After 3 hours in the supine position, the older client tells the nurse that the client is too uncomfortable to move. Which is the best nursing intervention to maintain skin integrity?

Question

1. Find an assistant to help move the client to lateral position now.
2. Express concern about the discomfort and promise to come back.
3. Assess the client's need for pain medication before repositioning.
4. Explain how important repositioning is for preventing pneumonia.

Answer 1

3
3. Lying motionless is common behavior for clients in pain. This client likely to have thin, fragile skin and has not moved for 3 hours, increasing the risk of skin break-down from tissue hypoxia; so, the nurse assesses the client's pain and determines a need for pain medication before attempting to reposition the client. To preserve skin integrity and to promote client comfort, the nurse moves the client to another position to facilitate the flow of oxygen-rich blood to the tissue, to assess the entire back for skin breakdown, and to provide hygiene, if necessary.
1. Moving the client without addressing the pain is likely to result in a negative out-come including client and family dissatisfaction and pain aggravation. In addition, the client is unlikely to feel that the client has an active role in the plan of care or feel valued.
2 and 4. Expressing concern about the pain and repositioning to prevent pneumonia are reasonable responses by the nurse; however, the nurse breaches the duty owed to the client by ignoring the client's need for pain relief.