A child is being cared for in the ICU after suffering a head injury. The patient requires a ventilator and he is sedated. The child is at risk of pressure ulcers because of his immobility. Which of the following nursing interventions is most appropriate to prevent skin breakdown in this child?

 

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Correct

- Turn or reposition the child in bed every 2 hours

- Feed the child every 3 hours to promote good nutrition

- Massage the bony prominences of the patient to ensure adequate circulation

- Have the child clean himself well after every bowel movement

Rationale

A child who suffers a lack of mobility, such as after a severe injury, is at risk of skin breakdown, particularly from pressure ulcers. Pressure ulcers are more likely to develop when a patient lies in one position for a consistent period of time and blood flow is cut off from the distal tissues. This causes tissue ischemia and ultimately, skin breakdown. The nurse can prevent skin breakdown in the pediatric client by monitoring the skin carefully and applying lotion or emollients after bathing, cleaning the child carefully after elimination, and turning or repositioning the child in bed at least every 2 hours.

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