QOD 58: Intervention for Pressure Ulcer (Integumentary/Basic Care and Comfort)

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Question:

A nurse is working with a client who has been confined to his bed for the past week because of illness. While turning this patient, the nurse notes a stage II pressure ulcer on his sacrum. Which action is most appropriate in responding to this finding? Select all that apply.

Answer:

D. Support the patients nutrition and mobility

E. Relieve pressure using pillows or foam cushions

Rationale: 

Pressure ulcers are unfortunate consequences of immobility; if the nurse finds a pressure ulcer on a patient, she must respond quickly to avoid further complications. The nurse should apply a dressing and medication as ordered, as well as quickly relieve pressure from the site using foam cushions or pillows. The nurse must avoid donut-shaped ring devices for support as these place too much pressure in certain areas. The nurse also should not massage the site, as this can cause tissue damage.

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