The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for
a. Infection.
b. Impaired skin integrity.
c. Trauma.
d. Imbalanced nutrition.
C
Heat causes vasodilatation and is used to improve blood flow to an injured body part. The application of heat incorrectly when the treatment is too hot, or is applied too long or to the wrong place, can result in a burn for the patient and risk for additional trauma. The skin already has impaired integrity owing to the surgical procedure, and because of this has been at risk for infection since the surgical procedure was performed. This patient is of childbearing age and has had a child. Additional needs for nutrition are present during pregnancy and breastfeeding, but this is an established nursing diagnosis. Data are insufficient to support the nursing diagnosis of Imbalanced nutrition.
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