The nurse is planning care for a patient who is at risk for pressure ulcer development. Which action should be included in this patient's plan of care?
Select all that apply.
1. Use pillows to offload pressure.
2. Turn at least every 2 hours.
3. Use a mild cleansing agent on the skin.
4. Keep on bed rest.
5. Pull up in bed every 2 hours or less.
Correct Answer: 1, 2, 3
Pillows provide a cushion for bony prominences, which decreases pressure. Turning every two hours takes prolonged pressure off a single area. Mild cleansing agents are less likely to remove the skin's natural barrier. Keeping a patient on bed rest would be inappropriate because activity and mobility prevent prolonged pressure in one area. Pulling patients up in bed increases friction and shear, but does not prevent pressure.
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