Question

For an immobile patient whose skin is intact but is at high risk for impaired skin integrity, the nurse should plan to use a pillow under the calves so that the heels are elevated to reduce the risk of heel breakdown. The nurse should also use an active support surface, such as an overlay or mattress, when frequent manual repositioning is difficult. Avoiding should also be part of the nursing plan prolonged head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx. The nurse should consider using either low-air-loss, alternating pressure, or air-fluidized support surface for patients who already have pressure ulcers. The nurse will also consider using a wheelchair cushion for a patient who has a sacral or coccyx pressure ulcer

For an immobile patient at high risk for impaired skin integrity, which nursing interventions should be included in the plan?

a) Using a wheelchair cushion
b) Avoiding prolonged head-of-bed elevation
c) Placing a pillow under the calves
d) Using low-air-loss support surfaces.

Answer 1

Nursing interventions for preventing impaired skin integrity in immobile patients include using a wheelchair cushion, avoiding prolonged head-of-bed elevation, placing a pillow under the calves, and using low-air-loss support surfaces to reduce the risk of pressure sores.

Step-by-step explanation:

When caring for an immobile patient at high risk for impaired skin integrity, a nurse's plan should prioritize interventions that reduce pressure on vulnerable areas of the body. Pressure sores, also known as decubitus ulcers, can develop due to prolonged pressure on specific areas, especially in elderly, immobile patients. These sores can deteriorate into serious infections if not managed correctly.

Incorporating nursing interventions such as using a wheelchair cushion can assist in distributing pressure more evenly when the patient is seated. It is also essential to avoid prolonged head-of-bed elevation beyond 30 degrees to reduce shear and pressure on the sacrum and coccyx. Additionally, placing a pillow under the calves can elevate the heels off the bed, decreasing the risk of heel breakdown.

Advanced care options like using low-air-loss support surfaces or other active support systems can be beneficial for patients who already have pressure ulcers or when manual repositioning is challenging. These support surfaces help in alternating pressure and improving air circulation around vulnerable areas of the skin.