Final answer:
A nurse assessing the skin of an immobilized patient will use the Braden Scale to evaluate the risk for pressure ulcers. Regular skin assessment should be done, but the frequency may vary depending on the patient's condition. Having specific times for inspection helps ensure comprehensive evaluation without interrupting routine care.
Step-by-step explanation:
A nurse assessing the skin of an immobilized patient will use a standardized tool such as the Braden Scale. This tool helps assess the patient's risk for developing pressure ulcers or bedsores by evaluating factors such as sensory perception, moisture, activity level, mobility, nutrition, and friction or shear. By using the Braden Scale, the nurse can identify areas of concern and implement appropriate preventative measures.
The nurse would also assess the patient's skin regularly but not necessarily every 4 hours unless there is a specific nursing care plan in place. The frequency of assessment would depend on factors such as the patient's condition, level of mobility, and risk for skin breakdown. The nurse would also incorporate regular repositioning of the patient, adequate hydration, proper nutrition, and moisture control to help maintain the integrity of the skin.
It is important for the nurse to have specific times for skin inspection so as not to interrupt routine care. This can be coordinated with other care activities, such as bathing or turning the patient, to minimize disruptions. By having designated times for skin inspection, the nurse can ensure thorough assessment and document any changes or concerns.