The client's sacrum has nonblanching redness on Monday; however, on Wednesday, the nurse determines the pressure ulcer on the client's sacrum is stage II despite skin care including an air-filled mattress overlay
Which is the best nursing intervention to implement? 1. Document progression of client's pressure ulcer.
2. Collaborate with the provider for physical therapy.
3. Reassess client need for alternative support surface.
4. Increase the frequency of bathing and linen changes.
3
3. The client's pressure ulcer is deteriorating and means that the skin care plan is un-successful and needs re-evaluation, so the nurse assesses the client for a different support surface.
1. The nurse should document the client's skin assessment; but the best response to client deterioration is to evaluate the plan, assess the client, and amend the plan of care to suit the revised assessment because the current plan led to deterioration, an undesirable outcome.
2. Nursing collaboration for physical therapy is a reasonable response and potentially benefits the client on a support surface, especially if the client is on bed rest; however, the nurse needs to first assess the client to determine whether physical therapy is indicated for the client.
4. The nurse provides bathing for a client with a pressure ulcer on a routine and as-needed basis but avoids planning frequent baths and linen changes as therapy be-cause excessive bathing strips the skin of essential moisture and surface oils. Al-though the risk of excessive bathing potentially aggravates the client's skin, the client potentially benefits from frequent turning and interaction with the nurse during linen changes, so the nurse plans frequent turning and client communication without linen changes.
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