A nurse is caring for a client with left hemiparesis after a right-sided ischemic stroke. Which of the following would the nurse do to prevent skin breakdown and contractures from disuse on the left side?

Elevate the client''s left arm.
Put the client on a toileting schedule.
Reposition the client every two hours.
Respond to call lights from the client promptly.

Explanation

• The nurse should respond to call lights in a timely fashion to assist the client with repositioning and toileting as needed. 

• The nurse should put the client on a toileting schedule to prevent incontinence since the client cannot get up independently. Many clients will have difficulty in using the restroom and will often need assistance to prevent incontinence. The nurse should assist with toileting at least every 2 hours and monitor for skin breakdown.

• Moisture from incontinence macerates the skin. Fecal incontinence is a greater risk due to bacteria and enzymes that are caustic to the skin. With urinary and fecal incontinence, fecal enzymes convert urea to ammonia, raising the skin's pH and making the skin more permeable to other irritants.

• Elevating the client's left arm and repositioning the client every two hours are important to prevent complications from immobility.

• Immobility is the most significant risk factor for pressure ulcer development. The patient should be repositioned as frequently as possible (at least every two hours) and should also be encouraged to move independently in bed to prevent complications of immobility such as pneumonia and constipation. 

• Patients who cannot lift themselves with repositioning and who must be lifted up in bed due to sliding down (when in semi-Fowler's) are at high risk for friction and shearing injuries, which are risk factors for skin breakdown.  Always use a draw sheet.

• Patients with any degree of immobility should be carefully monitored for pressure ulcer development. Risk for edema and skin injuries is increased due to immobility, decreased sensation, and fragile skin. The affected arm should be elevated above the level of the heart to promote venous return and reduce edema.

 

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