The nurse is providing care to a child with a long-leg hip spica cast. Which of the following would be a priority nursing diagnosis?
A) Risk for impaired skin integrity due to cast and location
B) Deficient knowledge related to cast care
C) Risk for delayed development related to immobility
D) Self-care deficit related to immobility
A
Feedback:
Although deficient knowledge, risk for delayed development, and self-care deficit may be applicable, the child is at increased risk for skin breakdown due to the size of the cast and its location. In addition, the cast has an opening, which allows for elimination. Soiling of cast edges or leakage of urine or stool can lead to skin breakdown.
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