Question

The nurse is caring for a client with a pressure ulcer who is at risk for impaired skin integrity. Which intervention should be included in the nursing plan of care? (Select all that apply)

1) Avoiding the side-lying position
2) Increasing amount of time with the head of the bed elevated
3) Massaging bony prominences
4) Cleaning the skin at time of soiling and routinely
5) Inspecting skin at least once a day

Answer 1

When caring for a client with a pressure ulcer, the nursing plan of care should include avoiding the side-lying position, increasing time with the head of the bed elevated, cleaning the skin regularly, and inspecting the skin daily.

Step-by-step explanation:

When caring for a client with a pressure ulcer who is at risk for impaired skin integrity, the following interventions should be included in the nursing plan of care:

1. Avoiding the side-lying position: This position can put additional pressure on the ulcer and hinder healing.
2. Increasing the amount of time with the head of the bed elevated: Elevating the head of the bed can help reduce pressure on the ulcer.
3. Cleaning the skin at the time of soiling and routinely: This helps maintain skin hygiene and prevents complications.
4. Inspecting skin at least once a day: Regular skin inspections help detect any changes or signs of infection early.