A nurse is caring for a bedridden patient at high risk for pressure injury development. Which nursing intervention is the MOST effective in preventing pressure injuries?
1Apply moisture barrier cream to all bony prominences twice daily
2Reposition the patient every 2 hours and maintain proper body alignment✓ 정답
3Use a donut-shaped cushion under the sacrum when the patient is sitting
4Massage bony prominences with lotion during each shift
해설
Repositioning every 2 hours is the most effective intervention as it relieves pressure and promotes circulation. Other options are secondary or contraindicated for high-risk patients.
Core Nursing ExplanationKey Concept Analysis: This question tests the fundamental, evidence-based principle for preventing Pressure injuries (Pressure ulcers). The core pathophysiology involves unrelieved pressure over bony prominences, which compresses capillaries and leads to tissue ischemia and necrosis. The most effective prevention strategy directly addresses this primary cause by relieving pressure.
Answer Rationale: Key Point! The cornerstone of pressure injury prevention is frequent repositioning. For a bedridden patient, repositioning every 2 hours is the standard of care. This action relieves pressure, restores blood flow to ischemic areas, and prevents prolonged tissue deformation. Combined with maintaining proper body alignment, it minimizes shear and friction forces, making it the single most effective intervention.
Distractor Analysis:
Watch out for confusion! Option ①: Moisture barrier creams are used to protect skin from incontinence-associated dermatitis, which is a moisture issue, not a direct solution for pressure. While important for skin integrity, it does not relieve pressure.
Option ③: Donut-shaped cushions are contraindicated. They create a ring of pressure around the wound or bony prominence, which can actually obstruct peripheral blood flow and worsen ischemia in the central area they are meant to protect.
Option ④: Massaging bony prominences is contraindicated. Vigorous massage over reddened, at-risk areas can cause micro-trauma to delicate capillaries and underlying tissue, increasing the risk of injury. Gentle skin care with lotion is appropriate, but not massage over pressure points.
Related Concepts: Prevention is a multi-modal approach summarized by the mnemonic SSKIN (Surface, Skin inspection, Keep moving, Incontinence, Nutrition). While all are important, relieving pressure (Keep moving) is the primary and most critical action. The nursing process requires prioritizing interventions that address the root cause of the problem.
Concept Summary
These can cause more harm. Use evidence-based guidelines (e.g., NPUAP/EPUAP).
Side-by-Side Comparison!
Effective Prevention
Ineffective/Harmful Practice
Rationale
Frequent Repositioning
Infrequent turning ("Let them sleep")
Relieves pressure vs. allows prolonged ischemia.
Pressure-Redistributing Support Surface (e.g., foam, air mattress)
Regular hospital mattress
Distributes weight over larger area vs. concentrates pressure on bony points.
Gentle cleansing & pat drying
Vigorous rubbing with rough towels
Protects skin barrier vs. causes micro-trauma.
Moisture barrier on intact skin *around* area
Massaging lotion *onto* a reddened bony prominence
Protects from moisture vs. damages compromised tissue.
Anatomy, Physiology & Pharmacology Points
Physiology: Capillary closing pressure is approximately 32 mmHg. Pressure exceeding this for a prolonged time occludes capillaries, leading to tissue anoxia.
Staging: Pressure injuries are staged I-IV, Unstageable, and Deep Tissue Injury (DTI) based on tissue depth involved. Prevention focuses on Stage 0 (at-risk skin).
Memory Tips
Mnemonic: "Turn for the Better" – Emphasizes that turning/repositioning is the #1 action.
Rule of 2s: Bed-bound patients turned every 2 hours; Chair-bound patients repositioned every 1 hour (think: sitting pressure is greater).
Donut = Don't use it! A simple association to remember the contraindication.
Selecting appropriate support surfaces based on patient risk level.
Identifying stages of pressure injuries from a description or image.
Watch Out for Question Variations!
From Symptom to Action: "The nurse observes non-blanchable erythema on a patient's sacrum. What is the priority action?" (Answer: Increase frequency of repositioning, document as a Stage I pressure injury, and initiate a prevention plan.)
Patient Education Focus: "Which instruction is most important to include when teaching a family member to care for a bedridden relative at home?" (Answer: Demonstrate how to turn and reposition the patient every 2 hours.)
Delegation Focus: "Which task can the RN delegate to an Unlicensed Assistive Personnel (UAP) regarding pressure injury prevention?" (Answer: Repositioning a stable patient every 2 hours according to the turn schedule. The RN retains assessment and care planning.)
Nursing Clinical Practice GuideClinical Scenario: You are caring for Mr. Johnson, an 82-year-old male admitted with a stroke, left-sided hemiparesis, and urinary incontinence. He is alert but unable to reposition himself. His Braden Scale score is 12 (High Risk).
Nursing Intervention Strategy:
Assessment: Perform a head-to-toe skin assessment with every turn, paying special attention to his sacrum, right heel (the non-paralyzed side often has more pressure), and right trochanter. Use the Braden Scale to document risk. Check for non-blanchable erythema.
Planning: Initiate a turn schedule (e.g., right side, back, left side). Plan for a pressure-redistributing mattress. Collaborate with dietary services for a high-protein diet.
Implementation:
Reposition Q2H using a lift sheet to avoid friction/shear. Use pillows to bridge heels off the bed and keep knees/ankles from touching.
Clean skin promptly after incontinence episodes. Apply a moisture barrier ointment (e.g., zinc oxide) to protect intact perineal skin.
Keep HOB at or below 30 degrees when feasible to reduce sacral shear.
Evaluation: Reassess skin condition daily and with each turn. Re-evaluate Braden score weekly or with condition change. Is skin intact? Is the turn schedule being followed?
Patient Safety and Precautions:
NEVER place a donut cushion under any body part.
NEVER massage reddened areas.
Do not use alcohol-based products on dry, fragile skin.
Ensure heels are floating off the bed—this is a critical and often missed step.
Nursing Procedure & Medication FlowProcedure: Performing a Q2H Turn
Explain the procedure to the patient.
Lower the head of the bed.
Place a lift/turn sheet under the patient.
With assistance if needed, gently roll the patient to the pre-determined position (30-degree lateral tilt is often recommended over 90 degrees).
Support the position with pillows: behind the back, between the knees/ankles, under the upper arm.
Ensure the bottom heel is offloaded (use a heel protector or pillow under the calf).
Perform a brief skin check on the newly exposed side.
Document the time, position, skin condition, and patient tolerance.
A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! Pressure injuries are often called 'never events' because they are largely preventable with diligent nursing care. In clinical practice, your disciplined adherence to that turn schedule is what protects your patient's skin. When studying for your boards, remember this: if the question is about preventing a pressure injury and one answer involves moving the patient, that's very likely the right answer. Connect the science (capillary pressure) to the action (turning). That critical thinking will make you a safe and effective nurse."
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.
Braden Scale — A validated tool used to assess a patient's risk for developing pressure injuries. It scores six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Shear Force — A mechanical force that occurs when tissue layers slide over each other, stretching and tearing capillaries (e.g., when a patient slides down in bed).
Non-blanchable Erythema — Redness of intact skin that does not turn white (blanch) when pressed. This is the hallmark sign of a Stage I pressure injury.
Pressure Redistribution — The principle of using support surfaces (mattresses, cushions) to spread pressure over a wider area of the body, thereby reducing pressure at any single point.