QLexNursing

🟩 Reposition the client every 3 hr. The client has impaired mobility and incontinence, placing them at high risk for pressure injuries, making scheduled repositioning essential.

🟩 Changing positions regularly reduces prolonged pressure on bony prominences.

🟩 This helps maintain skin integrity in clients with sensory deficits such as diabetic neuropathy.

🟩 Request a consult with a registered dietitian. Adequate nutrition is vital for skin integrity and healing, especially in clients at risk for pressure injuries.

🟩 A dietitian can assess for protein or caloric deficits that may contribute to skin breakdown.

🟩 Early nutritional intervention supports prevention of further complications.

🟩 Provide a support pressure-redistribution surface Clients with limited mobility benefit from specialized mattresses or overlays that reduce pressure intensity.

🟩 These surfaces help distribute body weight more evenly, protecting vulnerable skin areas.

🟩 This intervention reduces the likelihood of pressure injury development in high-risk clients.

🟩 Use a moisture barrier ointment after cleaning the client's skin. Frequent loose stools place the client at risk for moisture-associated skin damage.

🟩 Moisture barriers protect the skin from irritants and breakdown caused by incontinence.

🟩 Protecting the perineal area helps prevent dermatitis and secondary infection.

Place the client on a donut-shaped cushion.

🟩 Donut cushions increase pressure on surrounding tissue and can worsen skin breakdown.

🟩 They are not recommended for pressure injury prevention.

Elevate the head of the bed to 45°.

🟩 Higher bed elevation increases shear and friction injury risk, especially in clients with decreasedsensation.

🟩 Lower angles are preferred unless medically required.

Perform a skin risk assessment weekly.

🟩 High-risk clients require daily skin checks and routine reassessment, not weekly evaluation.

🟩 Weekly assessment delays early detection of skin changes.