Question

When planning care for a client at risk for developing a pressure ulcer, the nurse addresses the potential problem of risk for impaired skin integrity. Which nursing intervention assists in meeting the goals of this diagnosis?

1) Placing the client in the side-lying position only
2) Avoiding massaging bony prominences
3) Keeping the head of the bed elevated more than thirty degrees
4) Using positioning devices
5) Inspecting the skin every day

Answer 1

To prevent pressure ulcers in at-risk clients, using positioning devices to relieve pressure and daily skin inspection are key interventions, while avoiding massaging bony prominences can help maintain skin integrity.

Step-by-step explanation:

When planning care for a client at risk for developing a pressure ulcer and addressing the potential problem of risk for impaired skin integrity, several nursing interventions can assist in meeting the goals of this diagnosis. Avoiding massaging bony prominences is crucial because massages in these areas can cause pressure ulcers rather than prevent them. Instead, interventions include using positioning devices to eliminate pressure points and regularly inspecting the skin every day to assess for early signs of pressure ulcer development. Keeping the head of the bed elevated more than thirty degrees might not directly prevent pressure ulcers and could potentially increase shear forces, while placing the client in the side-lying position only is not adequate as regular repositioning is necessary to redistribute pressure.