Which interventions increase the risk for impaired skin integrity in the patient with congestive heart failure who requires total care? Select all that apply.

Incorrect

  • Administer furosemide q8h by mouth
  • Transfer patient to chair for 1 hour each day
  • Add polyethylene glycol to orange juice each morning
  • Crush all medications and mix in applesauce before administering
  • Apply sequential compression devices (SCDs) continuously while in bed

Rationale

The patient who requires total care is at an increased risk for impaired skin integrity. Administering diuretics (furosemide) and laxatives (polyethylene glycol) increases the risk for incontinence and subsequent maceration of skin. Transferring the patient to the chair can cause shear injury to the skin as well as place more pressure on the patient’s ischial spines. The continuous application of sequential compression devices (SCDs) can also impair skin integrity by causing new pressure points. Crushing medications and mixing them in applesauce does not increase the patient’s risk for impaired skin integrity.

  • Category: Physiological Adaptation
  • Difficulty: 9
  • Tags: Disease Prevention Communication & Documentation Health Promotion Mobility Musculoskeletal Nursing Interventions Tissue Integrity

Question 44 of 75

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