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문제

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?

해설
Repositioning every 2 hours with proper body alignment is most effective as it relieves pressure and promotes circulation. Other options like moisturizing, donut cushions, or vigorous massage are less effective or contraindicated.
같은 주제 다음 문제A nurse is assessing a 78-year-old patient who has been bedridden for 10 days following hi…

심화 해설

Correct Answer: 2. Reposition the patient every 2 hours and maintain proper body alignment

Analysis of the Most Effective Intervention
The cornerstone of pressure injury prevention for a bedridden patient is the consistent relief of pressure, particularly over bony prominences. The most effective, evidence-based nursing intervention to achieve this is a systematic repositioning schedule. The rationale is rooted in the pathophysiology of pressure injury development: sustained pressure occludes capillaries, leading to tissue ischemia, hypoxia, and ultimately necrosis. Repositioning the patient every 2 hours redistributes body weight, restores capillary blood flow, and prevents the cascade of tissue damage. Maintaining proper body alignment is equally critical, as it prevents shearing and friction forces that exacerbate tissue injury when a patient slides down in bed.

This intervention is a central component of pressure injury prevention care bundles. A study by Başayar and Yazıcı (2026) evaluating a prevention care bundle in an intensive care unit demonstrated that structured training for nurses on such protocols directly improves compliance and positively impacts patient outcomes [1]. The bundle approach inherently relies on consistent, scheduled repositioning. Furthermore, a quality education initiative by Khattak et al. (2026) specifically highlighted the effectiveness of a simple "Turning Clock Tool" to prompt regular repositioning, which significantly reduced the occurrence and severity of pressure injuries in high-risk patients in a low-resource setting [3]. This underscores that the frequency and reliability of the intervention, not its complexity, are what drive its effectiveness.

Why the Other Options Are Incorrect or Harmful

- Option 1: Apply moisturizing lotion to all bony prominences twice daily. While maintaining skin integrity is a component of a comprehensive prevention plan, moisturizing alone does not address the primary cause of pressure injuries: unrelieved pressure and resultant tissue ischemia. Over-moisturizing can also macerate the skin, making it more susceptible to breakdown from friction and shear. This is a supportive, not a primary, intervention.

- Option 3: Use donut-shaped cushions under the sacrum and heels. This is a dangerous and outdated practice. Donut-shaped or ring cushions are contraindicated for pressure injury prevention. They create a circular area of high pressure that occludes blood flow to the tissues in the center of the ring, directly causing the very tissue ischemia and pressure injury they are intended to prevent. This violates the fundamental principle of pressure redistribution.

- Option 4: Massage reddened areas vigorously to improve circulation. This intervention is strictly contraindicated. A reddened area over a bony prominence, especially one that does not blanch, indicates a Stage 1 pressure injury where underlying capillaries are already damaged and tissue ischemia is present. Vigorous massage can cause further trauma to the fragile capillary bed and subcutaneous tissues, worsening the injury through inflammation and deep tissue damage. The evidence-based approach is to relieve pressure from the area immediately, not to massage it. The research by Tumala et al. (2026) confirms that a critical gap in pressure injury prevention is the gap between nurses' knowledge and their actual practice, with adherence to correct guidelines—like avoiding massage on reddened areas—being critically inconsistent .

The integration of these principles into system-level strategies, as described by Giuliano and Vollman (2026), is where Clinical Nurse Specialists translate evidence into practice, ensuring that frontline interventions like scheduled repositioning are standardized and hardwired into care delivery to prevent hospital-acquired conditions .
References (research sources)
  • [1]
    Evaluation of the effectiveness of a pressure injury prevention care bundle in an intensive care unit.Research articleBaşayar Z, Yazıcı G. (2026) · DOI: 10.1186/s12912-026-04658-0
  • [3]
    Quality education initiative to reduce pressure ulcers in high-risk-admitted patients in low-resource settings.Research articleKhattak AF, Hussain S, Ahmad B, Khattak M, Afridi WV, Khan B. (2026) · DOI: 10.1136/bmjoq-2025-003722

임상 시나리오

Clinical Practice Guide: Repositioning for Pressure Injury Prevention
Core Principle

The most effective intervention for preventing pressure injuries in bedridden patients is a systematic repositioning schedule every 2 hours, combined with proper body alignment. This practice relieves sustained pressure on bony prominences, restores capillary blood flow, and prevents the ischemia-reperfusion injury cycle that leads to tissue necrosis.

Step-by-Step Repositioning Protocol
  1. Assess Patient Status: Evaluate the patient's overall condition, pain level, and specific risk factors using a validated tool like the Braden Scale before initiating movement.
  2. Gather Equipment: Use pillows, foam wedges, or positioning devices to maintain alignment and offload pressure. Ensure draw sheets or slide boards are available to minimize friction and shearing during turns.
  3. Execute the Turn: Using a draw sheet and at least two caregivers, move the patient to a 30-degree lateral tilt position. Avoid positioning directly on the trochanter. Document the position as left lateral, right lateral, or supine.
  4. Maintain Proper Alignment: Place a pillow between the knees and ankles to prevent bony contact. Support the upper arm with a pillow to prevent shoulder drop. Ensure heels are completely suspended off the bed surface using a heel-suspension device or pillow placed under the calves.
  5. Inspect Skin: At each turn, visually inspect all bony prominences (sacrum, heels, elbows, occiput) for non-blanchable erythema, warmth, or induration. Report any Stage 1 findings immediately.
  6. Document and Communicate: Record the time, position change, and skin assessment findings. Use a turning clock tool or electronic health record alert to cue the next repositioning event.
Critical Safety Alerts
  • Avoid Donut Cushions: These devices create a ring of high pressure that occludes capillary flow to the center tissue, paradoxically increasing the risk of pressure injury.
  • Never Massage Reddened Areas: Vigorous massage can disrupt fragile capillaries in ischemic tissue, causing deep tissue injury and worsening inflammation.
  • Minimize Friction and Shear: Keep the head of the bed at or below 30 degrees unless contraindicated, and use a trapeze bar to encourage patient self-repositioning if able.
  • Individualize the Schedule: While every 2 hours is the standard, patients on high-specification reactive or active support surfaces may have different turning intervals per manufacturer guidelines. Always verify.
Supporting Evidence

Structured repositioning protocols are a cornerstone of pressure injury prevention bundles. Quality improvement initiatives using visual cues like the Turning Clock Tool have demonstrated significant reductions in hospital-acquired pressure injury rates by improving nursing compliance with scheduled turns.

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