# 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? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542656 > language: ko > subject: Adult Health ## 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? ## 보기 1. Apply moisture barrier cream to all bony prominences twice daily 2. Reposition the patient every 2 hours and maintain proper body alignment **✔ 정답** 3. Use a donut-shaped cushion under the sacrum when the patient is sitting 4. Massage bony prominences with lotion during each shift **정답: 2** ## 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. ## 심화 해설 Understanding the Core Issue Pressure injuries, also known as pressure ulcers, are localized damage to the skin and underlying soft tissue, usually over a bony prominence, resulting from intense and/or prolonged pressure in combination with shear. For a bedridden patient, the primary pathophysiological mechanism is the compression of capillaries supplying the skin and subcutaneous tissues. When external pressure exceeds normal capillary filling pressure (approximately 32 mmHg), the microcirculation is occluded. This leads to tissue ischemia, cellular death, and eventually necrosis if the pressure is not relieved. A systematic review identified multidimensional intervention pathways as a core element for prevention, emphasizing that no single topical intervention can substitute for the fundamental need to relieve pressure [1]. Analysis of the Correct Answer Repositioning the patient every 2 hours and maintaining proper body alignment is the most effective intervention because it directly addresses the root cause of pressure injury formation: prolonged, unrelieved pressure. This practice works by periodically redistributing the body's weight, allowing capillary blood flow to return to previously compressed tissues, thereby reversing the ischemic process before irreversible damage occurs. The "Turning Clock Tool" is an example of a simple, effective strategy used in quality improvement initiatives to standardize this practice and has been shown to reduce the occurrence and severity of pressure injuries in high-risk, immobile patients [2]. Maintaining proper alignment is equally critical, as it prevents shearing forces—where the skin remains stationary while the underlying bone and tissue are pulled by gravity, which can kink and tear blood vessels, significantly accelerating tissue damage. Critique of the Incorrect Options - Option 1: Apply moisture barrier cream to all bony prominences twice daily. While moisture management is a component of skin care, it is a secondary preventive measure, not the most effective primary one. Moisture from incontinence or perspiration can macerate the skin, weakening its barrier function and making it more susceptible to breakdown from pressure and friction. However, a barrier cream does nothing to relieve the mechanical force of pressure that causes deep tissue ischemia. It is an adjunct, not a substitute for pressure redistribution [1]. - Option 3: Use a donut-shaped cushion under the sacrum when the patient is sitting. This is a contraindicated practice. Donut-shaped cushions create a ring of pressure around the area they are meant to protect, which can impair blood flow in a circular pattern, cause venous congestion, and actually increase the risk of tissue ischemia and pressure injury in the center of the donut. This intervention is harmful and reflects a critical knowledge gap. Studies assessing nurses' knowledge often identify such outdated or harmful practices as areas needing improvement . - Option 4: Massage bony prominences with lotion during each shift. Massaging bony prominences is an outdated and potentially harmful practice. In patients at high risk, the underlying capillaries are already fragile and may be damaged from the initial stages of pressure injury. Vigorous massage can cause further trauma to these compromised microvessels, accelerating tissue breakdown rather than preventing it. Current evidence-based guidelines explicitly advise against massaging reddened areas over bony prominences, a point often covered in assessments of nurses' knowledge and attitudes towards immobility complications . Key Takeaway for Clinical Practice The cornerstone of pressure injury prevention is the consistent relief of pressure. All other interventions, including nutritional support, skin care, and support surface use, are built upon this foundational nursing action. A knowledge assessment of nurses revealed that while attitudes towards prevention are often positive, practical knowledge gaps persist, particularly regarding the correct frequency of repositioning and the avoidance of harmful interventions like massaging bony prominences . The most effective, evidence-based protocol for a bedridden patient at high risk is a strict, individualized turning schedule, typically every 2 hours, combined with meticulous body alignment to minimize pressure, friction, and shear [1][2].References (research sources) - [1]Prevention and Care of Pressure Ulcers in Long-Term Bedridden Adult and Older Adult Patients in the Community: A Systematic Review.Meta-analysis/systematic reviewMeng L, Banharak S, Sommana C, Ransinyo K, Cheumnok W, Tian J. (2026) · DOI: 10.2147/tcrm.s592581 - [2]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: Bedridden Patient Repositioning Core Principle: Repositioning is the single most effective intervention for pressure injury prevention because it directly reverses the primary cause—prolonged capillary occlusion leading to tissue ischemia. Standardized Turning Protocol - Frequency: Reposition bedridden patients at least every 2 hours around the clock. Document each turn using a standardized tool such as the Turning Clock Tool to ensure compliance. - Positioning Sequence: Rotate through right lateral (30-degree tilt), supine, left lateral (30-degree tilt), and prone positions if not contraindicated. A 30-degree lateral tilt is preferred over a 90-degree side-lying position to avoid direct pressure on the trochanter. - Body Alignment: Maintain proper anatomical alignment using pillows or foam wedges between bony prominences (e.g., knees, ankles) to prevent skin-to-skin contact and reduce shear forces. Critical Safety Considerations - Avoid Donut Cushions: Never use ring-shaped or donut cushions. They concentrate pressure on the surrounding tissue, impairing blood flow and increasing the risk of edema and injury in the center area. - Avoid Massage: Massaging bony prominences is contraindicated. For patients at risk, the underlying capillaries are already fragile, and massage can cause friction, shear, and microvascular damage. - Use Support Surfaces: Repositioning should be combined with a high-specification foam mattress or dynamic support surface as part of a multidimensional prevention strategy, but these do not replace the need for manual turning. Documentation: Record each position change, the patient's skin assessment findings, and tolerance to repositioning in the electronic health record. Use a validated risk assessment scale such as the Braden Scale upon admission and with any change in condition. ## 핵심 개념 - **Pressure Injury** — Localized damage to the skin and underlying soft tissue usually over a bony prominence, caused by intense or prolonged pressure combined with shear. - **Capillary Filling Pressure** — The pressure required to occlude capillary blood flow, approximately 32 mmHg; external pressure exceeding this leads to tissue ischemia and necrosis. - **Tissue Ischemia** — Inadequate blood supply to an organ or tissue, often caused by compression of capillaries, leading to oxygen deprivation and cell death. - **Shear** — A mechanical force that acts parallel to the skin surface, causing distortion of deeper tissues and blood vessels, often occurring when the head of the bed is elevated. - **Repositioning** — The act of changing a patient's position at regular intervals to redistribute body weight and restore blood flow to compressed tissues. ## 같은 주제 문제 - [A nurse is assessing a 78-year-old patient who has been bedridden for 10 days following hi…](https://mymerci.kr/pages/nclex_q.php?qn_id=540965) - [A nurse is assessing a 65-year-old patient who has been immobile in a wheelchair for 4 wee…](https://mymerci.kr/pages/nclex_q.php?qn_id=540966) - [A nurse is assessing a 78-year-old bedridden patient who has been hospitalized for 10 days…](https://mymerci.kr/pages/nclex_q.php?qn_id=540967) - [A nurse is caring for a 70-year-old patient with diabetes and a stage 3 pressure injury on…](https://mymerci.kr/pages/nclex_q.php?qn_id=540968) - [A nurse is caring for an elderly patient with a stage 3 pressure injury on the sacrum. 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