The nurse is caring for a client who is wheelchair bound. Which interventions will the nurse implement to prevent skin breakdown? (Select all that apply.)

Question

a. Change the client's position every 1 to 2 hours.
b. Place pillows under the client's heels.
c. Have the client do wheelchair pushups.
d. Remove the client's shoes to check for pressure areas.
e. Assess the client's lower legs for pressure from the wheelchair.
f. Massage the client's calves and feet with lotion.

Answer 1

A, C, D
Clients who sit for prolonged periods in a wheelchair need to be repositioned at least every 1 to 2 hours. Wheelchair push-ups should be done for at least 10 seconds every hour. If the client is wearing tennis shoes to prevent foot drop, the shoes should be removed every 2 hours to check for pressure areas. The lower legs, where the wheelchair could rub against the legs, also needs to be assessed. Pillows under the heels could exert pressure on the heels. It is better to place the pillow under the ankle. The calves of a client with no or decreased lower extremity mobility should not be massaged because of the risk of embolization or thrombus.