What instruction should the nurse provide to a nursing assistant who is assigned to care for an older patient with a stage I pressure injury on the right heel?
1. Apply a dry dressing to the site.
2. Apply a donut under the right heal.
3. Cleanse the area with tepid water.
4. Keep the head of the bed elevated.
3. Cleanse the area with tepid water.
Explanation: 1. A dry dressing is not indicated for this type of pressure ulcer.
2. Mechanical devices can exacerbate pressure ulcers and should not be used.
3. The area at risk for pressure sore development should be washed gently with tepid water, and minimal soap. Soap removes natural oils from the skin, and cleaning the soap off may cause additional friction damage.
4. Elevating the head of the bed increases pressure on the sacrum and lower extremities which could cause the pressure ulcer to become worse.
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