Question

A nurse identifies several interventions to resolve a patient's nursing diagnosis of "impaired skin integrity." Which of the following are written in error? (Select all that apply) [18]

1. Turn the patient regularly from side to back to side.
2. Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence
3. Apply a pressure-relief device to bed
4. Apply transparent dressing to sacral pressure ulcer

Answer 1

The interventions written in error are:

1. Turn the patient regularly from side to back to side.

2. Apply transparent dressing to sacral pressure ulcer.

Step-by-step explanation:

The first error is in the intervention "Turn the patient regularly from side to back to side." Turning the patient is a correct intervention to prevent pressure ulcers, but the description lacks specificity. The frequency and timing of turning should be individualized based on the patient's condition, not a generic side-to-back-to-side routine.

The second error is in the intervention "Apply transparent dressing to sacral pressure ulcer." While transparent dressings can be appropriate for some wounds, they are not the best choice for pressure ulcers. These ulcers often require a moist healing environment, and transparent dressings may not provide adequate moisture. Instead, appropriate dressings for sacral pressure ulcers should promote moisture balance and protect against infection.

The other interventions, "Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence" and "Apply a pressure-relief device to bed," are appropriate for addressing impaired skin integrity. Perineal care helps maintain cleanliness, preventing skin breakdown, and pressure-relief devices distribute weight to reduce the risk of pressure ulcers. Overall, the correct interventions should be precise, individualized, and evidence-based for effective resolution of impaired skin integrity.