The nurse in the PICU is caring for a 4-year-old child who was in a motor vehicle accident three days ago. The child is sedated with many IV lines, a catheter, and a ventilator
The plan of care requires new positioning every three hours and indicates for the child to have a skin check done every hour. Indicate an area of concern for skin breakdown. (Select all that apply.) 1. The area around the child's mouth where the endotracheal tube is taped
2. The peri-area because of the immobility and dampness to the area
3. The IV site because of the possibility of infiltrations
4. The scapula because the child rests more comfortably on her back
5. All of the above are areas of concern for skin breakdown.
1, 2, 3
Feedback
1. The tape and the endotracheal tube can irritate the skin, cause chaffing and increased skin breakdown.
2. Since the child is sedated, incontinence can be present, increasing the risk for skin breakdown.
3. IV sites should be checked every hour with the assessment to find possibilities of infiltrations.
4. This area is not at a high risk because the child is repositioned every three hours.
5. Not all of the above are areas are concerns for skin breakdown.
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