QLexNursing

Reposition the client every 2 hr.

🌟 The client has decreased sensation and mobility in the lower extremities, which greatly increases the risk for pressure injuries due to prolonged, unrelieved pressure.

🌟 Repositioning every 2 hours is a core pressure injury prevention intervention that helps redistribute pressure over bony prominences like the sacrum and heels.

🌟 Because the client also has urinary and fecal incontinence, moisture further weakens skin integrity, making scheduled turning even more important to protect the skin.

🌟 Regular repositioning also promotes circulation and oxygenation to tissues, which is essential for maintaining healthy skin and preventing ischemia.

🌟 Including q2h repositioning in the plan of care reflects evidence-based practice for a high-risk, immobile, incontinent client and is a priority nursing action.

Request a consult with a registered dietitian.

🌟 The client’s intake shows they are only eating 25% of breakfast and 10% of lunch, which is inadequate nutrition for healing and skin maintenance.

🌟 Poor nutritional intake—especially low protein and calories—compromises wound healing and increases the risk of skin breakdown and pressure injuries.

🌟 A registered dietitian can assess the client’s caloric, protein, and fluid needs, and recommend supplements or modifications to support tissue repair and immunity.

🌟 This intervention is particularly important in a client with diabetes mellitus, as they are already at higher risk for poor wound healing and neuropathy.

🌟 Including a dietitian consult in the plan of care is a proactive step to address underlying nutritional risk factors contributing to impaired skin integrity.

Provide a support pressure-redistribution surface.

🌟 A client with decreased mobility, incontinence, and diabetes is at very high risk for pressure injury and benefits from a specialized mattress or pressure-redistribution surface.

🌟 These surfaces help distribute body weight more evenly, reducing intense pressure on bony prominences such as the sacrum, ischium, and heels.

🌟 Pressure-redistribution devices support the effects of regular repositioning and are especially important when the client spends significant time in bed.

🌟 In addition, this intervention can help decrease discomfort and may assist in maintaining skin integrity over time.

🌟 Providing a support surface is an appropriate and evidence-based component of a comprehensive pressure injury prevention plan for this client.

Use a moisture barrier ointment after cleaning the client's skin.

🌟 The client has urinary and fecal incontinence, which exposes the skin to constant moisture, enzymes, and irritants that break down the epidermis.

🌟 Applying a moisture barrier ointment after thoroughly cleaning the skin helps protect against maceration and incontinence-associated dermatitis.

🌟 This barrier forms a protective film between the skin and urine or stool, reducing friction and irritation, which are major contributors to pressure injury development.

🌟 Regular use of moisture barrier products is especially important in areas prone to soiling such as the perineum, buttocks, and sacral region.

🌟 Including moisture barrier use in the plan of care directly addresses one of the client’s most significant risk factors: continuous exposure to moisture from loose stool and incontinence.

Place the client on a donut-shaped cushion.

🌟 Donut-shaped cushions are not recommended because they concentrate pressure around the edges of the ring, which can impair blood flow to surrounding tissues.

🌟 Instead of relieving pressure, these devices can actually increase the risk of pressure injury, especially in high-risk clients with decreased mobility and sensation.

🌟 Professional guidelines for pressure injury prevention advise using pressure-redistribution surfaces, not donut cushions, for seated or bed-bound clients.

🌟 For a client who already has incontinence and neuropathy, using a donut cushion could cause skin breakdown over the sacrum or ischial tuberosities.

🌟 Therefore, placing the client on a donut-shaped cushion is unsafe and not an appropriate intervention for protecting skin integrity in this scenario.

Elevate the head of the bed to 45°.

🌟 Keeping the head of the bed at 45° for prolonged periods increases shearing forces, especially over the sacrum and coccyx, as the client slides down in bed.

🌟 Shear and friction contribute significantly to deep tissue injury, particularly in clients with limited mobility and decreased sensation.

🌟 Unless there is a specific respiratory or swallowing indication, the head of the bed should be maintained at the lowest elevation compatible with the client’s condition, often 30° or less.

🌟 In a client already at high risk for pressure injuries, routinely elevating the bed to 45° does not protect the skin and can worsen the risk of breakdown.

🌟 Therefore, including HOB 45° as a standard part of the plan of care for skin protection would be inappropriate and potentially harmful.

Perform a skin risk assessment weekly.

🌟 A client with diabetes, incontinence, and decreased mobility is at high risk, and such clients require frequent skin and risk assessments, not just weekly reviews.

🌟 Evidence-based practice recommends performing a skin assessment and pressure injury risk assessment at least once per shift or daily, and with any change in condition.

🌟 Limiting the assessment to weekly would delay recognition of early signs of skin breakdown, such as non-blanchable erythema or moisture damage.

🌟 This client is already showing risk factors that demand ongoing, routine monitoring, along with early intervention when changes occur.

🌟 Therefore, planning to perform a skin risk assessment only weekly is insufficient and does not meet the standard of care for a high-risk client.