The nurse is concerned about device-related pressure ulcers in her patients. Which of the following interventions should she take?(Select all that apply.)
a. Perform frequent skin assessment under devices and tubes.
b. Assess for edema in the skin underlying a tube.
c. Rotate tubes to different positions to re-lieve pressure.
d. Implement pressure ulcer care bundles.
e. Do not remove the adhesive tape until it is time to remove the device.
A, B, C, D
Medical devices known to contribute to pressure ulcers include nasogastric tubes, endotracheal tubes, Foley catheters, and other plastic, rubber, or silicone tubes. It is thought that the de-vice-related pressure ulcer may occur because of poor fixation or positioning of the equipment. To prevent breakdown, the following should be done:
1 . Frequently perform skin assessment around and under devices and tubes. Frequently assess for edema in the skin underlying a tube or other medical device.
2 . Remove adhesive tape and assess underlying skin; determine if another type of tape is needed.
3 . Rotate tubes to different positions to decrease pressure in the area where the tube is in con-tact with the skin. For example, endotracheal (ET) tubes can be moved from one side of the mouth to the other.
4 . Double-check and determine that the tube or device is properly positioned and has proper fixation to decrease unnecessary tube movement and skin damage.
5 . Implement care bundle for pressure ulcer prevention.
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