When assessing the skin of an immobilized patient, the nurse should
a. Assess the skin at least every 4 hours.
b. Use a standardized tool such as the Braden Scale.
c. Use nursing instinct instead of a standardized tool.
d. Have special times for inspection so as to not interrupt routine care.
B
Consistently use a standardized tool, such as the Braden Scale. This identifies patients with high risk of impaired skin integrity. Nursing instinct in this case is not enough. At a minimum, skin assessment occurs every 2 hours. Continually assess the patient's skin for breakdown and color changes such as pallor or redness. Continual assessment reduces the need for the creation of special times for inspection.
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