A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.)
a. Use a lift sheet when moving the client in bed.
b. Avoid tape when applying dressings.
c. Avoid whirlpool therapy.
d. Use loose dressing on all wounds.
e. Implement pressure-relieving devices.
ANS: A, B, E
Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin won't tear. Using pressure-relieving devices for clients who are at risk for pressure ulcer formation, including older adults, is a proactive approach to prevent skin breakdown. No contraindication to using whirlpool therapy for the older client is known. Dressings should be applied as prescribed, not so loose that they do not provide required treatment, and not so tight that they decrease blood flow to tissues.
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