A nurse is planning care for an older adult client who is at risk for developing pressure ulcers.
Which of the following interventions should the nurse use to help maintain the integrity of the client’s skin?
A.
Elevate the head of the bed no more than 45°.
B.
Use a transfer device to lift the client up in bed.
C.
Massage the skin over the client’s bony prominences.
D.
Apply cornstarch to keep sensitive skin areas dry.
The Correct Answer and Explanation is:
The correct answer is B. Use a transfer device to lift the client up in bed.
Explanation:
Pressure ulcers, also known as bedsores or decubitus ulcers, are injuries to the skin and underlying tissue that result from prolonged pressure on the skin. Older adults are at higher risk due to factors like decreased mobility, reduced skin elasticity, and other age-related changes. Preventing pressure ulcers requires careful management of various factors, including pressure relief, skin care, and mobility.
Option A: Elevate the head of the bed no more than 45°. While elevating the head of the bed to 45° can help reduce the risk of aspiration and improve comfort, it is not a direct intervention for preventing pressure ulcers. The most critical aspect for pressure ulcer prevention is reducing pressure on vulnerable areas, such as the sacrum, heels, and elbows. Positioning strategies that relieve pressure are more effective than merely elevating the head of the bed.
Option B: Use a transfer device to lift the client up in bed. This is the correct answer. Using a transfer device, such as a slide sheet or a lift, helps in repositioning the client without dragging them across the bed, which can cause friction and shear forces. These forces can damage the skin and underlying tissues, increasing the risk of pressure ulcers. A transfer device helps to minimize these risks by reducing friction and distributing pressure more evenly during repositioning.
Option C: Massage the skin over the client’s bony prominences. This is not recommended for pressure ulcer prevention. Massage over bony prominences can actually exacerbate the risk of developing pressure ulcers by causing further tissue damage. The skin over bony areas is already at risk due to pressure, and massage can disrupt the delicate balance of blood flow in these areas, potentially leading to more damage.
Option D: Apply cornstarch to keep sensitive skin areas dry. While keeping skin dry is important, cornstarch is not recommended for this purpose as it can contribute to fungal infections or other skin problems. Instead, appropriate skin care involves using moisture-wicking fabrics and maintaining skin hygiene with suitable barrier creams or products designed for sensitive skin.
In summary, using a transfer device to lift and reposition the client helps maintain skin integrity by reducing friction and shear forces, which are crucial in preventing pressure ulcers.