A nurse is caring for a client with a spinal cord injury who has been immobile for 1 week. Which nursing intervention should be the priority to prevent complications related to immobility?
1Encourage deep breathing exercises every 2 hours while awake
2Apply sequential compression devices to lower extremities
3Perform passive range of motion exercises to all joints twice daily
4Reposition the client every 2 hours and assess skin integrity✓ 정답
해설
Repositioning every 2 hours with skin assessment is the priority to prevent pressure ulcers, which develop rapidly in immobilized clients. Other interventions address different complications but are less immediate.
Core Nursing ExplanationKey Concept Analysis: This question tests the nurse's ability to prioritize interventions for a patient with a Spinal cord injury (SCI) who is at high risk for complications of immobility. The core principle is Maslow's Hierarchy of Needs and patient safety. While all options are valid nursing actions, the priority is determined by which complication poses the most immediate and severe threat to the patient's physiological integrity.
Answer Rationale: Key Point! The correct answer is 4. Reposition the client every 2 hours and assess skin integrity. This directly addresses the prevention of Pressure ulcers (Pressure injuries), which can develop in as little as 2-6 hours in an immobile patient. A spinal cord injury patient has impaired sensation (numbness) and motor function, eliminating their natural ability to shift weight. This, combined with pressure over bony prominences, leads to tissue ischemia and rapid skin breakdown. Preventing a pressure ulcer is a fundamental, high-priority nursing responsibility that protects the patient from a serious, painful, and potentially life-threatening infection.
Distractor Analysis:
Option 1 (Encourage deep breathing exercises): This is important to prevent Atelectasis and Pneumonia (complications of immobility). However, it is typically not the immediate priority over skin integrity in the first week, as respiratory complications often take slightly longer to manifest as a critical threat compared to rapid skin breakdown.
Option 2 (Apply sequential compression devices): This is a crucial intervention to prevent Deep vein thrombosis (DVT). DVT is a serious risk for immobile patients, but its prevention, while critical, is often managed with both mechanical (SCDs) and pharmacological (anticoagulants) prophylaxis. Skin assessment and repositioning are more frequent, hands-on nursing assessments that form the foundation of care.
Option 3 (Perform passive range of motion): This is essential to prevent Contractures and maintain joint function. However, contractures develop over a longer period (days to weeks). The priority in the first week is to address threats to immediate tissue viability (skin) and circulation (DVT, respiration).
Related Concepts: The nursing process requires constant re-prioritization. For this patient, a comprehensive plan includes all these interventions. The question asks for the priority, which is founded on the principle of preventing harm from the most rapidly occurring complication. Remember the mnemonic for complications of immobility: Watch out for confusion! Think of systems affected: Respiratory, Cardiovascular, Musculoskeletal, Integumentary, Elimination (Constipation), and Psychological. The integumentary (skin) system often requires the most immediate and consistent nursing action.
Concept Summary
Complication of Immobility
Nursing Intervention
Rationale & Timing
Pressure Ulcer
Reposition q2h, skin assessment
Key Point! Highest priority. Can develop in hours.
Deep Vein Thrombosis (DVT)
SCDs, anticoagulants, leg exercises
High priority, but prevention is multi-modal.
Atelectasis/Pneumonia
Deep breathing, incentive spirometry, cough
Important, but often a secondary priority to skin.
Contractures
Passive/Active ROM exercises
Essential for long-term function, but not the most immediate threat.
Side-by-Side Comparison!
Priority Setting Framework
Application to This Scenario
Example
Maslow's Hierarchy
Physiological needs (skin integrity, breathing) come before safety/psychosocial needs.
Preventing a pressure ulcer (physiological) is prioritized over preventing anxiety.
ABCs (Airway, Breathing, Circulation)
If the patient had acute respiratory distress, breathing exercises would be priority. In a stable patient, complication prevention follows a different hierarchy.
For a stable SCI patient, "C" for circulation to the skin (preventing ischemia) is a critical interpretation of priority.
Acute vs. Chronic Threat
Interventions for acute, rapid-onset threats are prioritized over those for slower-developing issues.
Skin breakdown (acute threat) vs. joint contracture (chronic threat).
Anatomy, Physiology & Pharmacology Points
The pathophysiology of a pressure ulcer is based on pressure exceeding capillary closing pressure (usually ~32 mmHg). This pressure, often over the sacrum, heels, ischial tuberosities, or trochanters, occludes blood flow, leading to tissue ischemia, necrosis, and ulcer formation. In SCI, the loss of sensory and motor function below the level of injury removes the patient's natural protective mechanisms (pain and movement).
Memory Tips
Mnemonics: For complications of bed rest, remember "DR. TIMED": DVT, Respiratory (atelectasis/pneumonia), Thinking (depression), Integument (pressure ulcers), Muscle (atrophy), Elimination (constipation/UTI), Digestion.
Skin First: In any question about priority care for an immobile patient, always consider skin integrity and repositioning first unless the patient is in acute respiratory or circulatory distress.
Q2H Turn: The "every 2 hours" rule is gold standard for preventing pressure ulcers.
High-Frequency NCLEX Topics
Priority-setting for immobile patients is a Core NCLEX topic. The exam frequently tests your ability to distinguish between important and most important/priority interventions. You must know the typical timeline for complications: pressure ulcers (hours-days), DVT (days), atelectasis (days), contractures (weeks).
Watch Out for Question Variations!
Shift in Priority: If the question adds "client reports sudden shortness of breath and chest pain," then Option 1 (deep breathing) and assessment for pulmonary embolism (linked to DVT from Option 2) become the immediate priority.
Different Patient: For a post-operative patient just out of surgery, preventing airway complications (deep breathing) might be the first priority listed.
Evaluation Focus: A question might ask: "The nurse repositioned a spinal cord injury client. Which finding indicates effective prevention of immobility complications?" Correct answer: "Skin remains intact, non-blanchable, without redness."
Nursing Clinical Practice GuideClinical Scenario: You are assigned to care for Mr. Johnson, a 28-year-old male with a T6 complete spinal cord injury sustained one week ago in a motorcycle accident. He is on bed rest and has no sensation or movement below the mid-chest level.
Nursing Intervention Strategy:
Assessment (Every 2 hours): Perform a head-to-toe skin assessment using a good light source. Pay special attention to the sacrum, heels, elbows, scapulae, and back of the head. Use the Braden Scale to assess pressure ulcer risk. Check for non-blanchable erythema (Stage 1 pressure injury).
Planning & Implementation:
Repositioning Schedule: Establish a strict turning schedule (e.g., left side, back, right side) using a clock or timer. Use pillows and foam wedges to keep bony prominences from direct contact. Consider a specialty low-air-loss or alternating-pressure mattress.
Comprehensive Care Bundle: While repositioning is priority, integrate other interventions into the care routine:
During turns: Perform quick passive ROM to major joints.
Every 2 hours while awake: Instruct/assist with deep breathing and coughing exercises.
Continuous: Ensure sequential compression devices (SCDs) are properly fitted and functioning.
Patient & Family Education: Even though the patient has no sensation, explain why turning is so critical. Teach family members how to perform skin checks for redness. Emphasize that pressure ulcers can start from the inside (deep tissue injury) before being visible on the skin.
Patient Safety and Precautions:
Lifting, Not Dragging: Always use a turn sheet or lift device to reposition. Dragging the patient across sheets creates shear forces, which are a major cause of skin damage.
Keep Skin Dry and Clean: Incontinence increases risk exponentially. Implement a rigorous bowel and bladder program. Use moisture-barrier creams.
Heel Off-Loading: Heels are especially vulnerable. Use heel protector boots or place pillows under the calves to "float" the heels off the bed.
Nursing Procedure & Medication FlowProcedure: Performing a Q2H Turn and Skin Assessment
1. Explain the procedure to the patient. Gather assistance if needed.
2. Lower the head of the bed to a flat or <30-degree angle to reduce shear.
3. Remove pressure from the area to be examined.
4. Inspect and palpate all at-risk skin areas. Look for color changes, warmth, induration, or blistering.
5. Reposition the patient onto their side at a 30-degree angle (not 90 degrees, which creates pressure on the trochanter).
6. Support the back with pillows, place a pillow between the knees and ankles.
7. Document skin condition, position, and any interventions.
Medication Context: While not directly a medication procedure, this patient will likely be on a subcutaneous anticoagulant (e.g., enoxaparin) for DVT prophylaxis. Administer this at the scheduled time, but do not massage the injection site, as this could cause tissue trauma in an insensate area.
A Word from Your Senior Nurse
"In the real world, turning a total-care patient every two hours is one of the most physically demanding and critically important parts of our job. It's a team effort. When you see perfect, intact skin on a patient who has been with you for weeks, that's a badge of honor for the entire nursing team. On the NCLEX, they are testing your clinical judgment: can you see the forest (the comprehensive plan) but also identify the one tree that will fall first if not supported (skin integrity)? That judgment is what keeps patients safe. Never underestimate the power of a timely turn!"
Pressure Ulcer (Pressure Injury) — Localized damage to the skin and/or underlying soft tissue, usually over a bony prominence, due to intense and/or prolonged pressure or pressure in combination with shear.
Spinal Cord Injury — Damage to the spinal cord resulting in temporary or permanent changes in its function, including loss of motor, sensory, and autonomic control below the level of injury.
Deep Vein Thrombosis — Formation of a blood clot (thrombus) in a deep vein, usually in the legs, a major risk for immobile patients that can lead to pulmonary embolism.
Sequential Compression Devices — Pneumatic sleeves placed on the legs that intermittently inflate and deflate to mimic muscle pump action, promoting venous return and preventing DVT.
Passive Range of Motion — Exercises in which the nurse or caregiver moves the patient's joints through their full motion without assistance from the patient, used to maintain joint flexibility and prevent contractures.