Question

A nurse is developing a plan of care for a client who is at high risk for developing pressure ulcers. Which of the following interventions should the nurse include in the plan to prevent the development of pressure ulcers?

a. Reposition the client every 2 hours.
b. Use a donut-shaped cushion.
c. Keep the skin moist to prevent dryness.
d. Encourage frequent massaging of bony areas.
e. Provide a high-protein diet.

Answer 1

To prevent pressure ulcers in high-risk clients, nurses should reposition the client every 2 hours and ensure a high-protein diet while avoiding practices that increase pressure or moisture on bony areas.

Step-by-step explanation:

When developing a plan of care for a client who is at high risk for developing pressure ulcers, the nurse should include several key interventions. These include:

• Repositioning the client every 2 hours to alleviate and distribute pressure away from bony areas.
• Providing a high-protein diet to support skin integrity and promote healing.
• Avoiding the use of a donut-shaped cushion, as these can actually increase pressure on surrounding tissues.
• Keeping the skin clean and dry, rather than moist, to prevent the maceration and breakdown of skin.
• Refraining from frequent massaging of bony areas to prevent damage to vulnerable skin and underlying tissues.

By implementing these interventions, the nurse can significantly reduce the risk of bedsore development in high-risk clients.