Integumentary Disorders Q 54 - Gyan Darpan : Learning Portal
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Friday, 1 April 2022

Integumentary Disorders Q 54

Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?
    A. Turn and reposition the client at least once every 8 hours.
    B. Vigorously massage lotion into bony prominences.
    C. Post a turning schedule at the client’s bedside.
    D. Slide the client, rather than lifting, when turning.

Correct Answer: C. Post a turning schedule at the client’s bedside.

A turning schedule with a signing sheet will help ensure that the client gets turned and, thus, help prevent pressure ulcers. Set goals with the patient or significant other for cooperation in activities or exercise and position changes. This enhances a sense of anticipation of progress or improvement and gives some sense of control or independence.

Option A: Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. Keep limbs in functional alignment with one or more of the following: pillows, sandbags, wedges, or prefabricated splints. This avoids footdrop and too much plantar flexion or tightness. Maintain feet in dorsiflexed position.
Option B: The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. Assess the skin over bony prominences (sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back of the head). These areas at highest risk for breakdown resulting from tissue ischemia from compression against a hard surface.
Option D: When moving the client, the nurse should lift — rather than slide — the client to avoid shearing. Assess client’s ability to move (shift weight while sitting, turn over in bed, move from the bed to a chair). Immobility is a huge risk factor for pressure ulcer development among adult hospitalized clients.

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