A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client’s risk of developing a pressure injury?
A.
Ensure the client’s heels are not touching the mattress.
B.
Massage the client’s bony prominences.
C.
Raise the head of the client’s bed to a 60° angle.
D.
Reposition the client every 4 hr.
The Correct answer and Explanation is:
The correct answer is A. Ensure the client’s heels are not touching the mattress.
Explanation:
Pressure injuries, also known as pressure ulcers or bedsores, are localized damage to the skin and underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. These injuries are particularly common in clients who are on bed rest, as they may experience prolonged pressure on certain areas of the body.
To decrease the risk of developing pressure injuries, it’s crucial to relieve pressure from bony prominences and areas that are at high risk of injury. Here’s how the options compare:
- Option A: Ensure the client’s heels are not touching the mattress.
- This action is crucial for preventing pressure injuries on the heels. When a client’s heels are in contact with the mattress, the pressure can lead to tissue damage and the formation of pressure ulcers. Elevating the heels off the mattress reduces the risk of pressure injury by alleviating direct pressure on this vulnerable area. This can be achieved using heel protectors or pillows to keep the heels from contacting the bed surface.
- Option B: Massage the client’s bony prominences.
- This is not recommended because massaging bony prominences can actually exacerbate the risk of developing pressure injuries. The friction and force from massage can cause further damage to the already compromised tissue. Instead, it’s important to avoid direct pressure and friction on these areas.
- Option C: Raise the head of the client’s bed to a 60° angle.
- Raising the head of the bed to a 60° angle increases the risk of shear forces and pressure injuries, particularly on the sacral area and heels. It is generally recommended to keep the head of the bed elevated no more than 30° when possible to minimize these risks.
- Option D: Reposition the client every 4 hr.
- While regular repositioning is important to prevent pressure injuries, repositioning every 4 hours might not be frequent enough for high-risk clients. The general recommendation is to reposition clients at least every 2 hours to reduce the risk of pressure ulcers.
In summary, ensuring that the client’s heels are not touching the mattress helps to specifically target a high-risk area for pressure injuries and is a direct method to decrease their risk.