A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown?
a. Place pillows under the client's heels.
b. Have the client do wheelchair push-ups.
c. Perform wound care as prescribed.
d. Massage the client's calves and feet with lotion.
ANS: B
Clients who sit for prolonged periods in a wheelchair should perform wheelchair push-ups for at least 10 seconds every hour. Chair-bound clients also need to be re-positioned at least every 1 to 2 hours. The lower legs, where the wheelchair could rub against the legs, also need to be assessed. Pillows under the heels could exert pressure on the heels; it is better to place the pillow under the ankle. Performing wound care as prescribed is important to improve the healing of pressure ulcers, but this intervention will not prevent skin breakdown. The calves of a client with no or decreased lower extremity mobility should not be massaged because of the risk of embolization or thrombus.
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