The nurse places an orthotic device onto the client's lower leg. Which is the priority nursing intervention to complete?
1. Instruct client that device is long-term therapy.
2. Provide client teaching before ending the visit.
3. Ensure orthotic device is free of client clothing.
4. Assess affected tissue for redness from pressure.
4
4. The most important nursing intervention is to assess the affected tissue for redness, a potential clinical indicator of a pressure point. This is important to accomplish with the client before regular use of the orthotic because a pressure point potentially leads to skin breakdown and can result in client inability to use the orthotic.
1. Orthotic devices are usually long-term therapy, but this is of secondary importance to maintaining skin integrity.
2. The nurse completes client teaching before ending the visit for proper use of the orthotic and maintenance of skin integrity.
3. To function properly, the orthotic device needs to assume the shape and position-ing of the affected tissue and therefore requires close proximity to the tissue. The on-ly clothing allowed is socks or stockings.
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