Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client’s need to maintain skin integrity?
A. Monitoring intake and output accurately.
B. Instructing the client to cough and deep breathe every 2 hours.
C. Keeping the linens dry and wrinkle-free.
D. Using a footboard to maintain correct anatomic position.
Correct Answer: C. Keeping the linens dry and wrinkle-free.
Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from interfering with adequate blood supply to the tissues, helping to maintain skin integrity. Encourage the implementation of a turning schedule, restricting time in one position to 2 hours or less, if the patient is restricted to bed.
Option A: Monitoring intake and output aids in assessing and maintaining bladder function. Assess patient’s nutritional status, including weight, weight loss, and serum albumin levels. An albumin level less than 2.5 g/dL is a grave sign, indicating severe protein depletion and at high risk of skin breakdown.
Option B: Coughing and deep breathing help promote gas exchange. Reinforce the importance of turning, mobility, and ambulation. These will enhance their sense of efficacy and can improve compliance with the prescribed interventions.
Option D: Using a footboard is appropriate for maintaining a normal body function position. Encourage the patient to change position every 15 minutes and change chair-bound positions every hour. Use pillows or foam wedges to keep bony prominences from direct contact with each other. Keep pillows under the heels to raise off the bed.
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