Question

A 63-year-old client in the ICU with a nursing diagnosis of risk for impaired skin integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to her left side, she notices that the client has a non-blanching reddened area over her right trochanter. What would be the most appropriate action for the nurse to take?

A) Continue with the repositioning schedule as planned
B) Apply a barrier cream to the reddened area
C) Document the presence of the non-blanching reddened area, reassess the client's overall skin condition, and notify the healthcare team
D) Discontinue repositioning to avoid further irritation

Answer 1

The nurse should document the reddened area, reassess the skin condition, and notify the healthcare team. Continuing the repositioning schedule is important, but the nurse may also need to implement additional interventions.

Step-by-step explanation:

The most appropriate action for the nurse to take upon noticing a non-blanching reddened area over the client's right trochanter is to document the presence of the non-blanching reddened area, reassess the client's overall skin condition, and notify the healthcare team. This response indicates the initial stage of a potential pressure ulcer, which requires immediate attention to prevent further deterioration. While continuing with the repositioning schedule is integral to the care plan, additional interventions may be necessary to address the compromised skin integrity.