Which activity should the nurse implement to decrease shearing force on a client’s stage Il pressure injury?
A.
pulling the client up from under the arms
B.
improving the client’s hydration
C.
lubricating the area with skin cream
D.
preventing the client from sliding in bed
The Correct Answer and Explanation is:
The correct answer is D. Preventing the client from sliding in bed.
Explanation:
A stage II pressure injury involves partial-thickness skin loss with exposed dermis. It can present as an open, shallow wound or an intact or ruptured blister. Preventing further damage and promoting healing are essential in managing these injuries.
Shearing force occurs when the skin is stationary, but the underlying tissues and bones move in opposite directions. This movement commonly happens when a client slides down in bed or when they are repositioned without proper technique. Shearing can damage deeper tissues and worsen a pressure injury. Therefore, the goal is to reduce or eliminate factors that cause shearing.
Why option D is correct:
By preventing the client from sliding in bed, the nurse reduces the chances of shear forces acting on the pressure injury. Using techniques like elevating the head of the bed at a minimal angle or ensuring that the client’s body is aligned and supported with pillows can help. Additionally, ensuring proper transfer techniques, such as using a draw sheet or lifting devices, reduces friction and prevents the client from being dragged across the bed.
Why the other options are incorrect:
- Option A (Pulling the client up from under the arms): This method creates more shear and friction forces, which can further damage the skin and exacerbate the pressure injury. A better practice is using a lifting device or a draw sheet to reduce stress on the skin.
- Option B (Improving the client’s hydration): While hydration is important for overall skin health, it doesn’t directly reduce shear forces. Proper hydration helps maintain skin elasticity and integrity but does not address mechanical factors like shearing.
- Option C (Lubricating the area with skin cream): Skin creams can help maintain skin moisture and prevent breakdown, but they do not address the underlying mechanical issue of shearing.
Thus, preventing the client from sliding in bed is the most effective way to reduce shearing forces and protect the integrity of the pressure injury site.