The nurse plans care to protect the skin covering an older adult's greater trochanter. Which is the nurse's priority intervention when the older adult is positioned on the side?

Question

a. Turn at least every hour.
b. Place a cushion between the knees.
c. Keep skin clean and dry.
d. Use the Sims' position.

Answer 1

A

Feedback
A Correct. The most important nursing intervention when an older adult is posi-tioned on the side is to relieve pressure on the head of the femur, the greater trochanter, because the greater trochanter is the most prominent bony projection on the side of a body. By turning the older adult at 1-hour intervals or less, the nurse helps to maintain tissue perfusion thus providing oxygenation to tissues and allowing the removal of waste from vulnerable skin.
B Incorrect. The nurse places a pillow between the knees to help maintain physio-logical body alignment and prevent strain on the hips and spine, and if posi-tioned properly, the pillow can help to maintain tissue integrity of the medial malleolus and ankle by elevating them off the mattress. However, because the nurse's priority is to maintain tissue oxygenation, preventing muscle and joint strain is not as important.
C Incorrect. The nurse keeps the skin clean and dry to help maintain skin integrity, but this is not as important as maintaining tissue oxygenation.
D Incorrect. The nurse uses Sims' position to supplement turning, because in the Sims' position, the patient is on the side but rotated slightly forward, allowing the chest and abdomen to fall forward and relieve some of the pressure on the patient's side.