The nurse is planning care for a patient at risk for pressure ulcer development. What should the nurse include in this patient's plan of care?
Select all that apply.
1. Initiate a frequent toileting schedule.
2. Turn the patient every 2 hours.
3. Massage pressure areas with lotion every 4 hours.
4. Use inflatable donut rings to reduce pressure on the sacrum.
5. Use hot water to cleanse the skin immediately after incontinence.
Correct Answer: 1, 2
Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and potential for skin breakdown. The patient should be turned at least every 2 hours. Massage of pressure areas can cause friction and damage to problem skin areas. Inflatable donut rings are contraindicated, as they increase pressure and reduce perfusion to affected areas. Use of hot water for cleansing may cause skin injury.
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