Carol; Lynn, Pamela (2014-08-25). Fundamentals of Nursing (Fundamentals of Nursing: The Art & Science of Nursing Care () (Page 980). 8th ed., LWW, 2015. Kindle Edition.
Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1018.
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