A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
A.
Reposition the client every 2 hr.
B.
Elevate the head of the client’s bed 45°
C.
Massage the client’s bony prominences.
D.
Provide the client with a high-calorie diet.
The correct answer and Explanation is :
The correct answer is A. Reposition the client every 2 hours.
Explanation:
Pressure injuries (pressure ulcers or bedsores) occur when there is prolonged pressure on the skin, especially over bony prominences, reducing blood flow and damaging tissues. The primary goal of nursing care for clients at risk of pressure injuries is to reduce pressure on vulnerable areas and maintain skin integrity.
Repositioning every 2 hours is a key intervention because it helps redistribute pressure and improves blood flow to areas that are prone to injury, such as the sacrum, heels, and elbows. Regular repositioning ensures that no single area of the body is subjected to continuous pressure for extended periods, which is one of the leading causes of pressure injuries.
Here’s why other options are not the best interventions:
- B. Elevating the head of the client’s bed 45°: While slightly elevating the head of the bed can help with breathing and prevent aspiration in certain conditions, elevating it to 45° may increase the risk of pressure injuries on the sacrum and coccyx due to sliding and shearing forces. It can lead to skin breakdown in these areas.
- C. Massaging the client’s bony prominences: Massaging over bony prominences is contraindicated. It can damage fragile tissues that are already compromised and may contribute to injury rather than prevent it.
- D. Providing a high-calorie diet: While nutrition is important in maintaining skin integrity and promoting wound healing, increasing calories alone won’t prevent pressure injuries. A well-balanced diet with adequate protein, vitamins, and hydration is important but must be combined with other preventive measures like repositioning.
In summary, repositioning every 2 hours is a proven and essential practice in preventing pressure injuries, and it should be part of a comprehensive care plan that also addresses skin care, support surfaces, and nutrition.