The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which interventions are appropriate? (Select all that apply.)
a. Place a small pillow between bony sur-faces.
b. Elevate the head of the bed to 45 degrees.
c. Limit fluids and proteins in the diet.
d. Use a lift sheet to assist with reposition-ing.
e. Reposition the client who is in a chair every 2 hours.
f. Keep the heels off the bed surfaces.
g. Use a rubber ring to decrease sacral pres-sure when up in the chair.
A, D, F
A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head of the bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.
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