The nurse understands that to prevent pressure ulcers, pressure must be removed from high-risk areas of the body

Question

What nursing interventions are essential to accomplish this goal? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Pull the patient up in bed every 2 hours or less.
2. Turn the patient at least every 2 hours.
3. Encourage the patient to be out of bed.
4. Position articles the patient uses just out of reach to encourage movement.
5. Float the heels off the bed with pillows beneath the ankles.

Answer 1

2,3,5
Rationale 1: Pulling patients up in bed increases friction and shear but does not prevent pressure. Increasing friction and shear may increase the risk of pressure ulcers.
Rationale 2: Turning takes prolonged pressure off a single area.
Rationale 3: Bed rest increases the risk for pressure ulcer development.
Rationale 4: The patient may move more to reach for these articles, but this technique would increase the risk for falls. The nurse must consider the patient holistically when planning care.
Rationale 5: Placing pillows under the ankles "floats" the heels off the bed, thereby offloading pressure.