A nurse cares for older adult clients in a long-term acute care ...

[tiffannnnyyyyyy]

A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.)
 
  a. Use a lift sheet when moving the client in bed.
  b. Avoid tape when applying dressings.
  c. Avoid whirlpool therapy.
  d. Use loose dressing on all wounds.
  e. Implement pressure-relieving devices.

Question 2

A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.)
 
  a. Place a small pillow between bony surfaces.
  b. Elevate the head of the bed to 45 degrees.
  c. Limit fluids and proteins in the diet.
  d. Use a lift sheet to assist with re-positioning.
  e. Re-position the client who is in a chair every 2 hours.
  f.
  Keep the client's heels off the bed surfaces.
  g.
  Use a rubber ring to decrease sacral pressure when up in the chair.

[jgranad15]

Answer to Question 1

ANS: A, B, E
Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin won't tear. Using pressure-relieving devices for clients who are at risk for pressure ulcer formation, including older adults, is a proactive approach to prevent skin breakdown. No contraindication to using whirlpool therapy for the older client is known. Dressings should be applied as prescribed, not so loose that they do not provide required treatment, and not so tight that they decrease blood flow to tissues.

Answer to Question 2

ANS: A, D, F
A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.