A student nurse is helping with the initial assessment of an 85-year-old patient. What can the student do to ensure that shearing forces are avoided? (Mark all that apply.)

Question

A) Puts on foam boots three or more times a day.
B) Inspect and provide skin care q shift.
C) Palpate the area of the traction tapes daily.
D) Provides back care at least q 2 hours.
E) Give massage q shift.

Answer 1

Ans: B, C, D
Feedback: During the initial assessment, the nurse identifies sensitive, fragile skin (common in older adults). The nurse also closely monitors the status of the skin in contact with tape or foam to ensure that shearing forces are avoided. The nurse performs the following procedures to monitor and prevent skin breakdown: removes the foam boots to inspect the skin, the ankle, and the Achilles tendon three times a day. A second nurse is needed to support the extremity during the inspection and skin care. The nurse palpates the area of the traction tapes daily to detect underlying tenderness, and provides back care at least every 2 hours to prevent pressure ulcers. The patient who must remain in a supine position is at increased risk for development of a pressure ulcer. Special mattress overlays (eg, air-filled, high-density foam) are used to prevent pressure ulcers.