The nurse admits the patient to the surgical unit and determines that the patient's Braden scale score is 18 . Which does the nurse include in the patient's initial plan of care?

Question

a. Using moisturizing lotion to massage the sacrum
b. Assisting the patient to turn and reposition every 4 hours
c. Keeping the skin clean and dry with fre-quent bathing
d. Maintaining the head of the bed at ap-proximately 30 degrees

Answer 1

D
The nurse elevates the head of the bed to 30 degrees or less to reduce shear forces. If the patient sits in the Fowler's or semi-Fowler's position, the lower back and buttocks receive excessive force from the his or her weight pressing into the mattress, which can increase the risk of skin breakdown. Moisturizing lotion applied to areas at risk for friction is indicated for any patient in bed. The nurse avoids massaging the skin over bony prominences such as the sacrum because the tissue lacks supportive structures such as muscle and fat to distribute pressure over a large surface and provide oxygenated blood. Al-though the patient has a slight risk for skin breakdown, repositioning and turning every 4 hours is inadequate to maintain adequate tissue oxygenation. Excessive bathing increases the risk of skin breakdown by stripping the skin of essential oils and moisture. The skin may be kept clean and dry with daily and as-needed bathing using mild soap or commercial bathing products.