A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.)

Question

a. Place a small pillow between bony surfaces.
b. Elevate the head of the bed to 45 degrees.
c. Limit fluids and proteins in the diet.
d. Use a lift sheet to assist with re-positioning.
e. Re-position the client who is in a chair every 2 hours.
f.
Keep the client's heels off the bed surfaces.
g.
Use a rubber ring to decrease sacral pressure when up in the chair.

Answer 1

ANS: A, D, F
A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.