The nurse is caring for an immobile patient being treated for diabetes mellitus and a urinary tract infection. What should be included in a plan of care to prevent pressure ulcers in this patient? (Select all that apply.)

Question

a. Apply moisturizer to the skin after bathing.
b. Reposition the patient at least every 2 hours.
c. Elevate the head of the bed no more than 30 degrees.
d. Massage bony prominences including hips and elbows.
e. Place the patient on a donut-shaped cushion when sitting.
f. Assure that skin is dried carefully and completely after washing.

Answer 1

ANS: A, B, C, F
When a patient is immobile, the highest possible level of mobility should be maintained; frequent active or passive range-of-motion exercises should be performed as well as turning according to a written repositioning schedule. If patients are on bedrest, turn and reposition them at least every 2 hours, but preferably more often because ischemia development begins after 20 to 40 minutes of pressure. The head of the bed should not be elevated more than 30 degrees to reduce pressure on the coccyx and to reduce friction and shear damage from sliding down in the bed. After bathing, lubricate the skin with moisturizers to prevent dryness. E. Donut-shaped cushions should never be used. They create a circle of pressure that cuts off the circulation to the surrounding tissue, promoting ischemia rather than preventing it. D. Avoid massaging bony prominences or reddened skin areas; research has shown that blood vessels are damaged by massage when ischemia is present or when they lie over a bone.