A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include?
a. Massaging reddened bony prominences
b. Teaching the parents to turn the child every 4 hours
c. Ensuring that nutritional intake meets requirements
d. Minimizing use of extra linens, which can irritate the child's skin
ANS: C
Children who are hospitalized and NPO (taking nothing by mouth) for several days are at risk for nutritional deficiencies and skin breakdown. If NPO status is prolonged, parenteral nutrition should be considered. Massaging bony prominences can cause deep tissue damage. This should be avoided. Although parents can participate, turning the child is the nurse's responsibility. If the child is alert and can move, position shifts should be done more frequently. If the child does not move, the nurse should reposition every 2 hours. The number of linens is not an issue. The child should not be dragged across the sheet. Children should be lifted and moved to avoid friction and shearing.
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