The nurse assesses the client receiving heat therapy and observes the affected tissue for redness. Which should the nurse implement next?

Question

1. Apply a cold compress to the area.
2. Reduce the setting of the temperature.
3. Document an expected client response.
4. Remove heat and reassess in 5 minutes.

Answer 1

4
4. On observing tissue redness, the nurse interrupts the heat application and reassesses the area in 5 minutes, expecting to reassess pink tissue, to prevent burns or client injury from excessive heat therapy.
1. Before exposing the client to additional treatment, the nurse obtains a clear as-sessment of the affected tissue. Cold application carries risks of tissue damage as well, so the nurse assesses the area first to determine follow-up nursing care.
2. The nurse obtains an assessment of the affected tissue first before planning fol-low-up nursing care.
3. The nurse avoids documenting an expected client response until the tissue assess-ment is complete because the nurse does not know whether the client response indi-cates tissue damage.