A nursing intervention directs the patient to be turned every 2 hours to prevent skin breakdown from immobility. Assessment findings on new reddened areas on the lateral aspects of the right knee and ankle are obtained. What is the most appropriate way for these findings to be used when the care plan is evaluated?

Question

Quizplus · Accepted Answer

Evaluation is the process of examining the effectiveness of the plan of care and adjusting it to ultimately meet the needs of the patient. Because redness is observed over bony prominences with turning the patient every 2 hours, the intervention must be adjusted, so the patient must be turned more frequently to prevent further skin breakdown. Documenting of information in the electronic medical record does not address the immediate skin integrity problem. Changing the actual problem to a potential problem is incorrect. Calling the physician is not an independent nursing intervention and does not address the issue of skin integrity.

A Nursing Intervention Directs the Patient to Be Turned Every