A nurse is caring for four patients on a general pediatric unit. The nurse identifies risk for impaired skin integrity as a nursing diagnosis for all four. Which patient's skin should the nurse assess first?
A.
Adolescent 4 hours postoperative after appendectomy
B.
School-age child just back from a tonsillectomy
C.
Teen eating in a chair 1 week post-burn
D.
Toddler with broken femur in skeletal traction
ANS: D
Immobility is a major risk factor for impaired skin integrity. The nurse should first assess the child in traction, as this child is the least mobile. A child sitting in a chair to eat is at least partially mobile. Children after routine surgery are expected to recover quickly and begin activity within a day.
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