Which intervention is most appropriate for the nursing diagnostic statement, Impaired skin integrity related to shearing forces?
a. Administer pain medication every 4 hours as needed.
b. Perform the ordered dressing change twice daily.
c. Do not document the wound appearance in the chart.
d. Keep the bed side rails up at all times.
ANS: B
The most appropriate intervention for the diagnosis of Impaired skin integrity is to perform the ordered dressing change. The other options do not directly address the skin integrity. The patient may need pain medication before dressing changes, but Acute pain would be another nursing diagnosis. Documenting all objective findings is the nurse's responsibility, even if a wound or infection is a health care–associated problem. Keeping the side rails up addresses safety, not skin integrity.
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