The nurse in the PICU is caring for a 4-year-old child who was in ...

[abarnes]

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.

Question 2

When the child with juvenile idiopathic arthritis (JIA) complains of stiffness in the joints in the morning and after a period of inactivity, the nurse recognizes the description of the _________ phenomenon.
 
  Fill in the blank(s) with correct word

[macagnavarro]

Answer to Question 1

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.

Answer to Question 2

Gel
The gel phenomenon is a stiffening of the joints in the morning and after a period of inactivity.