Question

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate (Select all that apply)?

a) Turn the client every 2 hours
b) Use a trapeze bar for transferring
c) Massage bony prominences
d) Apply a heating pad to reddened areas

Answer 1

The appropriate nursing actions to prevent skin breakdown for a client with spinal cord injury and paralysis are to turn the client every 2 hours and to use a trapeze bar for transferring, avoiding massaging bony prominences and applying heat to reddened areas.

Step-by-step explanation:

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Among the actions to be taken, the following are appropriate:

• Turn the client every 2 hours
• Use a trapeze bar for transferring

Turning the client every 2 hours helps to relieve pressure and prevent the development of pressure ulcers, which are a risk with immobility. A trapeze bar will assist with movement and transferring, thereby reducing friction and shear forces that can contribute to skin breakdown.

However, it is important to avoid massaging bony prominences as this can cause damage to sensitive tissues, and applying a heating pad to reddened areas should be avoided as it might aggravate potential pressure ulcers.